hospital_name,last_updated_on,version,location_name,hospital_address,license_number|VA,type_2_npi,"To the best of its knowledge and belief, this 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 in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",attester_name,general_contract_provisions,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
MedStar National Rehab Hospital,    2025-12-30,3.0.0,MedStar Health Physical Therapy at McLean,"1420 Beverly RD, McLean, VA 22101-3732",HFD01-0014,1508932708,TRUE,John Rockwood,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,modifiers,setting,billing_class,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,standard_charge|min,standard_charge|max,additional_generic_notes,standard_charge|Aetna Medicare|Aetna Medicare|negotiated_dollar,standard_charge|Aetna Medicare|Aetna Medicare|negotiated_percentage,standard_charge|Aetna Medicare|Aetna Medicare|negotiated_algorithm,median_amount|Aetna Medicare|Aetna Medicare,10th_percentile|Aetna Medicare|Aetna Medicare,90th_percentile|Aetna Medicare|Aetna Medicare,count|Aetna Medicare|Aetna Medicare,standard_charge|Aetna Medicare|Aetna Medicare|methodology,additional_payer_notes|Aetna Medicare|Aetna Medicare,standard_charge|Aetna US HealthCare Inc|Aetna All HMO and PPO Plans|negotiated_dollar,standard_charge|Aetna US HealthCare Inc|Aetna All HMO and PPO Plans|negotiated_percentage,standard_charge|Aetna US HealthCare Inc|Aetna All HMO and PPO Plans|negotiated_algorithm,median_amount|Aetna US HealthCare Inc|Aetna All HMO and PPO Plans,10th_percentile|Aetna US HealthCare Inc|Aetna All HMO and PPO Plans,90th_percentile|Aetna US HealthCare Inc|Aetna All HMO and PPO Plans,count|Aetna US HealthCare Inc|Aetna All HMO and PPO Plans,standard_charge|Aetna US HealthCare Inc|Aetna All HMO and PPO Plans|methodology,additional_payer_notes|Aetna US HealthCare Inc|Aetna All HMO and PPO Plans,standard_charge|AmeriGroup|AmeriGroup DC|negotiated_dollar,standard_charge|AmeriGroup|AmeriGroup DC|negotiated_percentage,standard_charge|AmeriGroup|AmeriGroup DC|negotiated_algorithm,median_amount|AmeriGroup|AmeriGroup DC,10th_percentile|AmeriGroup|AmeriGroup DC,90th_percentile|AmeriGroup|AmeriGroup DC,count|AmeriGroup|AmeriGroup DC,standard_charge|AmeriGroup|AmeriGroup DC|methodology,additional_payer_notes|AmeriGroup|AmeriGroup DC,standard_charge|AmeriHealth Caritas District of Columbia|AmeriHealth|negotiated_dollar,standard_charge|AmeriHealth Caritas District of Columbia|AmeriHealth|negotiated_percentage,standard_charge|AmeriHealth Caritas District of Columbia|AmeriHealth|negotiated_algorithm,median_amount|AmeriHealth Caritas District of Columbia|AmeriHealth,10th_percentile|AmeriHealth Caritas District of Columbia|AmeriHealth,90th_percentile|AmeriHealth Caritas District of Columbia|AmeriHealth,count|AmeriHealth Caritas District of Columbia|AmeriHealth,standard_charge|AmeriHealth Caritas District of Columbia|AmeriHealth|methodology,additional_payer_notes|AmeriHealth Caritas District of Columbia|AmeriHealth,standard_charge|Anthem of Virginia |Anthem Healthkeepers HMO/POS/POS OA|negotiated_dollar,standard_charge|Anthem of Virginia |Anthem Healthkeepers HMO/POS/POS OA|negotiated_percentage,standard_charge|Anthem of Virginia |Anthem Healthkeepers HMO/POS/POS OA|negotiated_algorithm,median_amount|Anthem of Virginia |Anthem Healthkeepers HMO/POS/POS OA,10th_percentile|Anthem of Virginia |Anthem Healthkeepers HMO/POS/POS OA,90th_percentile|Anthem of Virginia |Anthem Healthkeepers HMO/POS/POS OA,count|Anthem of Virginia |Anthem Healthkeepers HMO/POS/POS OA,standard_charge|Anthem of Virginia |Anthem Healthkeepers HMO/POS/POS OA|methodology,additional_payer_notes|Anthem of Virginia |Anthem Healthkeepers HMO/POS/POS OA,standard_charge|Anthem of Virginia |Anthem Medicaid HMO|negotiated_dollar,standard_charge|Anthem of Virginia |Anthem Medicaid HMO|negotiated_percentage,standard_charge|Anthem of Virginia |Anthem Medicaid HMO|negotiated_algorithm,median_amount|Anthem of Virginia |Anthem Medicaid HMO,10th_percentile|Anthem of Virginia |Anthem Medicaid HMO,90th_percentile|Anthem of Virginia |Anthem Medicaid HMO,count|Anthem of Virginia |Anthem Medicaid HMO,standard_charge|Anthem of Virginia |Anthem Medicaid HMO|methodology,additional_payer_notes|Anthem of Virginia |Anthem Medicaid HMO,standard_charge|CareFirst Blue Choice Inc|All Carefirst HMO Plans|negotiated_dollar,standard_charge|CareFirst Blue Choice Inc|All Carefirst HMO Plans|negotiated_percentage,standard_charge|CareFirst Blue Choice Inc|All Carefirst HMO Plans|negotiated_algorithm,median_amount|CareFirst Blue Choice Inc|All Carefirst HMO Plans,10th_percentile|CareFirst Blue Choice Inc|All Carefirst HMO Plans,90th_percentile|CareFirst Blue Choice Inc|All Carefirst HMO Plans,count|CareFirst Blue Choice Inc|All Carefirst HMO Plans,standard_charge|CareFirst Blue Choice Inc|All Carefirst HMO Plans|methodology,additional_payer_notes|CareFirst Blue Choice Inc|All Carefirst HMO Plans,standard_charge|CareFirst Advantage Inc|CareFirst Medicare Advantage|negotiated_dollar,standard_charge|CareFirst Advantage Inc|CareFirst Medicare Advantage|negotiated_percentage,standard_charge|CareFirst Advantage Inc|CareFirst Medicare Advantage|negotiated_algorithm,median_amount|CareFirst Advantage Inc|CareFirst Medicare Advantage,10th_percentile|CareFirst Advantage Inc|CareFirst Medicare Advantage,90th_percentile|CareFirst Advantage Inc|CareFirst Medicare Advantage,count|CareFirst Advantage Inc|CareFirst Medicare Advantage,standard_charge|CareFirst Advantage Inc|CareFirst Medicare Advantage|methodology,additional_payer_notes|CareFirst Advantage Inc|CareFirst Medicare Advantage,standard_charge|CareFirst Blue Choice Inc|All Carefirst PPO Plans|negotiated_dollar,standard_charge|CareFirst Blue Choice Inc|All Carefirst PPO Plans|negotiated_percentage,standard_charge|CareFirst Blue Choice Inc|All Carefirst PPO Plans|negotiated_algorithm,median_amount|CareFirst Blue Choice Inc|All Carefirst PPO Plans,10th_percentile|CareFirst Blue Choice Inc|All Carefirst PPO Plans,90th_percentile|CareFirst Blue Choice Inc|All Carefirst PPO Plans,count|CareFirst Blue Choice Inc|All Carefirst PPO Plans,standard_charge|CareFirst Blue Choice Inc|All Carefirst PPO Plans|methodology,additional_payer_notes|CareFirst Blue Choice Inc|All Carefirst PPO Plans,standard_charge|Health Care Service Corporation|Health Care Service Corporation|negotiated_dollar,standard_charge|Health Care Service Corporation|Health Care Service Corporation|negotiated_percentage,standard_charge|Health Care Service Corporation|Health Care Service Corporation|negotiated_algorithm,median_amount|Health Care Service Corporation|Health Care Service Corporation,10th_percentile|Health Care Service Corporation|Health Care Service Corporation,90th_percentile|Health Care Service Corporation|Health Care Service Corporation,count|Health Care Service Corporation|Health Care Service Corporation,standard_charge|Health Care Service Corporation|Health Care Service Corporation|methodology,additional_payer_notes|Health Care Service Corporation|Health Care Service Corporation,standard_charge|Cigna HealthCare MidAtlantic Inc|Cigna All HMO and PPO|negotiated_dollar,standard_charge|Cigna HealthCare MidAtlantic Inc|Cigna All HMO and PPO|negotiated_percentage,standard_charge|Cigna HealthCare MidAtlantic Inc|Cigna All HMO and PPO|negotiated_algorithm,median_amount|Cigna HealthCare MidAtlantic Inc|Cigna All HMO and PPO,10th_percentile|Cigna HealthCare MidAtlantic Inc|Cigna All HMO and PPO,90th_percentile|Cigna HealthCare MidAtlantic Inc|Cigna All HMO and PPO,count|Cigna HealthCare MidAtlantic Inc|Cigna All HMO and PPO,standard_charge|Cigna HealthCare MidAtlantic Inc|Cigna All HMO and PPO|methodology,additional_payer_notes|Cigna HealthCare MidAtlantic Inc|Cigna All HMO and PPO,standard_charge|HSCSN|HSCSN|negotiated_dollar,standard_charge|HSCSN|HSCSN|negotiated_percentage,standard_charge|HSCSN|HSCSN|negotiated_algorithm,median_amount|HSCSN|HSCSN,10th_percentile|HSCSN|HSCSN,90th_percentile|HSCSN|HSCSN,count|HSCSN|HSCSN,standard_charge|HSCSN|HSCSN|methodology,additional_payer_notes|HSCSN|HSCSN,standard_charge|Humana|Humana Medicare Advantage|negotiated_dollar,standard_charge|Humana|Humana Medicare Advantage|negotiated_percentage,standard_charge|Humana|Humana Medicare Advantage|negotiated_algorithm,median_amount|Humana|Humana Medicare Advantage,10th_percentile|Humana|Humana Medicare Advantage,90th_percentile|Humana|Humana Medicare Advantage,count|Humana|Humana Medicare Advantage,standard_charge|Humana|Humana Medicare Advantage|methodology,additional_payer_notes|Humana|Humana Medicare Advantage,standard_charge|JHHC|JHHC EHP and USFHP|negotiated_dollar,standard_charge|JHHC|JHHC EHP and USFHP|negotiated_percentage,standard_charge|JHHC|JHHC EHP and USFHP|negotiated_algorithm,median_amount|JHHC|JHHC EHP and USFHP,10th_percentile|JHHC|JHHC EHP and USFHP,90th_percentile|JHHC|JHHC EHP and USFHP,count|JHHC|JHHC EHP and USFHP,standard_charge|JHHC|JHHC EHP and USFHP|methodology,additional_payer_notes|JHHC|JHHC EHP and USFHP,standard_charge|Kaiser Permanente|Kaiser MD MCO|negotiated_dollar,standard_charge|Kaiser Permanente|Kaiser MD MCO|negotiated_percentage,standard_charge|Kaiser Permanente|Kaiser MD MCO|negotiated_algorithm,median_amount|Kaiser Permanente|Kaiser MD MCO,10th_percentile|Kaiser Permanente|Kaiser MD MCO,90th_percentile|Kaiser Permanente|Kaiser MD MCO,count|Kaiser Permanente|Kaiser MD MCO,standard_charge|Kaiser Permanente|Kaiser MD MCO|methodology,additional_payer_notes|Kaiser Permanente|Kaiser MD MCO,standard_charge|Kaiser Permanente|Kaiser Medicare Advantage|negotiated_dollar,standard_charge|Kaiser Permanente|Kaiser Medicare Advantage|negotiated_percentage,standard_charge|Kaiser Permanente|Kaiser Medicare Advantage|negotiated_algorithm,median_amount|Kaiser Permanente|Kaiser Medicare Advantage,10th_percentile|Kaiser Permanente|Kaiser Medicare Advantage,90th_percentile|Kaiser Permanente|Kaiser Medicare Advantage,count|Kaiser Permanente|Kaiser Medicare Advantage,standard_charge|Kaiser Permanente|Kaiser Medicare Advantage|methodology,additional_payer_notes|Kaiser Permanente|Kaiser Medicare Advantage,standard_charge|Kaiser Permanente|All Kaiser Commercial Excluding Kaiser Permanente Signature and Signature Added Choice Plans|negotiated_dollar,standard_charge|Kaiser Permanente|All Kaiser Commercial Excluding Kaiser Permanente Signature and Signature Added Choice Plans|negotiated_percentage,standard_charge|Kaiser Permanente|All Kaiser Commercial Excluding Kaiser Permanente Signature and Signature Added Choice Plans|negotiated_algorithm,median_amount|Kaiser Permanente|All Kaiser Commercial Excluding Kaiser Permanente Signature and Signature Added Choice Plans,10th_percentile|Kaiser Permanente|All Kaiser Commercial Excluding Kaiser Permanente Signature and Signature Added Choice Plans,90th_percentile|Kaiser Permanente|All Kaiser Commercial Excluding Kaiser Permanente Signature and Signature Added Choice Plans,count|Kaiser Permanente|All Kaiser Commercial Excluding Kaiser Permanente Signature and Signature Added Choice Plans,standard_charge|Kaiser Permanente|All Kaiser Commercial Excluding Kaiser Permanente Signature and Signature Added Choice Plans|methodology,additional_payer_notes|Kaiser Permanente|All Kaiser Commercial Excluding Kaiser Permanente Signature and Signature Added Choice Plans,standard_charge|Kaiser Permanente|Kaiser VA MCO|negotiated_dollar,standard_charge|Kaiser Permanente|Kaiser VA MCO|negotiated_percentage,standard_charge|Kaiser Permanente|Kaiser VA MCO|negotiated_algorithm,median_amount|Kaiser Permanente|Kaiser VA MCO,10th_percentile|Kaiser Permanente|Kaiser VA MCO,90th_percentile|Kaiser Permanente|Kaiser VA MCO,count|Kaiser Permanente|Kaiser VA MCO,standard_charge|Kaiser Permanente|Kaiser VA MCO|methodology,additional_payer_notes|Kaiser Permanente|Kaiser VA MCO,standard_charge|Medstar Family Choice Inc|Medstar Family Choice DC |negotiated_dollar,standard_charge|Medstar Family Choice Inc|Medstar Family Choice DC |negotiated_percentage,standard_charge|Medstar Family Choice Inc|Medstar Family Choice DC |negotiated_algorithm,median_amount|Medstar Family Choice Inc|Medstar Family Choice DC ,10th_percentile|Medstar Family Choice Inc|Medstar Family Choice DC ,90th_percentile|Medstar Family Choice Inc|Medstar Family Choice DC ,count|Medstar Family Choice Inc|Medstar Family Choice DC ,standard_charge|Medstar Family Choice Inc|Medstar Family Choice DC |methodology,additional_payer_notes|Medstar Family Choice Inc|Medstar Family Choice DC,standard_charge|Medstar Family Choice|Medstar Family Choice MD|negotiated_dollar,standard_charge|Medstar Family Choice|Medstar Family Choice MD|negotiated_percentage,standard_charge|Medstar Family Choice|Medstar Family Choice MD|negotiated_algorithm,median_amount|Medstar Family Choice|Medstar Family Choice MD,10th_percentile|Medstar Family Choice|Medstar Family Choice MD,90th_percentile|Medstar Family Choice|Medstar Family Choice MD,count|Medstar Family Choice|Medstar Family Choice MD,standard_charge|Medstar Family Choice|Medstar Family Choice MD|methodology,additional_payer_notes|Medstar Family Choice|Medstar Family Choice MD,standard_charge|Private HealthCare Systems (PHCS)|Private HealthCare Systems (PHCS)|negotiated_dollar,standard_charge|Private HealthCare Systems (PHCS)|Private HealthCare Systems (PHCS)|negotiated_percentage,standard_charge|Private HealthCare Systems (PHCS)|Private HealthCare Systems (PHCS)|negotiated_algorithm,median_amount|Private HealthCare Systems (PHCS)|Private HealthCare Systems (PHCS),10th_percentile|Private HealthCare Systems (PHCS)|Private HealthCare Systems (PHCS),90th_percentile|Private HealthCare Systems (PHCS)|Private HealthCare Systems (PHCS),count|Private HealthCare Systems (PHCS)|Private HealthCare Systems (PHCS),standard_charge|Private HealthCare Systems (PHCS)|Private HealthCare Systems (PHCS)|methodology,additional_payer_notes|Private HealthCare Systems (PHCS)|Private HealthCare Systems (PHCS),standard_charge|PFC|PFC|negotiated_dollar,standard_charge|PFC|PFC|negotiated_percentage,standard_charge|PFC|PFC|negotiated_algorithm,median_amount|PFC|PFC,10th_percentile|PFC|PFC,90th_percentile|PFC|PFC,count|PFC|PFC,standard_charge|PFC|PFC|methodology,additional_payer_notes|PFC|PFC,standard_charge|Tricare|Tricare|negotiated_dollar,standard_charge|Tricare|Tricare|negotiated_percentage,standard_charge|Tricare|Tricare|negotiated_algorithm,median_amount|Tricare|Tricare,10th_percentile|Tricare|Tricare,90th_percentile|Tricare|Tricare,count|Tricare|Tricare,standard_charge|Tricare|Tricare|methodology,additional_payer_notes|Tricare|Tricare,standard_charge|United Healthcare|UHC Compass/ IEX|negotiated_dollar,standard_charge|United Healthcare|UHC Compass/ IEX|negotiated_percentage,standard_charge|United Healthcare|UHC Compass/ IEX|negotiated_algorithm,median_amount|United Healthcare|UHC Compass/ IEX,10th_percentile|United Healthcare|UHC Compass/ IEX,90th_percentile|United Healthcare|UHC Compass/ IEX,count|United Healthcare|UHC Compass/ IEX,standard_charge|United Healthcare|UHC Compass/ IEX|methodology,additional_payer_notes|United Healthcare|UHC Compass/ IEX,standard_charge|United Healthcare|UHC Navigate/Core|negotiated_dollar,standard_charge|United Healthcare|UHC Navigate/Core|negotiated_percentage,standard_charge|United Healthcare|UHC Navigate/Core|negotiated_algorithm,median_amount|United Healthcare|UHC Navigate/Core,10th_percentile|United Healthcare|UHC Navigate/Core,90th_percentile|United Healthcare|UHC Navigate/Core,count|United Healthcare|UHC Navigate/Core,standard_charge|United Healthcare|UHC Navigate/Core|methodology,additional_payer_notes|United Healthcare|UHC Navigate/Core,standard_charge|United Healthcare|UnitedHealthcare Community Plan of Maryland|negotiated_dollar,standard_charge|United Healthcare|UnitedHealthcare Community Plan of Maryland|negotiated_percentage,standard_charge|United Healthcare|UnitedHealthcare Community Plan of Maryland|negotiated_algorithm,median_amount|United Healthcare|UnitedHealthcare Community Plan of Maryland,10th_percentile|United Healthcare|UnitedHealthcare Community Plan of Maryland,90th_percentile|United Healthcare|UnitedHealthcare Community Plan of Maryland,count|United Healthcare|UnitedHealthcare Community Plan of Maryland,standard_charge|United Healthcare|UnitedHealthcare Community Plan of Maryland|methodology,additional_payer_notes|United Healthcare|UnitedHealthcare Community Plan of Maryland,standard_charge|United Healthcare|United Healthcare All Commercial|negotiated_dollar,standard_charge|United Healthcare|United Healthcare All Commercial|negotiated_percentage,standard_charge|United Healthcare|United Healthcare All Commercial|negotiated_algorithm,median_amount|United Healthcare|United Healthcare All Commercial,10th_percentile|United Healthcare|United Healthcare All Commercial,90th_percentile|United Healthcare|United Healthcare All Commercial,count|United Healthcare|United Healthcare All Commercial,standard_charge|United Healthcare|United Healthcare All Commercial|methodology,additional_payer_notes|United Healthcare|United Healthcare All Commercial,standard_charge|United Healthcare-Ovations|United Secure|negotiated_dollar,standard_charge|United Healthcare-Ovations|United Secure|negotiated_percentage,standard_charge|United Healthcare-Ovations|United Secure|negotiated_algorithm,median_amount|United Healthcare-Ovations|United Secure,10th_percentile|United Healthcare-Ovations|United Secure,90th_percentile|United Healthcare-Ovations|United Secure,count|United Healthcare-Ovations|United Secure,standard_charge|United Healthcare-Ovations|United Secure|methodology,additional_payer_notes|United Healthcare-Ovations|United Secure,standard_charge|UnitedHealthcare Insurance Company|Optum VA Community Care|negotiated_dollar,standard_charge|UnitedHealthcare Insurance Company|Optum VA Community Care|negotiated_percentage,standard_charge|UnitedHealthcare Insurance Company|Optum VA Community Care|negotiated_algorithm,median_amount|UnitedHealthcare Insurance Company|Optum VA Community Care,10th_percentile|UnitedHealthcare Insurance Company|Optum VA Community Care,90th_percentile|UnitedHealthcare Insurance Company|Optum VA Community Care,count|UnitedHealthcare Insurance Company|Optum VA Community Care,standard_charge|UnitedHealthcare Insurance Company|Optum VA Community Care|methodology,additional_payer_notes|UnitedHealthcare Insurance Company|Optum VA Community Care
PT NDL INS W/O NJX 1 OR 2 MUSC,93400018,CDM,0420,RC,20560,CPT,11,Local,GP  ,outpatient,professional,,,137,137,23.03,116.45,,28.27,,,,,,,fee schedule,Payment capped at billed charges.,68.33,,,,,,,fee schedule,Payment capped at billed charges.,23.71,,,,,,,fee schedule,Payment capped at billed charges.,23.71,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,54.1,,,,,,,fee schedule,Payment capped at billed charges.,27.44,,,,,,,fee schedule,Payment capped at billed charges.,60.11,,,,,,,fee schedule,Payment capped at billed charges.,28.27,,,,,,,fee schedule,Payment capped at billed charges.,73.63,,,,,,,fee schedule,Payment capped at billed charges.,68.5,,,,,,,fee schedule,,29.28,,,,,,,fee schedule,Payment capped at billed charges.,27.89,,,,,,,fee schedule,Payment capped at billed charges.,26.22,,,,,,,fee schedule,Payment capped at billed charges.,28.82,,,,,,,fee schedule,Payment capped at billed charges.,34.58,,,,,,,fee schedule,Payment capped at billed charges.,27.01,,,,,,,fee schedule,Payment capped at billed charges.,23.71,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,116.45,,,,,,,percent of total billed charges,,89.05,,,,,,,percent of total billed charges,,109.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,53.01,,,,,,,fee schedule,Payment capped at billed charges.,63.76,,,,,,,fee schedule,Payment capped at billed charges.,23.03,,,,,,,fee schedule,,71.64,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,,27.89,,,,,,,fee schedule,Payment capped at billed charges.
PT NDL INSJ W/O NJX 3  MUSC,93400026,CDM,0420,RC,20561,CPT,11,Local,GP  ,outpatient,professional,,,137,137,34.25,116.45,,41.23,,,,,,,fee schedule,Payment capped at billed charges.,99.22,,,,,,,fee schedule,Payment capped at billed charges.,34.58,,,,,,,fee schedule,Payment capped at billed charges.,34.58,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,76.7,,,,,,,fee schedule,Payment capped at billed charges.,40.03,,,,,,,fee schedule,Payment capped at billed charges.,85.22,,,,,,,fee schedule,Payment capped at billed charges.,41.23,,,,,,,fee schedule,Payment capped at billed charges.,104.39,,,,,,,fee schedule,Payment capped at billed charges.,68.5,,,,,,,fee schedule,,42.71,,,,,,,fee schedule,Payment capped at billed charges.,40.68,,,,,,,fee schedule,Payment capped at billed charges.,39,,,,,,,fee schedule,Payment capped at billed charges.,42.03,,,,,,,fee schedule,Payment capped at billed charges.,50.44,,,,,,,fee schedule,Payment capped at billed charges.,39.45,,,,,,,fee schedule,Payment capped at billed charges.,34.58,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,116.45,,,,,,,percent of total billed charges,,89.05,,,,,,,percent of total billed charges,,109.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,76.25,,,,,,,fee schedule,Payment capped at billed charges.,91.71,,,,,,,fee schedule,Payment capped at billed charges.,34.25,,,,,,,fee schedule,,103.04,,,,,,,fee schedule,Payment capped at billed charges.,40.83,,,,,,,fee schedule,,40.68,,,,,,,fee schedule,Payment capped at billed charges.
PT BIOFEEDBACK TRAINING,93400034,CDM,0420,RC,90901,CPT,11,Local,GP  ,outpatient,professional,,,141,141,28.82,120.85,,45.84,,,,,,,fee schedule,Payment capped at billed charges.,109.44,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,72,,,,,,,fee schedule,Payment capped at billed charges.,44.51,,,,,,,fee schedule,Payment capped at billed charges.,80.01,,,,,,,fee schedule,Payment capped at billed charges.,45.84,,,,,,,fee schedule,Payment capped at billed charges.,120.5,,,,,,,fee schedule,Payment capped at billed charges.,70.5,,,,,,,fee schedule,,47.49,,,,,,,fee schedule,Payment capped at billed charges.,45.23,,,,,,,fee schedule,Payment capped at billed charges.,32.81,,,,,,,fee schedule,Payment capped at billed charges.,46.73,,,,,,,fee schedule,Payment capped at billed charges.,56.09,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,38.45,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,119.85,,,,,,,percent of total billed charges,,91.65,,,,,,,percent of total billed charges,,43.87,,,,,,,fee schedule,Payment capped at 80% of billed charges.,89.43,,,,,,,fee schedule,Payment capped at billed charges.,107.56,,,,,,,fee schedule,Payment capped at billed charges.,28.82,,,,,,,fee schedule,,120.85,,,,,,,fee schedule,Payment capped at billed charges.,45.4,,,,,,,fee schedule,,45.23,,,,,,,fee schedule,Payment capped at billed charges.
PT BIOFEEDBACK INCONT 1ST15MIN,93400042,CDM,0420,RC,90912,CPT,11,Local,GP  ,outpatient,professional,,,237,237,60,237,,89.78,,,,,,,fee schedule,Payment capped at billed charges.,214.19,,,,,,,fee schedule,Payment capped at billed charges.,75.29,,,,,,,fee schedule,Payment capped at billed charges.,75.29,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,135.24,,,,,,,fee schedule,Payment capped at billed charges.,87.16,,,,,,,fee schedule,Payment capped at billed charges.,150.27,,,,,,,fee schedule,Payment capped at billed charges.,89.78,,,,,,,fee schedule,Payment capped at billed charges.,237,,,,,,,fee schedule,Payment capped at billed charges.,118.5,,,,,,,fee schedule,,93.01,,,,,,,fee schedule,Payment capped at billed charges.,88.58,,,,,,,fee schedule,Payment capped at billed charges.,80.3,,,,,,,fee schedule,Payment capped at billed charges.,91.52,,,,,,,fee schedule,Payment capped at billed charges.,109.84,,,,,,,fee schedule,Payment capped at billed charges.,106.24,,,,,,,fee schedule,Payment capped at billed charges.,75.29,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,201.45,,,,,,,percent of total billed charges,,154.05,,,,,,,percent of total billed charges,,85.91,,,,,,,fee schedule,Payment capped at 80% of billed charges.,175.13,,,,,,,fee schedule,Payment capped at billed charges.,210.63,,,,,,,fee schedule,Payment capped at billed charges.,70.53,,,,,,,fee schedule,,236.66,,,,,,,fee schedule,Payment capped at billed charges.,88.91,,,,,,,fee schedule,,88.58,,,,,,,fee schedule,Payment capped at billed charges.
PT BIOFEEDBACK INCONT ADD15MIN,93400059,CDM,0420,RC,90913,CPT,11,Local,GP  ,outpatient,professional,,,91,91,28.38,91,,35.67,,,,,,,fee schedule,Payment capped at billed charges.,83.99,,,,,,,fee schedule,Payment capped at billed charges.,29.91,,,,,,,fee schedule,Payment capped at billed charges.,29.91,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,53.66,,,,,,,fee schedule,Payment capped at billed charges.,34.63,,,,,,,fee schedule,Payment capped at billed charges.,59.61,,,,,,,fee schedule,Payment capped at billed charges.,35.67,,,,,,,fee schedule,Payment capped at billed charges.,91,,,,,,,fee schedule,Payment capped at billed charges.,45.5,,,,,,,fee schedule,,36.95,,,,,,,fee schedule,Payment capped at billed charges.,35.19,,,,,,,fee schedule,Payment capped at billed charges.,32.32,,,,,,,fee schedule,Payment capped at billed charges.,36.36,,,,,,,fee schedule,Payment capped at billed charges.,43.64,,,,,,,fee schedule,Payment capped at billed charges.,42.94,,,,,,,fee schedule,Payment capped at billed charges.,29.91,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,77.35,,,,,,,percent of total billed charges,,59.15,,,,,,,percent of total billed charges,,34.14,,,,,,,fee schedule,Payment capped at 80% of billed charges.,68.23,,,,,,,fee schedule,Payment capped at billed charges.,82.06,,,,,,,fee schedule,Payment capped at billed charges.,28.38,,,,,,,fee schedule,,91,,,,,,,fee schedule,Payment capped at billed charges.,35.32,,,,,,,fee schedule,,35.19,,,,,,,fee schedule,Payment capped at billed charges.
PT CANALITH REPOSITIONING,93400067,CDM,0420,RC,95992,CPT,11,Local,GP  ,outpatient,professional,,,124,124,33.84,120.98,,46.29,,,,,,,fee schedule,Payment capped at billed charges.,111.9,,,,,,,fee schedule,Payment capped at billed charges.,38.37,,,,,,,fee schedule,Payment capped at billed charges.,38.37,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,80.39,,,,,,,fee schedule,Payment capped at billed charges.,44.94,,,,,,,fee schedule,Payment capped at billed charges.,89.32,,,,,,,fee schedule,Payment capped at billed charges.,46.29,,,,,,,fee schedule,Payment capped at billed charges.,100.95,,,,,,,fee schedule,Payment capped at billed charges.,38.37,,,,,,,fee schedule,,47.95,,,,,,,fee schedule,Payment capped at billed charges.,45.67,,,,,,,fee schedule,Payment capped at billed charges.,38.53,,,,,,,fee schedule,Payment capped at billed charges.,47.19,,,,,,,fee schedule,Payment capped at billed charges.,56.63,,,,,,,fee schedule,Payment capped at billed charges.,45.14,,,,,,,fee schedule,Payment capped at billed charges.,38.37,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,105.4,,,,,,,percent of total billed charges,,80.6,,,,,,,percent of total billed charges,,44.3,,,,,,,fee schedule,Payment capped at 80% of billed charges.,89.53,,,,,,,fee schedule,Payment capped at billed charges.,107.67,,,,,,,fee schedule,Payment capped at billed charges.,33.84,,,,,,,fee schedule,,120.98,,,,,,,fee schedule,Payment capped at billed charges.,45.84,,,,,,,fee schedule,,45.67,,,,,,,fee schedule,Payment capped at billed charges.
PT DEVEL TEST ADMIN 1ST HR,93400075,CDM,0420,RC,96112,CPT,11,Local,GP  ,outpatient,professional,,,378,378,60,354.81,,142.13,,,,,,,fee schedule,Payment capped at billed charges.,319.72,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,235.55,,,,,,,fee schedule,Payment capped at billed charges.,137.99,,,,,,,fee schedule,Payment capped at billed charges.,261.71,,,,,,,fee schedule,Payment capped at billed charges.,142.13,,,,,,,fee schedule,Payment capped at billed charges.,354.81,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,,147.24,,,,,,,fee schedule,Payment capped at billed charges.,140.23,,,,,,,fee schedule,Payment capped at billed charges.,133.03,,,,,,,fee schedule,Payment capped at billed charges.,144.89,,,,,,,fee schedule,Payment capped at billed charges.,173.89,,,,,,,fee schedule,Payment capped at billed charges.,173.96,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,321.3,,,,,,,percent of total billed charges,,245.7,,,,,,,percent of total billed charges,,136.01,,,,,,,fee schedule,Payment capped at 80% of billed charges.,259.02,,,,,,,fee schedule,Payment capped at billed charges.,311.53,,,,,,,fee schedule,Payment capped at billed charges.,116.84,,,,,,,fee schedule,,350.03,,,,,,,fee schedule,Payment capped at billed charges.,140.75,,,,,,,fee schedule,,140.23,,,,,,,fee schedule,Payment capped at billed charges.
PT DEVEL TEST ADMIN EA ADD 30M,93400083,CDM,0420,RC,96113,CPT,11,Local,GP  ,outpatient,professional,,,169,169,49.16,169,,59.31,,,,,,,fee schedule,Payment capped at billed charges.,151.94,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,110.86,,,,,,,fee schedule,Payment capped at billed charges.,57.58,,,,,,,fee schedule,Payment capped at billed charges.,123.18,,,,,,,fee schedule,Payment capped at billed charges.,59.31,,,,,,,fee schedule,Payment capped at billed charges.,168.24,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,,61.45,,,,,,,fee schedule,Payment capped at billed charges.,58.52,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,60.46,,,,,,,fee schedule,Payment capped at billed charges.,72.56,,,,,,,fee schedule,Payment capped at billed charges.,73.04,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,143.65,,,,,,,percent of total billed charges,,109.85,,,,,,,percent of total billed charges,,56.76,,,,,,,fee schedule,Payment capped at 80% of billed charges.,126.01,,,,,,,fee schedule,Payment capped at billed charges.,151.55,,,,,,,fee schedule,Payment capped at billed charges.,55.66,,,,,,,fee schedule,,169,,,,,,,fee schedule,Payment capped at billed charges.,58.74,,,,,,,fee schedule,,58.52,,,,,,,fee schedule,Payment capped at billed charges.
PT TRACTION MECHANICAL,93400091,CDM,0420,RC,97012,CPT,11,Local,GP  ,outpatient,professional,,,41,41,12.92,90,,16.08,,,,,,,fee schedule,Payment capped at billed charges.,37.3,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.64,,,,,,,fee schedule,Payment capped at billed charges.,15.62,,,,,,,fee schedule,Payment capped at billed charges.,24.03,,,,,,,fee schedule,Payment capped at billed charges.,16.08,,,,,,,fee schedule,Payment capped at billed charges.,33.06,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,,16.66,,,,,,,fee schedule,Payment capped at billed charges.,15.87,,,,,,,fee schedule,Payment capped at billed charges.,14.57,,,,,,,fee schedule,Payment capped at billed charges.,16.4,,,,,,,fee schedule,Payment capped at billed charges.,19.68,,,,,,,fee schedule,Payment capped at billed charges.,15.64,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,34.85,,,,,,,percent of total billed charges,,26.65,,,,,,,percent of total billed charges,,15.38,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.08,,,,,,,fee schedule,Payment capped at billed charges.,31.36,,,,,,,fee schedule,Payment capped at billed charges.,12.92,,,,,,,fee schedule,,35.24,,,,,,,fee schedule,Payment capped at billed charges.,15.93,,,,,,,fee schedule,,15.87,,,,,,,fee schedule,Payment capped at billed charges.
PT E-STIM UNATT,93400109,CDM,0420,RC,97014,CPT,11,Local,GP  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,13.86,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
PT E-STIM WOUND CARE UNATTEND,93400117,CDM,0420,RC,97014,CPT,11,Local,GP  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,13.86,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
PT ELEC STIM UNATTENDED,93400125,CDM,0420,RC,97014,CPT,11,Local,GP  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,13.86,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
PT VASOPNEUMATIC DEVICES,93400133,CDM,0420,RC,97016,CPT,11,Local,GP  ,outpatient,professional,,,49,49,10.99,90,,13.27,,,,,,,fee schedule,Payment capped at billed charges.,30.65,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,31.6,,,,,,,fee schedule,Payment capped at billed charges.,12.88,,,,,,,fee schedule,Payment capped at billed charges.,34.95,,,,,,,fee schedule,Payment capped at billed charges.,13.27,,,,,,,fee schedule,Payment capped at billed charges.,27.92,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,,13.74,,,,,,,fee schedule,Payment capped at billed charges.,13.09,,,,,,,fee schedule,Payment capped at billed charges.,14.13,,,,,,,fee schedule,Payment capped at billed charges.,13.52,,,,,,,fee schedule,Payment capped at billed charges.,16.23,,,,,,,fee schedule,Payment capped at billed charges.,12.8,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,41.65,,,,,,,percent of total billed charges,,31.85,,,,,,,percent of total billed charges,,12.69,,,,,,,fee schedule,Payment capped at 80% of billed charges.,21.95,,,,,,,fee schedule,Payment capped at billed charges.,26.4,,,,,,,fee schedule,Payment capped at billed charges.,13.19,,,,,,,fee schedule,,29.66,,,,,,,fee schedule,Payment capped at billed charges.,13.14,,,,,,,fee schedule,,13.09,,,,,,,fee schedule,Payment capped at billed charges.
PT PARAFFIN BATH,93400141,CDM,0420,RC,97018,CPT,11,Local,GP  ,outpatient,professional,,,50,50,5.93,90,,7.16,,,,,,,fee schedule,Payment capped at billed charges.,15.23,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,27.77,,,,,,,fee schedule,Payment capped at billed charges.,6.95,,,,,,,fee schedule,Payment capped at billed charges.,31.12,,,,,,,fee schedule,Payment capped at billed charges.,7.16,,,,,,,fee schedule,Payment capped at billed charges.,13.92,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,,7.41,,,,,,,fee schedule,Payment capped at billed charges.,7.06,,,,,,,fee schedule,Payment capped at billed charges.,6.97,,,,,,,fee schedule,Payment capped at billed charges.,7.29,,,,,,,fee schedule,Payment capped at billed charges.,8.75,,,,,,,fee schedule,Payment capped at billed charges.,6.75,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,42.5,,,,,,,percent of total billed charges,,32.5,,,,,,,percent of total billed charges,,6.85,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,6.51,,,,,,,fee schedule,,,,,,,,,,service not payable,7.09,,,,,,,fee schedule,,7.06,,,,,,,fee schedule,Payment capped at billed charges.
PT MODALTY WHIRLPOOL,93400158,CDM,0420,RC,97022,CPT,11,Local,GP  ,outpatient,professional,,,62,62,14.92,90,,18,,,,,,,fee schedule,Payment capped at billed charges.,45.78,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,29.68,,,,,,,fee schedule,Payment capped at billed charges.,17.48,,,,,,,fee schedule,Payment capped at billed charges.,32.56,,,,,,,fee schedule,Payment capped at billed charges.,18,,,,,,,fee schedule,Payment capped at billed charges.,41.82,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,,18.65,,,,,,,fee schedule,Payment capped at billed charges.,17.76,,,,,,,fee schedule,Payment capped at billed charges.,20.76,,,,,,,fee schedule,Payment capped at billed charges.,18.35,,,,,,,fee schedule,Payment capped at billed charges.,22.02,,,,,,,fee schedule,Payment capped at billed charges.,17.06,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,52.7,,,,,,,percent of total billed charges,,40.3,,,,,,,percent of total billed charges,,17.23,,,,,,,fee schedule,Payment capped at 80% of billed charges.,32.68,,,,,,,fee schedule,Payment capped at billed charges.,39.3,,,,,,,fee schedule,Payment capped at billed charges.,19.19,,,,,,,fee schedule,,44.16,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,17.76,,,,,,,fee schedule,Payment capped at billed charges.
PT E-STIM ATTENDED PER 15 MIN,93400166,CDM,0420,RC,97032,CPT,11,Local,GP  ,outpatient,professional,,,48,48,13.34,90,,16.08,,,,,,,fee schedule,Payment capped at billed charges.,37.3,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,19.61,,,,,,,fee schedule,Payment capped at billed charges.,15.62,,,,,,,fee schedule,Payment capped at billed charges.,21.77,,,,,,,fee schedule,Payment capped at billed charges.,16.08,,,,,,,fee schedule,Payment capped at billed charges.,33.93,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,,16.66,,,,,,,fee schedule,Payment capped at billed charges.,15.87,,,,,,,fee schedule,Payment capped at billed charges.,17.2,,,,,,,fee schedule,Payment capped at billed charges.,16.4,,,,,,,fee schedule,Payment capped at billed charges.,19.68,,,,,,,fee schedule,Payment capped at billed charges.,15.64,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,40.8,,,,,,,percent of total billed charges,,31.2,,,,,,,percent of total billed charges,,15.38,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.75,,,,,,,fee schedule,Payment capped at billed charges.,32.17,,,,,,,fee schedule,Payment capped at billed charges.,15.26,,,,,,,fee schedule,,36.15,,,,,,,fee schedule,Payment capped at billed charges.,15.93,,,,,,,fee schedule,,15.87,,,,,,,fee schedule,Payment capped at billed charges.
PT IONTOPHORESIS EACH 15 M,93400174,CDM,0420,RC,97033,CPT,11,Local,GP  ,outpatient,professional,,,59,59,17.83,90,,21.51,,,,,,,fee schedule,Payment capped at billed charges.,52.19,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,28.38,,,,,,,fee schedule,Payment capped at billed charges.,20.88,,,,,,,fee schedule,Payment capped at billed charges.,31.54,,,,,,,fee schedule,Payment capped at billed charges.,21.51,,,,,,,fee schedule,Payment capped at billed charges.,46.72,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,22.28,,,,,,,fee schedule,Payment capped at billed charges.,21.22,,,,,,,fee schedule,Payment capped at billed charges.,20.1,,,,,,,fee schedule,Payment capped at billed charges.,21.92,,,,,,,fee schedule,Payment capped at billed charges.,26.31,,,,,,,fee schedule,Payment capped at billed charges.,20.61,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,50.15,,,,,,,percent of total billed charges,,38.35,,,,,,,percent of total billed charges,,20.58,,,,,,,fee schedule,Payment capped at 80% of billed charges.,36.67,,,,,,,fee schedule,Payment capped at billed charges.,44.11,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,49.56,,,,,,,fee schedule,Payment capped at billed charges.,21.3,,,,,,,fee schedule,,21.22,,,,,,,fee schedule,Payment capped at billed charges.
PT CONTRAST BATH 1-15MIN,93400182,CDM,0420,RC,97034,CPT,11,Local,GP  ,outpatient,professional,,,45,45,12.83,90,,15.48,,,,,,,fee schedule,Payment capped at billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,18.92,,,,,,,fee schedule,Payment capped at billed charges.,15.03,,,,,,,fee schedule,Payment capped at billed charges.,21.03,,,,,,,fee schedule,Payment capped at billed charges.,15.48,,,,,,,fee schedule,Payment capped at billed charges.,34.43,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,,16.03,,,,,,,fee schedule,Payment capped at billed charges.,15.27,,,,,,,fee schedule,Payment capped at billed charges.,16.3,,,,,,,fee schedule,Payment capped at billed charges.,15.78,,,,,,,fee schedule,Payment capped at billed charges.,18.93,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,38.25,,,,,,,percent of total billed charges,,29.25,,,,,,,percent of total billed charges,,14.81,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.38,,,,,,,fee schedule,Payment capped at billed charges.,31.73,,,,,,,fee schedule,Payment capped at billed charges.,14.45,,,,,,,fee schedule,,35.65,,,,,,,fee schedule,Payment capped at billed charges.,15.33,,,,,,,fee schedule,,15.27,,,,,,,fee schedule,Payment capped at billed charges.
PT ULTRASOUND 15MIN,93400190,CDM,0420,RC,97035,CPT,11,Local,GP  ,outpatient,professional,,,37,37,10.1,90,,15.86,,,,,,,fee schedule,Payment capped at billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,19.26,,,,,,,fee schedule,Payment capped at billed charges.,15.4,,,,,,,fee schedule,Payment capped at billed charges.,21.41,,,,,,,fee schedule,Payment capped at billed charges.,15.86,,,,,,,fee schedule,Payment capped at billed charges.,33.56,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,,16.43,,,,,,,fee schedule,Payment capped at billed charges.,15.65,,,,,,,fee schedule,Payment capped at billed charges.,11.39,,,,,,,fee schedule,Payment capped at billed charges.,16.17,,,,,,,fee schedule,Payment capped at billed charges.,19.41,,,,,,,fee schedule,Payment capped at billed charges.,15.29,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,31.45,,,,,,,percent of total billed charges,,24.05,,,,,,,percent of total billed charges,,15.19,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.38,,,,,,,fee schedule,Payment capped at billed charges.,31.73,,,,,,,fee schedule,Payment capped at billed charges.,10.1,,,,,,,fee schedule,,35.65,,,,,,,fee schedule,Payment capped at billed charges.,15.71,,,,,,,fee schedule,,15.65,,,,,,,fee schedule,Payment capped at billed charges.
PT THER EX EA 15 MIN,93400208,CDM,0420,RC,97110,CPT,11,Local,GP  ,outpatient,professional,,,80,80,27.16,90,,32.78,,,,,,,fee schedule,Payment capped at billed charges.,77.07,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,31.82,,,,,,,fee schedule,Payment capped at billed charges.,42.31,,,,,,,fee schedule,Payment capped at billed charges.,32.78,,,,,,,fee schedule,Payment capped at billed charges.,69.34,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,,33.96,,,,,,,fee schedule,Payment capped at billed charges.,32.34,,,,,,,fee schedule,Payment capped at billed charges.,33.38,,,,,,,fee schedule,Payment capped at billed charges.,33.41,,,,,,,fee schedule,Payment capped at billed charges.,40.1,,,,,,,fee schedule,Payment capped at billed charges.,31.64,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,68,,,,,,,percent of total billed charges,,52,,,,,,,percent of total billed charges,,31.37,,,,,,,fee schedule,Payment capped at 80% of billed charges.,54.01,,,,,,,fee schedule,Payment capped at billed charges.,64.95,,,,,,,fee schedule,Payment capped at billed charges.,29.61,,,,,,,fee schedule,,72.98,,,,,,,fee schedule,Payment capped at billed charges.,32.46,,,,,,,fee schedule,,32.34,,,,,,,fee schedule,Payment capped at billed charges.
PT NEURO RE-ED BAL 15MIN,93400216,CDM,0420,RC,97112,CPT,11,Local,GP  ,outpatient,professional,,,90,90,27.11,90,,36.47,,,,,,,fee schedule,Payment capped at billed charges.,88.64,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,34.24,,,,,,,fee schedule,Payment capped at billed charges.,35.4,,,,,,,fee schedule,Payment capped at billed charges.,40.29,,,,,,,fee schedule,Payment capped at billed charges.,36.47,,,,,,,fee schedule,Payment capped at billed charges.,80.77,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,,37.78,,,,,,,fee schedule,Payment capped at billed charges.,35.98,,,,,,,fee schedule,Payment capped at billed charges.,30.57,,,,,,,fee schedule,Payment capped at billed charges.,37.17,,,,,,,fee schedule,Payment capped at billed charges.,44.62,,,,,,,fee schedule,Payment capped at billed charges.,35.19,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,76.5,,,,,,,percent of total billed charges,,58.5,,,,,,,percent of total billed charges,,34.9,,,,,,,fee schedule,Payment capped at 80% of billed charges.,62.1,,,,,,,fee schedule,Payment capped at billed charges.,74.69,,,,,,,fee schedule,Payment capped at billed charges.,27.11,,,,,,,fee schedule,,83.92,,,,,,,fee schedule,Payment capped at billed charges.,36.11,,,,,,,fee schedule,,35.98,,,,,,,fee schedule,Payment capped at billed charges.
PT AQUA THER W/EXERCISE 15 MIN,93400224,CDM,0420,RC,97113,CPT,11,Local,GP  ,outpatient,professional,,,108,108,34.66,97.33,,42.03,,,,,,,fee schedule,Payment capped at billed charges.,97.33,,,,,,,fee schedule,Payment capped at billed charges.,34.84,,,,,,,fee schedule,Payment capped at billed charges.,34.84,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,47.72,,,,,,,fee schedule,Payment capped at billed charges.,40.81,,,,,,,fee schedule,Payment capped at billed charges.,53.03,,,,,,,fee schedule,Payment capped at billed charges.,42.03,,,,,,,fee schedule,Payment capped at billed charges.,87.92,,,,,,,fee schedule,Payment capped at billed charges.,34.84,,,,,,,fee schedule,,43.54,,,,,,,fee schedule,Payment capped at billed charges.,41.47,,,,,,,fee schedule,Payment capped at billed charges.,39.08,,,,,,,fee schedule,Payment capped at billed charges.,42.85,,,,,,,fee schedule,Payment capped at billed charges.,51.42,,,,,,,fee schedule,Payment capped at billed charges.,40.16,,,,,,,fee schedule,Payment capped at billed charges.,34.84,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,91.8,,,,,,,percent of total billed charges,,70.2,,,,,,,percent of total billed charges,,40.22,,,,,,,fee schedule,Payment capped at 80% of billed charges.,68.11,,,,,,,fee schedule,Payment capped at billed charges.,81.92,,,,,,,fee schedule,Payment capped at billed charges.,34.66,,,,,,,fee schedule,,92.04,,,,,,,fee schedule,Payment capped at billed charges.,41.62,,,,,,,fee schedule,,41.47,,,,,,,fee schedule,Payment capped at billed charges.
PT GAIT TRAINING EA 15 MIN,93400232,CDM,0420,RC,97116,CPT,11,Local,GP  ,outpatient,professional,,,76,76,22.52,90,,32.78,,,,,,,fee schedule,Payment capped at billed charges.,77.07,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,32.08,,,,,,,fee schedule,Payment capped at billed charges.,31.82,,,,,,,fee schedule,Payment capped at billed charges.,35.91,,,,,,,fee schedule,Payment capped at billed charges.,32.78,,,,,,,fee schedule,Payment capped at billed charges.,69.34,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,,33.96,,,,,,,fee schedule,Payment capped at billed charges.,32.34,,,,,,,fee schedule,Payment capped at billed charges.,25.39,,,,,,,fee schedule,Payment capped at billed charges.,33.41,,,,,,,fee schedule,Payment capped at billed charges.,40.1,,,,,,,fee schedule,Payment capped at billed charges.,31.64,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,64.6,,,,,,,percent of total billed charges,,49.4,,,,,,,percent of total billed charges,,31.37,,,,,,,fee schedule,Payment capped at 80% of billed charges.,54.01,,,,,,,fee schedule,Payment capped at billed charges.,64.95,,,,,,,fee schedule,Payment capped at billed charges.,22.52,,,,,,,fee schedule,,72.98,,,,,,,fee schedule,Payment capped at billed charges.,32.46,,,,,,,fee schedule,,32.34,,,,,,,fee schedule,Payment capped at billed charges.
PT COGNITIVE FUNC INTRV 1ST15M,93400240,CDM,0420,RC,97129,CPT,11,Local,GP  ,outpatient,professional,,,72,72,20.09,90,,23.96,,,,,,,fee schedule,Payment capped at billed charges.,56.75,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.09,,,,,,,fee schedule,Payment capped at billed charges.,23.26,,,,,,,fee schedule,Payment capped at billed charges.,41.21,,,,,,,fee schedule,Payment capped at billed charges.,23.96,,,,,,,fee schedule,Payment capped at billed charges.,51.47,,,,,,,fee schedule,Payment capped at billed charges.,36,,,,,,,fee schedule,,24.82,,,,,,,fee schedule,Payment capped at billed charges.,23.64,,,,,,,fee schedule,Payment capped at billed charges.,23.58,,,,,,,fee schedule,Payment capped at billed charges.,24.42,,,,,,,fee schedule,Payment capped at billed charges.,29.31,,,,,,,fee schedule,Payment capped at billed charges.,23.81,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,61.2,,,,,,,percent of total billed charges,,46.8,,,,,,,percent of total billed charges,,22.93,,,,,,,fee schedule,Payment capped at 80% of billed charges.,39.95,,,,,,,fee schedule,Payment capped at billed charges.,48.05,,,,,,,fee schedule,Payment capped at billed charges.,20.71,,,,,,,fee schedule,,53.99,,,,,,,fee schedule,Payment capped at billed charges.,23.73,,,,,,,fee schedule,,23.64,,,,,,,fee schedule,Payment capped at billed charges.
PT UNLISTED PM R,93400257,CDM,0420,RC,97139,CPT,11,Local,GP  ,outpatient,professional,,,65,65,6.23,90,,14.1,,,,,,,fee schedule,Payment capped at billed charges.,33.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.85,,,,,,,fee schedule,Payment capped at billed charges.,32.5,,,,,,,fee schedule,,,,,,,,,,,42.25,,,,,,,fee schedule,Payment capped at billed charges.,15.39,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,6.23,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,55.25,,,,,,,percent of total billed charges,,42.25,,,,,,,percent of total billed charges,,52,,,,,,,fee schedule,Payment capped at 80% of billed charges.,42.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,13.51,,,,,,,fee schedule,,,,,,,,,,,22.75,,,,,,,fee schedule,,65,,,,,,,fee schedule,Payment capped at billed charges.
PT MANUAL THER EA 15 MIN,93400265,CDM,0420,RC,97140,CPT,11,Local,GP  ,outpatient,professional,,,74,74,23.92,90,,30.91,,,,,,,fee schedule,Payment capped at billed charges.,70.75,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.38,,,,,,,fee schedule,Payment capped at billed charges.,30.01,,,,,,,fee schedule,Payment capped at billed charges.,39.31,,,,,,,fee schedule,Payment capped at billed charges.,30.91,,,,,,,fee schedule,Payment capped at billed charges.,63.56,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,,32.02,,,,,,,fee schedule,Payment capped at billed charges.,30.5,,,,,,,fee schedule,Payment capped at billed charges.,26.97,,,,,,,fee schedule,Payment capped at billed charges.,31.51,,,,,,,fee schedule,Payment capped at billed charges.,37.82,,,,,,,fee schedule,Payment capped at billed charges.,29.86,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,62.9,,,,,,,percent of total billed charges,,48.1,,,,,,,percent of total billed charges,,29.59,,,,,,,fee schedule,Payment capped at 80% of billed charges.,49.59,,,,,,,fee schedule,Payment capped at billed charges.,59.64,,,,,,,fee schedule,Payment capped at billed charges.,23.92,,,,,,,fee schedule,,67.01,,,,,,,fee schedule,Payment capped at billed charges.,30.61,,,,,,,fee schedule,,30.5,,,,,,,fee schedule,Payment capped at billed charges.
PT THERAPEUTIC PROCEDURES GRP,93400273,CDM,0423,RC,97150,CPT,11,Local,GP  ,outpatient,professional,,,46,46,16.42,90,,19.81,,,,,,,fee schedule,Payment capped at billed charges.,46.2,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.54,,,,,,,fee schedule,Payment capped at billed charges.,19.24,,,,,,,fee schedule,Payment capped at billed charges.,23.94,,,,,,,fee schedule,Payment capped at billed charges.,19.81,,,,,,,fee schedule,Payment capped at billed charges.,41.18,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,,20.53,,,,,,,fee schedule,Payment capped at billed charges.,19.55,,,,,,,fee schedule,Payment capped at billed charges.,20.99,,,,,,,fee schedule,Payment capped at billed charges.,20.2,,,,,,,fee schedule,Payment capped at billed charges.,24.24,,,,,,,fee schedule,Payment capped at billed charges.,17.27,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,39.1,,,,,,,percent of total billed charges,,29.9,,,,,,,percent of total billed charges,,18.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,33.04,,,,,,,fee schedule,Payment capped at billed charges.,39.74,,,,,,,fee schedule,Payment capped at billed charges.,18.62,,,,,,,fee schedule,,44.65,,,,,,,fee schedule,Payment capped at billed charges.,19.62,,,,,,,fee schedule,,19.55,,,,,,,fee schedule,Payment capped at billed charges.
PT EVAL LOW COMPLEX,93400281,CDM,0424,RC,97161,CPT,11,Local,GP  ,outpatient,professional,,,262,262,60,262.63,,111.56,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,131.12,,,,,,,fee schedule,Payment capped at billed charges.,108.31,,,,,,,fee schedule,Payment capped at billed charges.,145.69,,,,,,,fee schedule,Payment capped at billed charges.,111.56,,,,,,,fee schedule,Payment capped at billed charges.,235.81,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,,115.57,,,,,,,fee schedule,Payment capped at billed charges.,110.07,,,,,,,fee schedule,Payment capped at billed charges.,79.58,,,,,,,fee schedule,Payment capped at billed charges.,113.72,,,,,,,fee schedule,Payment capped at billed charges.,136.49,,,,,,,fee schedule,Payment capped at billed charges.,107.7,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,106.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,184.7,,,,,,,fee schedule,Payment capped at billed charges.,222.14,,,,,,,fee schedule,Payment capped at billed charges.,70.58,,,,,,,fee schedule,,249.59,,,,,,,fee schedule,Payment capped at billed charges.,110.48,,,,,,,fee schedule,,110.07,,,,,,,fee schedule,Payment capped at billed charges.
PT EVAL MOD COMPLEX,93400299,CDM,0424,RC,97162,CPT,11,Local,GP  ,outpatient,professional,,,262,262,60,262.63,,111.56,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,134.89,,,,,,,fee schedule,Payment capped at billed charges.,108.31,,,,,,,fee schedule,Payment capped at billed charges.,149.89,,,,,,,fee schedule,Payment capped at billed charges.,111.56,,,,,,,fee schedule,Payment capped at billed charges.,235.81,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,,115.57,,,,,,,fee schedule,Payment capped at billed charges.,110.07,,,,,,,fee schedule,Payment capped at billed charges.,79.58,,,,,,,fee schedule,Payment capped at billed charges.,113.72,,,,,,,fee schedule,Payment capped at billed charges.,136.49,,,,,,,fee schedule,Payment capped at billed charges.,107.7,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,106.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,184.7,,,,,,,fee schedule,Payment capped at billed charges.,222.14,,,,,,,fee schedule,Payment capped at billed charges.,70.58,,,,,,,fee schedule,,249.59,,,,,,,fee schedule,Payment capped at billed charges.,110.48,,,,,,,fee schedule,,110.07,,,,,,,fee schedule,Payment capped at billed charges.
PT EVAL HIGH COMPLEX,93400307,CDM,0424,RC,97163,CPT,11,Local,GP  ,outpatient,professional,,,262,262,60,262.63,,111.56,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,142.82,,,,,,,fee schedule,Payment capped at billed charges.,108.31,,,,,,,fee schedule,Payment capped at billed charges.,158.7,,,,,,,fee schedule,Payment capped at billed charges.,111.56,,,,,,,fee schedule,Payment capped at billed charges.,235.81,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,,115.57,,,,,,,fee schedule,Payment capped at billed charges.,110.07,,,,,,,fee schedule,Payment capped at billed charges.,79.58,,,,,,,fee schedule,Payment capped at billed charges.,113.72,,,,,,,fee schedule,Payment capped at billed charges.,136.49,,,,,,,fee schedule,Payment capped at billed charges.,107.7,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,106.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,184.7,,,,,,,fee schedule,Payment capped at billed charges.,222.14,,,,,,,fee schedule,Payment capped at billed charges.,70.58,,,,,,,fee schedule,,249.59,,,,,,,fee schedule,Payment capped at billed charges.,110.48,,,,,,,fee schedule,,110.07,,,,,,,fee schedule,Payment capped at billed charges.
PT RE-EVAL EST PLAN CARE,93400315,CDM,0424,RC,97164,CPT,11,Local,GP  ,outpatient,professional,,,183,183,48.13,183.43,,77.41,,,,,,,fee schedule,Payment capped at billed charges.,183.43,,,,,,,fee schedule,Payment capped at billed charges.,64.16,,,,,,,fee schedule,Payment capped at billed charges.,64.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,91.06,,,,,,,fee schedule,Payment capped at billed charges.,75.16,,,,,,,fee schedule,Payment capped at billed charges.,101.19,,,,,,,fee schedule,Payment capped at billed charges.,77.41,,,,,,,fee schedule,Payment capped at billed charges.,163.77,,,,,,,fee schedule,Payment capped at billed charges.,64.16,,,,,,,fee schedule,,80.2,,,,,,,fee schedule,Payment capped at billed charges.,76.38,,,,,,,fee schedule,Payment capped at billed charges.,54.27,,,,,,,fee schedule,Payment capped at billed charges.,78.92,,,,,,,fee schedule,Payment capped at billed charges.,94.71,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,64.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,155.55,,,,,,,percent of total billed charges,,118.95,,,,,,,percent of total billed charges,,74.08,,,,,,,fee schedule,Payment capped at 80% of billed charges.,129.05,,,,,,,fee schedule,Payment capped at billed charges.,155.21,,,,,,,fee schedule,Payment capped at billed charges.,48.13,,,,,,,fee schedule,,174.39,,,,,,,fee schedule,Payment capped at billed charges.,76.66,,,,,,,fee schedule,,76.38,,,,,,,fee schedule,Payment capped at billed charges.
PT THER ACT EA 15 MIN,93400323,CDM,0420,RC,97530,CPT,11,Local,GP  ,outpatient,professional,,,102,102,31.17,98.75,,39.86,,,,,,,fee schedule,Payment capped at billed charges.,98.75,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,38.7,,,,,,,fee schedule,Payment capped at billed charges.,42.5,,,,,,,fee schedule,Payment capped at billed charges.,39.86,,,,,,,fee schedule,Payment capped at billed charges.,89.29,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,,41.3,,,,,,,fee schedule,Payment capped at billed charges.,39.33,,,,,,,fee schedule,Payment capped at billed charges.,35.14,,,,,,,fee schedule,Payment capped at billed charges.,40.64,,,,,,,fee schedule,Payment capped at billed charges.,48.77,,,,,,,fee schedule,Payment capped at billed charges.,38.04,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,86.7,,,,,,,percent of total billed charges,,66.3,,,,,,,percent of total billed charges,,38.15,,,,,,,fee schedule,Payment capped at 80% of billed charges.,68.41,,,,,,,fee schedule,Payment capped at billed charges.,82.27,,,,,,,fee schedule,Payment capped at billed charges.,31.17,,,,,,,fee schedule,,92.44,,,,,,,fee schedule,Payment capped at billed charges.,39.47,,,,,,,fee schedule,,39.33,,,,,,,fee schedule,Payment capped at billed charges.
PT SENSORY INTEGRATON EA15 MIN,93400331,CDM,0420,RC,97533,CPT,11,Local,GP  ,outpatient,professional,,,172,172,23.32,172.37,,70.95,,,,,,,fee schedule,Payment capped at billed charges.,172.37,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,49.69,,,,,,,fee schedule,Payment capped at billed charges.,68.88,,,,,,,fee schedule,Payment capped at billed charges.,55.21,,,,,,,fee schedule,Payment capped at billed charges.,70.95,,,,,,,fee schedule,Payment capped at billed charges.,158.57,,,,,,,fee schedule,Payment capped at billed charges.,86,,,,,,,fee schedule,,73.5,,,,,,,fee schedule,Payment capped at billed charges.,70,,,,,,,fee schedule,Payment capped at billed charges.,26.29,,,,,,,fee schedule,Payment capped at billed charges.,72.32,,,,,,,fee schedule,Payment capped at billed charges.,86.8,,,,,,,fee schedule,Payment capped at billed charges.,66.46,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,146.2,,,,,,,percent of total billed charges,,111.8,,,,,,,percent of total billed charges,,67.9,,,,,,,fee schedule,Payment capped at 80% of billed charges.,118.27,,,,,,,fee schedule,Payment capped at billed charges.,142.25,,,,,,,fee schedule,Payment capped at billed charges.,23.32,,,,,,,fee schedule,,159.83,,,,,,,fee schedule,Payment capped at billed charges.,70.26,,,,,,,fee schedule,,70,,,,,,,fee schedule,Payment capped at billed charges.
PT ADL SELF CARE/HOME IND 15M,93400349,CDM,0420,RC,97535,CPT,11,Local,GP  ,outpatient,professional,,,86,86,27.98,90,,36.69,,,,,,,fee schedule,Payment capped at billed charges.,86.43,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,35.62,,,,,,,fee schedule,Payment capped at billed charges.,39.26,,,,,,,fee schedule,Payment capped at billed charges.,36.69,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,,38.01,,,,,,,fee schedule,Payment capped at billed charges.,36.2,,,,,,,fee schedule,Payment capped at billed charges.,31.54,,,,,,,fee schedule,Payment capped at billed charges.,37.4,,,,,,,fee schedule,Payment capped at billed charges.,44.89,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,30.41,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,73.1,,,,,,,percent of total billed charges,,55.9,,,,,,,percent of total billed charges,,35.11,,,,,,,fee schedule,Payment capped at 80% of billed charges.,60.51,,,,,,,fee schedule,Payment capped at billed charges.,72.78,,,,,,,fee schedule,Payment capped at billed charges.,27.98,,,,,,,fee schedule,,81.77,,,,,,,fee schedule,Payment capped at billed charges.,36.33,,,,,,,fee schedule,,36.2,,,,,,,fee schedule,Payment capped at billed charges.
PT COM/WORK REINTEG 15M,93400356,CDM,0420,RC,97537,CPT,11,Local,GP  ,outpatient,professional,,,84,84,24.2,90,,36.16,,,,,,,fee schedule,Payment capped at billed charges.,83.26,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,35.11,,,,,,,fee schedule,Payment capped at billed charges.,39.26,,,,,,,fee schedule,Payment capped at billed charges.,36.16,,,,,,,fee schedule,Payment capped at billed charges.,74.98,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,,37.46,,,,,,,fee schedule,Payment capped at billed charges.,35.68,,,,,,,fee schedule,Payment capped at billed charges.,27.29,,,,,,,fee schedule,Payment capped at billed charges.,36.86,,,,,,,fee schedule,Payment capped at billed charges.,44.24,,,,,,,fee schedule,Payment capped at billed charges.,33.39,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,71.4,,,,,,,percent of total billed charges,,54.6,,,,,,,percent of total billed charges,,67.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,58.34,,,,,,,fee schedule,Payment capped at billed charges.,70.17,,,,,,,fee schedule,Payment capped at billed charges.,24.2,,,,,,,fee schedule,,78.84,,,,,,,fee schedule,Payment capped at billed charges.,35.81,,,,,,,fee schedule,,35.68,,,,,,,fee schedule,Payment capped at billed charges.
PT WHEELCHAIR MGMT 15M,93400364,CDM,0420,RC,97542,CPT,11,Local,GP  ,outpatient,professional,,,83,83,27.74,90,,35,,,,,,,fee schedule,Payment capped at billed charges.,83.26,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,29.68,,,,,,,fee schedule,Payment capped at billed charges.,33.98,,,,,,,fee schedule,Payment capped at billed charges.,32.56,,,,,,,fee schedule,Payment capped at billed charges.,35,,,,,,,fee schedule,Payment capped at billed charges.,74.98,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,,36.26,,,,,,,fee schedule,Payment capped at billed charges.,34.53,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,35.68,,,,,,,fee schedule,Payment capped at billed charges.,42.82,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,70.55,,,,,,,percent of total billed charges,,53.95,,,,,,,percent of total billed charges,,33.49,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,27.74,,,,,,,fee schedule,,,,,,,,,,service not payable,34.66,,,,,,,fee schedule,,34.53,,,,,,,fee schedule,Payment capped at billed charges.
PT WRK HARD CONDT 2 HRS,93400372,CDM,0420,RC,97545,CPT,11,Local,GP  ,outpatient,professional,,,413,413,10.61,413,,136.09,,,,,,,fee schedule,Payment capped at billed charges.,326.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,326.53,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,362.8,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,412.96,,,,,,,fee schedule,Payment capped at billed charges.,206.5,,,,,,,fee schedule,,,,,,,,,,,268.45,,,,,,,fee schedule,Payment capped at billed charges.,12.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,351.05,,,,,,,percent of total billed charges,,268.45,,,,,,,percent of total billed charges,,330.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,313.44,,,,,,,fee schedule,Payment capped at billed charges.,376.98,,,,,,,fee schedule,Payment capped at billed charges.,10.61,,,,,,,fee schedule,,413,,,,,,,fee schedule,Payment capped at billed charges.,144.55,,,,,,,fee schedule,,263.01,,,,,,,fee schedule,Payment capped at billed charges.
PT WORK HARD COND ADD HR,93400380,CDM,0420,RC,97546,CPT,11,Local,GP  ,outpatient,professional,,,184,184,54.22,181.41,,54.22,,,,,,,fee schedule,Payment capped at billed charges.,130,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,163.27,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,181.41,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,163.16,,,,,,,fee schedule,Payment capped at billed charges.,92,,,,,,,fee schedule,,,,,,,,,,,119.6,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,156.4,,,,,,,percent of total billed charges,,119.6,,,,,,,percent of total billed charges,,147.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,124.99,,,,,,,fee schedule,Payment capped at billed charges.,150.33,,,,,,,fee schedule,Payment capped at billed charges.,62.56,,,,,,,fee schedule,,168.91,,,,,,,fee schedule,Payment capped at billed charges.,64.4,,,,,,,fee schedule,,77.76,,,,,,,fee schedule,Payment capped at billed charges.
PT SELECT DEBRIDE1ST20SQCMLESS,93400398,CDM,0420,RC,97597,CPT,11,Local,GP  ,outpatient,professional,,,273,273,60,273,,113.39,,,,,,,fee schedule,Payment capped at billed charges.,273,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,94.83,,,,,,,fee schedule,Payment capped at billed charges.,110.09,,,,,,,fee schedule,Payment capped at billed charges.,105.38,,,,,,,fee schedule,Payment capped at billed charges.,113.39,,,,,,,fee schedule,Payment capped at billed charges.,251.6,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,,117.47,,,,,,,fee schedule,Payment capped at billed charges.,111.88,,,,,,,fee schedule,Payment capped at billed charges.,68.79,,,,,,,fee schedule,Payment capped at billed charges.,115.59,,,,,,,fee schedule,Payment capped at billed charges.,138.73,,,,,,,fee schedule,Payment capped at billed charges.,106.27,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,232.05,,,,,,,percent of total billed charges,,177.45,,,,,,,percent of total billed charges,,108.53,,,,,,,fee schedule,Payment capped at 80% of billed charges.,191.65,,,,,,,fee schedule,Payment capped at billed charges.,230.5,,,,,,,fee schedule,Payment capped at billed charges.,60.42,,,,,,,fee schedule,,258.99,,,,,,,fee schedule,Payment capped at billed charges.,112.29,,,,,,,fee schedule,,111.88,,,,,,,fee schedule,Payment capped at billed charges.
PT SELECT DEBRIDE EA ADD20SQCM,93400406,CDM,0420,RC,97598,CPT,11,Local,GP  ,outpatient,professional,,,138,138,25.94,133.51,,50.11,,,,,,,fee schedule,Payment capped at billed charges.,119.66,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,120.17,,,,,,,fee schedule,Payment capped at billed charges.,48.65,,,,,,,fee schedule,Payment capped at billed charges.,133.51,,,,,,,fee schedule,Payment capped at billed charges.,50.11,,,,,,,fee schedule,Payment capped at billed charges.,110.28,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,,51.91,,,,,,,fee schedule,Payment capped at billed charges.,49.44,,,,,,,fee schedule,Payment capped at billed charges.,29.53,,,,,,,fee schedule,Payment capped at billed charges.,51.08,,,,,,,fee schedule,Payment capped at billed charges.,61.31,,,,,,,fee schedule,Payment capped at billed charges.,47.63,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,117.3,,,,,,,percent of total billed charges,,89.7,,,,,,,percent of total billed charges,,47.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,84.19,,,,,,,fee schedule,Payment capped at billed charges.,101.26,,,,,,,fee schedule,Payment capped at billed charges.,25.94,,,,,,,fee schedule,,113.77,,,,,,,fee schedule,Payment capped at billed charges.,49.62,,,,,,,fee schedule,,49.44,,,,,,,fee schedule,Payment capped at billed charges.
PT PHYSICAL PERF TEST EA 15MIN,93400414,CDM,0420,RC,97750,CPT,11,Local,GP  ,outpatient,professional,,,90,90,26.23,90,,38.25,,,,,,,fee schedule,Payment capped at billed charges.,89.26,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,54.58,,,,,,,fee schedule,Payment capped at billed charges.,37.14,,,,,,,fee schedule,Payment capped at billed charges.,60.32,,,,,,,fee schedule,Payment capped at billed charges.,38.25,,,,,,,fee schedule,Payment capped at billed charges.,79.68,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,,39.63,,,,,,,fee schedule,Payment capped at billed charges.,37.74,,,,,,,fee schedule,Payment capped at billed charges.,29.58,,,,,,,fee schedule,Payment capped at billed charges.,38.99,,,,,,,fee schedule,Payment capped at billed charges.,46.8,,,,,,,fee schedule,Payment capped at billed charges.,36.61,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,76.5,,,,,,,percent of total billed charges,,58.5,,,,,,,percent of total billed charges,,36.61,,,,,,,fee schedule,Payment capped at 80% of billed charges.,63.12,,,,,,,fee schedule,Payment capped at billed charges.,75.92,,,,,,,fee schedule,Payment capped at billed charges.,26.23,,,,,,,fee schedule,,85.3,,,,,,,fee schedule,Payment capped at billed charges.,37.88,,,,,,,fee schedule,,37.74,,,,,,,fee schedule,Payment capped at billed charges.
PT ASSISTIVE TECHN ASSES 15MIN,93400422,CDM,0420,RC,97755,CPT,11,Local,GP  ,outpatient,professional,,,100,100,28.23,100.32,,42.57,,,,,,,fee schedule,Payment capped at billed charges.,100.32,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,64.84,,,,,,,fee schedule,Payment capped at billed charges.,41.33,,,,,,,fee schedule,Payment capped at billed charges.,72.04,,,,,,,fee schedule,Payment capped at billed charges.,42.57,,,,,,,fee schedule,Payment capped at billed charges.,88.72,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,,44.1,,,,,,,fee schedule,Payment capped at billed charges.,42,,,,,,,fee schedule,Payment capped at billed charges.,31.83,,,,,,,fee schedule,Payment capped at billed charges.,43.39,,,,,,,fee schedule,Payment capped at billed charges.,52.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,35.28,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,85,,,,,,,percent of total billed charges,,65,,,,,,,percent of total billed charges,,40.74,,,,,,,fee schedule,Payment capped at 80% of billed charges.,70.33,,,,,,,fee schedule,Payment capped at billed charges.,84.59,,,,,,,fee schedule,Payment capped at billed charges.,28.23,,,,,,,fee schedule,,95.04,,,,,,,fee schedule,Payment capped at billed charges.,42.15,,,,,,,fee schedule,,42,,,,,,,fee schedule,Payment capped at billed charges.
PT ORTH FIT/TRAIN INIT EA15MIN,93400430,CDM,0420,RC,97760,CPT,11,Local,GP  ,outpatient,professional,,,130,130,42.87,129.92,,53.27,,,,,,,fee schedule,Payment capped at billed charges.,129.92,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,48.3,,,,,,,fee schedule,Payment capped at billed charges.,51.72,,,,,,,fee schedule,Payment capped at billed charges.,53.68,,,,,,,fee schedule,Payment capped at billed charges.,53.27,,,,,,,fee schedule,Payment capped at billed charges.,117.81,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,,55.19,,,,,,,fee schedule,Payment capped at billed charges.,52.56,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,54.3,,,,,,,fee schedule,Payment capped at billed charges.,65.17,,,,,,,fee schedule,Payment capped at billed charges.,50.48,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,110.5,,,,,,,percent of total billed charges,,84.5,,,,,,,percent of total billed charges,,50.98,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,42.87,,,,,,,fee schedule,,,,,,,,,,service not payable,52.75,,,,,,,fee schedule,,52.56,,,,,,,fee schedule,Payment capped at billed charges.
PT PROSTH TRAIN INIT EA 15MIN,93400448,CDM,0420,RC,97761,CPT,11,Local,GP  ,outpatient,professional,,,111,111,36.5,111.16,,46.63,,,,,,,fee schedule,Payment capped at billed charges.,111.16,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,48.01,,,,,,,fee schedule,Payment capped at billed charges.,45.27,,,,,,,fee schedule,Payment capped at billed charges.,53.33,,,,,,,fee schedule,Payment capped at billed charges.,46.63,,,,,,,fee schedule,Payment capped at billed charges.,99.72,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,,48.31,,,,,,,fee schedule,Payment capped at billed charges.,46.01,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,47.54,,,,,,,fee schedule,Payment capped at billed charges.,57.05,,,,,,,fee schedule,Payment capped at billed charges.,44.42,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,94.35,,,,,,,percent of total billed charges,,72.15,,,,,,,percent of total billed charges,,44.62,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,36.5,,,,,,,fee schedule,,,,,,,,,,service not payable,46.18,,,,,,,fee schedule,,46.01,,,,,,,fee schedule,Payment capped at billed charges.
PT ORTH/PROS SUBS ENC EA15MIN,93400455,CDM,0420,RC,97763,CPT,11,Local,GP  ,outpatient,professional,,,144,144,47.77,143.3,,58.44,,,,,,,fee schedule,Payment capped at billed charges.,143.3,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,67.68,,,,,,,fee schedule,Payment capped at billed charges.,56.74,,,,,,,fee schedule,Payment capped at billed charges.,75.2,,,,,,,fee schedule,Payment capped at billed charges.,58.44,,,,,,,fee schedule,Payment capped at billed charges.,131.86,,,,,,,fee schedule,Payment capped at billed charges.,72,,,,,,,fee schedule,,60.54,,,,,,,fee schedule,Payment capped at billed charges.,57.66,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,59.57,,,,,,,fee schedule,Payment capped at billed charges.,71.5,,,,,,,fee schedule,Payment capped at billed charges.,55.1,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,122.4,,,,,,,percent of total billed charges,,93.6,,,,,,,percent of total billed charges,,55.93,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,47.77,,,,,,,fee schedule,,,,,,,,,,service not payable,57.87,,,,,,,fee schedule,,57.66,,,,,,,fee schedule,Payment capped at billed charges.
PT DRIVING EVAL,93400463,CDM,0420,RC,97799,CPT,11,Local,GP  ,outpatient,professional,,,350,350,20.2,350,,,,,,,,,,service not payable,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.5,,,,,,,fee schedule,Payment capped at billed charges.,175,,,,,,,fee schedule,,,,,,,,,,,227.5,,,,,,,fee schedule,Payment capped at billed charges.,23,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,297.5,,,,,,,percent of total billed charges,,227.5,,,,,,,percent of total billed charges,,280,,,,,,,fee schedule,Payment capped at 80% of billed charges.,227.5,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,20.2,,,,,,,fee schedule,,,,,,,,,,,122.5,,,,,,,fee schedule,,350,,,,,,,fee schedule,Payment capped at billed charges.
OT BIOFEEDBACK TRAIN ANY METH,93400471,CDM,0430,RC,90901,CPT,11,Local,GO  ,outpatient,professional,,,141,141,28.82,120.85,,45.84,,,,,,,fee schedule,Payment capped at billed charges.,109.44,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,72,,,,,,,fee schedule,Payment capped at billed charges.,44.51,,,,,,,fee schedule,Payment capped at billed charges.,80.01,,,,,,,fee schedule,Payment capped at billed charges.,45.84,,,,,,,fee schedule,Payment capped at billed charges.,120.5,,,,,,,fee schedule,Payment capped at billed charges.,70.5,,,,,,,fee schedule,,47.49,,,,,,,fee schedule,Payment capped at billed charges.,58.8,,,,,,,fee schedule,Payment capped at billed charges.,32.81,,,,,,,fee schedule,Payment capped at billed charges.,46.73,,,,,,,fee schedule,Payment capped at billed charges.,56.09,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,38.45,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,119.85,,,,,,,percent of total billed charges,,91.65,,,,,,,percent of total billed charges,,43.87,,,,,,,fee schedule,Payment capped at 80% of billed charges.,89.43,,,,,,,fee schedule,Payment capped at billed charges.,107.56,,,,,,,fee schedule,Payment capped at billed charges.,28.82,,,,,,,fee schedule,,120.85,,,,,,,fee schedule,Payment capped at billed charges.,45.4,,,,,,,fee schedule,,45.23,,,,,,,fee schedule,Payment capped at billed charges.
OT DEVEL TEST ADMIN 1ST HR,93400489,CDM,0430,RC,96112,CPT,11,Local,GO  ,outpatient,professional,,,378,378,60,354.81,,142.13,,,,,,,fee schedule,Payment capped at billed charges.,319.72,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,235.55,,,,,,,fee schedule,Payment capped at billed charges.,137.99,,,,,,,fee schedule,Payment capped at billed charges.,261.71,,,,,,,fee schedule,Payment capped at billed charges.,142.13,,,,,,,fee schedule,Payment capped at billed charges.,354.81,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,,147.24,,,,,,,fee schedule,Payment capped at billed charges.,182.3,,,,,,,fee schedule,Payment capped at billed charges.,133.03,,,,,,,fee schedule,Payment capped at billed charges.,144.89,,,,,,,fee schedule,Payment capped at billed charges.,173.89,,,,,,,fee schedule,Payment capped at billed charges.,173.96,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,321.3,,,,,,,percent of total billed charges,,245.7,,,,,,,percent of total billed charges,,136.01,,,,,,,fee schedule,Payment capped at 80% of billed charges.,259.02,,,,,,,fee schedule,Payment capped at billed charges.,311.53,,,,,,,fee schedule,Payment capped at billed charges.,116.84,,,,,,,fee schedule,,350.03,,,,,,,fee schedule,Payment capped at billed charges.,140.75,,,,,,,fee schedule,,140.23,,,,,,,fee schedule,Payment capped at billed charges.
OT DEVEL TEST ADMIN EA ADD 30M,93400497,CDM,0430,RC,96113,CPT,11,Local,GO  ,outpatient,professional,,,169,169,49.16,169,,59.31,,,,,,,fee schedule,Payment capped at billed charges.,151.94,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,110.86,,,,,,,fee schedule,Payment capped at billed charges.,57.58,,,,,,,fee schedule,Payment capped at billed charges.,123.18,,,,,,,fee schedule,Payment capped at billed charges.,59.31,,,,,,,fee schedule,Payment capped at billed charges.,168.24,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,,61.45,,,,,,,fee schedule,Payment capped at billed charges.,76.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,60.46,,,,,,,fee schedule,Payment capped at billed charges.,72.56,,,,,,,fee schedule,Payment capped at billed charges.,73.04,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,143.65,,,,,,,percent of total billed charges,,109.85,,,,,,,percent of total billed charges,,56.76,,,,,,,fee schedule,Payment capped at 80% of billed charges.,126.01,,,,,,,fee schedule,Payment capped at billed charges.,151.55,,,,,,,fee schedule,Payment capped at billed charges.,55.66,,,,,,,fee schedule,,169,,,,,,,fee schedule,Payment capped at billed charges.,58.74,,,,,,,fee schedule,,58.52,,,,,,,fee schedule,Payment capped at billed charges.
OT COG PERF TEST PER HR,93400505,CDM,0434,RC,96125,CPT,11,Local,GO  ,outpatient,professional,,,305,305,60,297.27,,112.79,,,,,,,fee schedule,Payment capped at billed charges.,265.41,,,,,,,fee schedule,Payment capped at billed charges.,94.6,,,,,,,fee schedule,Payment capped at billed charges.,94.6,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,226.03,,,,,,,fee schedule,Payment capped at billed charges.,109.51,,,,,,,fee schedule,Payment capped at billed charges.,251.15,,,,,,,fee schedule,Payment capped at billed charges.,112.79,,,,,,,fee schedule,Payment capped at billed charges.,297.27,,,,,,,fee schedule,Payment capped at billed charges.,152.5,,,,,,,fee schedule,,116.85,,,,,,,fee schedule,Payment capped at billed charges.,144.68,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,114.98,,,,,,,fee schedule,Payment capped at billed charges.,138,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,94.6,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,259.25,,,,,,,percent of total billed charges,,198.25,,,,,,,percent of total billed charges,,107.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,217.4,,,,,,,fee schedule,Payment capped at billed charges.,261.46,,,,,,,fee schedule,Payment capped at billed charges.,90.19,,,,,,,fee schedule,,293.78,,,,,,,fee schedule,Payment capped at billed charges.,111.7,,,,,,,fee schedule,,111.29,,,,,,,fee schedule,Payment capped at billed charges.
OT MECHANICAL TRACTION THERAPY,93400513,CDM,0430,RC,97012,CPT,11,Local,GO  ,outpatient,professional,,,41,41,12.92,90,,16.08,,,,,,,fee schedule,Payment capped at billed charges.,37.3,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.64,,,,,,,fee schedule,Payment capped at billed charges.,15.62,,,,,,,fee schedule,Payment capped at billed charges.,24.03,,,,,,,fee schedule,Payment capped at billed charges.,16.08,,,,,,,fee schedule,Payment capped at billed charges.,33.06,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,,16.66,,,,,,,fee schedule,Payment capped at billed charges.,20.63,,,,,,,fee schedule,Payment capped at billed charges.,14.57,,,,,,,fee schedule,Payment capped at billed charges.,16.4,,,,,,,fee schedule,Payment capped at billed charges.,19.68,,,,,,,fee schedule,Payment capped at billed charges.,15.64,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,34.85,,,,,,,percent of total billed charges,,26.65,,,,,,,percent of total billed charges,,15.38,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.08,,,,,,,fee schedule,Payment capped at billed charges.,31.36,,,,,,,fee schedule,Payment capped at billed charges.,12.92,,,,,,,fee schedule,,35.24,,,,,,,fee schedule,Payment capped at billed charges.,15.93,,,,,,,fee schedule,,15.87,,,,,,,fee schedule,Payment capped at billed charges.
OT E-STIM UNATT,93400521,CDM,0430,RC,97014,CPT,11,Local,GO  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,18.02,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
OT E-STIM WOUND CARE UNATTEND,93400539,CDM,0430,RC,97014,CPT,11,Local,GO  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,18.02,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
OT E-STIM NOT WND PART TX PLAN,93400547,CDM,0430,RC,97014,CPT,11,Local,GO  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,18.02,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
OT VASOPNEUMATIC DEVICES,93400554,CDM,0430,RC,97016,CPT,11,Local,GO  ,outpatient,professional,,,49,49,10.99,90,,13.27,,,,,,,fee schedule,Payment capped at billed charges.,30.65,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,31.6,,,,,,,fee schedule,Payment capped at billed charges.,12.88,,,,,,,fee schedule,Payment capped at billed charges.,34.95,,,,,,,fee schedule,Payment capped at billed charges.,13.27,,,,,,,fee schedule,Payment capped at billed charges.,27.92,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,,13.74,,,,,,,fee schedule,Payment capped at billed charges.,17.02,,,,,,,fee schedule,Payment capped at billed charges.,14.13,,,,,,,fee schedule,Payment capped at billed charges.,13.52,,,,,,,fee schedule,Payment capped at billed charges.,16.23,,,,,,,fee schedule,Payment capped at billed charges.,12.8,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,41.65,,,,,,,percent of total billed charges,,31.85,,,,,,,percent of total billed charges,,12.69,,,,,,,fee schedule,Payment capped at 80% of billed charges.,21.95,,,,,,,fee schedule,Payment capped at billed charges.,26.4,,,,,,,fee schedule,Payment capped at billed charges.,13.19,,,,,,,fee schedule,,29.66,,,,,,,fee schedule,Payment capped at billed charges.,13.14,,,,,,,fee schedule,,13.09,,,,,,,fee schedule,Payment capped at billed charges.
OT PARAFFIN BATH,93400562,CDM,0430,RC,97018,CPT,11,Local,GO  ,outpatient,professional,,,50,50,5.93,90,,7.16,,,,,,,fee schedule,Payment capped at billed charges.,15.23,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,27.77,,,,,,,fee schedule,Payment capped at billed charges.,6.95,,,,,,,fee schedule,Payment capped at billed charges.,31.12,,,,,,,fee schedule,Payment capped at billed charges.,7.16,,,,,,,fee schedule,Payment capped at billed charges.,13.92,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,,7.41,,,,,,,fee schedule,Payment capped at billed charges.,9.18,,,,,,,fee schedule,Payment capped at billed charges.,6.97,,,,,,,fee schedule,Payment capped at billed charges.,7.29,,,,,,,fee schedule,Payment capped at billed charges.,8.75,,,,,,,fee schedule,Payment capped at billed charges.,6.75,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,42.5,,,,,,,percent of total billed charges,,32.5,,,,,,,percent of total billed charges,,6.85,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,6.51,,,,,,,fee schedule,,,,,,,,,,service not payable,7.09,,,,,,,fee schedule,,7.06,,,,,,,fee schedule,Payment capped at billed charges.
OT MODALTY WHIRLPOOL,93400570,CDM,0430,RC,97022,CPT,11,Local,GO  ,outpatient,professional,,,62,62,14.92,90,,18,,,,,,,fee schedule,Payment capped at billed charges.,45.78,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,29.68,,,,,,,fee schedule,Payment capped at billed charges.,17.48,,,,,,,fee schedule,Payment capped at billed charges.,32.56,,,,,,,fee schedule,Payment capped at billed charges.,18,,,,,,,fee schedule,Payment capped at billed charges.,41.82,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,,18.65,,,,,,,fee schedule,Payment capped at billed charges.,23.09,,,,,,,fee schedule,Payment capped at billed charges.,20.76,,,,,,,fee schedule,Payment capped at billed charges.,18.35,,,,,,,fee schedule,Payment capped at billed charges.,22.02,,,,,,,fee schedule,Payment capped at billed charges.,17.06,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,52.7,,,,,,,percent of total billed charges,,40.3,,,,,,,percent of total billed charges,,17.23,,,,,,,fee schedule,Payment capped at 80% of billed charges.,32.68,,,,,,,fee schedule,Payment capped at billed charges.,39.3,,,,,,,fee schedule,Payment capped at billed charges.,19.19,,,,,,,fee schedule,,44.16,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,17.76,,,,,,,fee schedule,Payment capped at billed charges.
OT E-STIM ATTENDED PER 15 MIN,93400588,CDM,0430,RC,97032,CPT,11,Local,GO  ,outpatient,professional,,,48,48,13.34,90,,16.08,,,,,,,fee schedule,Payment capped at billed charges.,37.3,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,19.61,,,,,,,fee schedule,Payment capped at billed charges.,15.62,,,,,,,fee schedule,Payment capped at billed charges.,21.77,,,,,,,fee schedule,Payment capped at billed charges.,16.08,,,,,,,fee schedule,Payment capped at billed charges.,33.93,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,,16.66,,,,,,,fee schedule,Payment capped at billed charges.,20.63,,,,,,,fee schedule,Payment capped at billed charges.,17.2,,,,,,,fee schedule,Payment capped at billed charges.,16.4,,,,,,,fee schedule,Payment capped at billed charges.,19.68,,,,,,,fee schedule,Payment capped at billed charges.,15.64,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,40.8,,,,,,,percent of total billed charges,,31.2,,,,,,,percent of total billed charges,,15.38,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.75,,,,,,,fee schedule,Payment capped at billed charges.,32.17,,,,,,,fee schedule,Payment capped at billed charges.,15.26,,,,,,,fee schedule,,36.15,,,,,,,fee schedule,Payment capped at billed charges.,15.93,,,,,,,fee schedule,,15.87,,,,,,,fee schedule,Payment capped at billed charges.
OT IONTOPHERESIS 15 MIN,93400596,CDM,0430,RC,97033,CPT,11,Local,GO  ,outpatient,professional,,,59,59,17.83,90,,21.51,,,,,,,fee schedule,Payment capped at billed charges.,52.19,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,28.38,,,,,,,fee schedule,Payment capped at billed charges.,20.88,,,,,,,fee schedule,Payment capped at billed charges.,31.54,,,,,,,fee schedule,Payment capped at billed charges.,21.51,,,,,,,fee schedule,Payment capped at billed charges.,46.72,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,22.28,,,,,,,fee schedule,Payment capped at billed charges.,27.59,,,,,,,fee schedule,Payment capped at billed charges.,20.1,,,,,,,fee schedule,Payment capped at billed charges.,21.92,,,,,,,fee schedule,Payment capped at billed charges.,26.31,,,,,,,fee schedule,Payment capped at billed charges.,20.61,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,50.15,,,,,,,percent of total billed charges,,38.35,,,,,,,percent of total billed charges,,20.58,,,,,,,fee schedule,Payment capped at 80% of billed charges.,36.67,,,,,,,fee schedule,Payment capped at billed charges.,44.11,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,49.56,,,,,,,fee schedule,Payment capped at billed charges.,21.3,,,,,,,fee schedule,,21.22,,,,,,,fee schedule,Payment capped at billed charges.
OT CONTRAST BATH THERAPY,93400604,CDM,0430,RC,97034,CPT,11,Local,GO  ,outpatient,professional,,,45,45,12.83,90,,15.48,,,,,,,fee schedule,Payment capped at billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,18.92,,,,,,,fee schedule,Payment capped at billed charges.,15.03,,,,,,,fee schedule,Payment capped at billed charges.,21.03,,,,,,,fee schedule,Payment capped at billed charges.,15.48,,,,,,,fee schedule,Payment capped at billed charges.,34.43,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,,16.03,,,,,,,fee schedule,Payment capped at billed charges.,19.85,,,,,,,fee schedule,Payment capped at billed charges.,16.3,,,,,,,fee schedule,Payment capped at billed charges.,15.78,,,,,,,fee schedule,Payment capped at billed charges.,18.93,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,38.25,,,,,,,percent of total billed charges,,29.25,,,,,,,percent of total billed charges,,14.81,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.38,,,,,,,fee schedule,Payment capped at billed charges.,31.73,,,,,,,fee schedule,Payment capped at billed charges.,14.45,,,,,,,fee schedule,,35.65,,,,,,,fee schedule,Payment capped at billed charges.,15.33,,,,,,,fee schedule,,15.27,,,,,,,fee schedule,Payment capped at billed charges.
OT ULTRASOUND 15MIN,93400612,CDM,0430,RC,97035,CPT,11,Local,GO  ,outpatient,professional,,,37,37,10.1,90,,15.86,,,,,,,fee schedule,Payment capped at billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,19.26,,,,,,,fee schedule,Payment capped at billed charges.,15.4,,,,,,,fee schedule,Payment capped at billed charges.,21.41,,,,,,,fee schedule,Payment capped at billed charges.,15.86,,,,,,,fee schedule,Payment capped at billed charges.,33.56,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,,16.43,,,,,,,fee schedule,Payment capped at billed charges.,20.35,,,,,,,fee schedule,Payment capped at billed charges.,11.39,,,,,,,fee schedule,Payment capped at billed charges.,16.17,,,,,,,fee schedule,Payment capped at billed charges.,19.41,,,,,,,fee schedule,Payment capped at billed charges.,15.29,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,31.45,,,,,,,percent of total billed charges,,24.05,,,,,,,percent of total billed charges,,15.19,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.38,,,,,,,fee schedule,Payment capped at billed charges.,31.73,,,,,,,fee schedule,Payment capped at billed charges.,10.1,,,,,,,fee schedule,,35.65,,,,,,,fee schedule,Payment capped at billed charges.,15.71,,,,,,,fee schedule,,15.65,,,,,,,fee schedule,Payment capped at billed charges.
OT THER EX EA 15 MIN,93400620,CDM,0430,RC,97110,CPT,11,Local,GO  ,outpatient,professional,,,80,80,27.16,90,,32.78,,,,,,,fee schedule,Payment capped at billed charges.,77.07,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,31.82,,,,,,,fee schedule,Payment capped at billed charges.,42.31,,,,,,,fee schedule,Payment capped at billed charges.,32.78,,,,,,,fee schedule,Payment capped at billed charges.,69.34,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,,33.96,,,,,,,fee schedule,Payment capped at billed charges.,42.04,,,,,,,fee schedule,Payment capped at billed charges.,33.38,,,,,,,fee schedule,Payment capped at billed charges.,33.41,,,,,,,fee schedule,Payment capped at billed charges.,40.1,,,,,,,fee schedule,Payment capped at billed charges.,31.64,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,68,,,,,,,percent of total billed charges,,52,,,,,,,percent of total billed charges,,31.37,,,,,,,fee schedule,Payment capped at 80% of billed charges.,54.01,,,,,,,fee schedule,Payment capped at billed charges.,64.95,,,,,,,fee schedule,Payment capped at billed charges.,29.61,,,,,,,fee schedule,,72.98,,,,,,,fee schedule,Payment capped at billed charges.,32.46,,,,,,,fee schedule,,32.34,,,,,,,fee schedule,Payment capped at billed charges.
OT NEURO RE-ED BAL 15MIN,93400638,CDM,0430,RC,97112,CPT,11,Local,GO  ,outpatient,professional,,,90,90,27.11,90,,36.47,,,,,,,fee schedule,Payment capped at billed charges.,88.64,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,34.24,,,,,,,fee schedule,Payment capped at billed charges.,35.4,,,,,,,fee schedule,Payment capped at billed charges.,40.29,,,,,,,fee schedule,Payment capped at billed charges.,36.47,,,,,,,fee schedule,Payment capped at billed charges.,80.77,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,,37.78,,,,,,,fee schedule,Payment capped at billed charges.,46.77,,,,,,,fee schedule,Payment capped at billed charges.,30.57,,,,,,,fee schedule,Payment capped at billed charges.,37.17,,,,,,,fee schedule,Payment capped at billed charges.,44.62,,,,,,,fee schedule,Payment capped at billed charges.,35.19,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,76.5,,,,,,,percent of total billed charges,,58.5,,,,,,,percent of total billed charges,,34.9,,,,,,,fee schedule,Payment capped at 80% of billed charges.,62.1,,,,,,,fee schedule,Payment capped at billed charges.,74.69,,,,,,,fee schedule,Payment capped at billed charges.,27.11,,,,,,,fee schedule,,83.92,,,,,,,fee schedule,Payment capped at billed charges.,36.11,,,,,,,fee schedule,,35.98,,,,,,,fee schedule,Payment capped at billed charges.
OT COGNITIVE FUNC INTRV 1ST15M,93400646,CDM,0430,RC,97129,CPT,11,Local,GO  ,outpatient,professional,,,72,72,20.09,90,,23.96,,,,,,,fee schedule,Payment capped at billed charges.,56.75,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.09,,,,,,,fee schedule,Payment capped at billed charges.,23.26,,,,,,,fee schedule,Payment capped at billed charges.,41.21,,,,,,,fee schedule,Payment capped at billed charges.,23.96,,,,,,,fee schedule,Payment capped at billed charges.,51.47,,,,,,,fee schedule,Payment capped at billed charges.,36,,,,,,,fee schedule,,24.82,,,,,,,fee schedule,Payment capped at billed charges.,30.73,,,,,,,fee schedule,Payment capped at billed charges.,23.58,,,,,,,fee schedule,Payment capped at billed charges.,24.42,,,,,,,fee schedule,Payment capped at billed charges.,29.31,,,,,,,fee schedule,Payment capped at billed charges.,23.81,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,61.2,,,,,,,percent of total billed charges,,46.8,,,,,,,percent of total billed charges,,22.93,,,,,,,fee schedule,Payment capped at 80% of billed charges.,39.95,,,,,,,fee schedule,Payment capped at billed charges.,48.05,,,,,,,fee schedule,Payment capped at billed charges.,20.71,,,,,,,fee schedule,,53.99,,,,,,,fee schedule,Payment capped at billed charges.,23.73,,,,,,,fee schedule,,23.64,,,,,,,fee schedule,Payment capped at billed charges.
OT COGNITIVE FUNC INTRV ADD15M,93400653,CDM,0430,RC,97130,CPT,11,Local,GO  ,outpatient,professional,,,72,72,19.18,90,,22.88,,,,,,,fee schedule,Payment capped at billed charges.,54.18,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,22.21,,,,,,,fee schedule,Payment capped at billed charges.,39.37,,,,,,,fee schedule,Payment capped at billed charges.,22.88,,,,,,,fee schedule,Payment capped at billed charges.,50,,,,,,,fee schedule,Payment capped at billed charges.,36,,,,,,,fee schedule,,23.7,,,,,,,fee schedule,Payment capped at billed charges.,29.34,,,,,,,fee schedule,Payment capped at billed charges.,22.53,,,,,,,fee schedule,Payment capped at billed charges.,23.32,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,22.75,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,61.2,,,,,,,percent of total billed charges,,46.8,,,,,,,percent of total billed charges,,21.89,,,,,,,fee schedule,Payment capped at 80% of billed charges.,38.15,,,,,,,fee schedule,Payment capped at billed charges.,45.88,,,,,,,fee schedule,Payment capped at billed charges.,19.79,,,,,,,fee schedule,,51.55,,,,,,,fee schedule,Payment capped at billed charges.,22.65,,,,,,,fee schedule,,22.57,,,,,,,fee schedule,Payment capped at billed charges.
OT UNLISTED PM R,93400661,CDM,0430,RC,97139,CPT,11,Local,GO  ,outpatient,professional,,,65,65,6.23,90,,14.1,,,,,,,fee schedule,Payment capped at billed charges.,33.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.85,,,,,,,fee schedule,Payment capped at billed charges.,32.5,,,,,,,fee schedule,,,,,,,,,,,42.25,,,,,,,fee schedule,Payment capped at billed charges.,15.39,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,6.23,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,55.25,,,,,,,percent of total billed charges,,42.25,,,,,,,percent of total billed charges,,52,,,,,,,fee schedule,Payment capped at 80% of billed charges.,42.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,13.51,,,,,,,fee schedule,,,,,,,,,,,22.75,,,,,,,fee schedule,,65,,,,,,,fee schedule,Payment capped at billed charges.
OT MANUAL THER EA 15 MIN,93400679,CDM,0430,RC,97140,CPT,11,Local,GO  ,outpatient,professional,,,74,74,23.92,90,,30.91,,,,,,,fee schedule,Payment capped at billed charges.,70.75,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.38,,,,,,,fee schedule,Payment capped at billed charges.,30.01,,,,,,,fee schedule,Payment capped at billed charges.,39.31,,,,,,,fee schedule,Payment capped at billed charges.,30.91,,,,,,,fee schedule,Payment capped at billed charges.,63.56,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,,32.02,,,,,,,fee schedule,Payment capped at billed charges.,39.65,,,,,,,fee schedule,Payment capped at billed charges.,26.97,,,,,,,fee schedule,Payment capped at billed charges.,31.51,,,,,,,fee schedule,Payment capped at billed charges.,37.82,,,,,,,fee schedule,Payment capped at billed charges.,29.86,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,62.9,,,,,,,percent of total billed charges,,48.1,,,,,,,percent of total billed charges,,29.59,,,,,,,fee schedule,Payment capped at 80% of billed charges.,49.59,,,,,,,fee schedule,Payment capped at billed charges.,59.64,,,,,,,fee schedule,Payment capped at billed charges.,23.92,,,,,,,fee schedule,,67.01,,,,,,,fee schedule,Payment capped at billed charges.,30.61,,,,,,,fee schedule,,30.5,,,,,,,fee schedule,Payment capped at billed charges.
OT THERAPEUTIC PROCEDURES GRP,93400687,CDM,0433,RC,97150,CPT,11,Local,GO  ,outpatient,professional,,,46,46,16.42,90,,19.81,,,,,,,fee schedule,Payment capped at billed charges.,46.2,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.54,,,,,,,fee schedule,Payment capped at billed charges.,19.24,,,,,,,fee schedule,Payment capped at billed charges.,23.94,,,,,,,fee schedule,Payment capped at billed charges.,19.81,,,,,,,fee schedule,Payment capped at billed charges.,41.18,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,,20.53,,,,,,,fee schedule,Payment capped at billed charges.,25.42,,,,,,,fee schedule,Payment capped at billed charges.,20.99,,,,,,,fee schedule,Payment capped at billed charges.,20.2,,,,,,,fee schedule,Payment capped at billed charges.,24.24,,,,,,,fee schedule,Payment capped at billed charges.,17.27,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,39.1,,,,,,,percent of total billed charges,,29.9,,,,,,,percent of total billed charges,,18.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,33.04,,,,,,,fee schedule,Payment capped at billed charges.,39.74,,,,,,,fee schedule,Payment capped at billed charges.,18.62,,,,,,,fee schedule,,44.65,,,,,,,fee schedule,Payment capped at billed charges.,19.62,,,,,,,fee schedule,,19.55,,,,,,,fee schedule,Payment capped at billed charges.
OT EVAL LOW COMPLEX,93400695,CDM,0434,RC,97165,CPT,11,Local,GO  ,outpatient,professional,,,262,262,60,262.63,,114.69,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,135.05,,,,,,,fee schedule,Payment capped at billed charges.,111.35,,,,,,,fee schedule,Payment capped at billed charges.,150.06,,,,,,,fee schedule,Payment capped at billed charges.,114.69,,,,,,,fee schedule,Payment capped at billed charges.,237.54,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,,118.82,,,,,,,fee schedule,Payment capped at billed charges.,147.11,,,,,,,fee schedule,Payment capped at billed charges.,77.06,,,,,,,fee schedule,Payment capped at billed charges.,116.92,,,,,,,fee schedule,Payment capped at billed charges.,140.32,,,,,,,fee schedule,Payment capped at billed charges.,110.55,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,109.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,186.65,,,,,,,fee schedule,Payment capped at billed charges.,224.48,,,,,,,fee schedule,Payment capped at billed charges.,68.35,,,,,,,fee schedule,,252.23,,,,,,,fee schedule,Payment capped at billed charges.,113.58,,,,,,,fee schedule,,113.16,,,,,,,fee schedule,Payment capped at billed charges.
OT EVAL MOD COMPLEX,93400703,CDM,0434,RC,97166,CPT,11,Local,GO  ,outpatient,professional,,,262,262,60,262.63,,114.69,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,132.1,,,,,,,fee schedule,Payment capped at billed charges.,111.35,,,,,,,fee schedule,Payment capped at billed charges.,146.77,,,,,,,fee schedule,Payment capped at billed charges.,114.69,,,,,,,fee schedule,Payment capped at billed charges.,237.54,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,,118.82,,,,,,,fee schedule,Payment capped at billed charges.,147.11,,,,,,,fee schedule,Payment capped at billed charges.,77.06,,,,,,,fee schedule,Payment capped at billed charges.,116.92,,,,,,,fee schedule,Payment capped at billed charges.,140.32,,,,,,,fee schedule,Payment capped at billed charges.,110.55,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,109.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,186.65,,,,,,,fee schedule,Payment capped at billed charges.,224.48,,,,,,,fee schedule,Payment capped at billed charges.,68.35,,,,,,,fee schedule,,252.23,,,,,,,fee schedule,Payment capped at billed charges.,113.58,,,,,,,fee schedule,,113.16,,,,,,,fee schedule,Payment capped at billed charges.
OT EVAL HIGH COMPLEX,93400711,CDM,0434,RC,97167,CPT,11,Local,GO  ,outpatient,professional,,,262,262,60,262.63,,114.69,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,138.15,,,,,,,fee schedule,Payment capped at billed charges.,111.35,,,,,,,fee schedule,Payment capped at billed charges.,153.49,,,,,,,fee schedule,Payment capped at billed charges.,114.69,,,,,,,fee schedule,Payment capped at billed charges.,237.54,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,,118.82,,,,,,,fee schedule,Payment capped at billed charges.,147.11,,,,,,,fee schedule,Payment capped at billed charges.,77.06,,,,,,,fee schedule,Payment capped at billed charges.,116.92,,,,,,,fee schedule,Payment capped at billed charges.,140.32,,,,,,,fee schedule,Payment capped at billed charges.,110.55,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,109.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,186.65,,,,,,,fee schedule,Payment capped at billed charges.,224.48,,,,,,,fee schedule,Payment capped at billed charges.,68.35,,,,,,,fee schedule,,252.23,,,,,,,fee schedule,Payment capped at billed charges.,113.58,,,,,,,fee schedule,,113.16,,,,,,,fee schedule,Payment capped at billed charges.
OT RE-EVAL EST PLAN CARE,93400729,CDM,0434,RC,97168,CPT,11,Local,GO  ,outpatient,professional,,,183,183,45.23,182.49,,79.74,,,,,,,fee schedule,Payment capped at billed charges.,182.49,,,,,,,fee schedule,Payment capped at billed charges.,66.09,,,,,,,fee schedule,Payment capped at billed charges.,66.09,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,91.56,,,,,,,fee schedule,Payment capped at billed charges.,77.42,,,,,,,fee schedule,Payment capped at billed charges.,101.72,,,,,,,fee schedule,Payment capped at billed charges.,79.74,,,,,,,fee schedule,Payment capped at billed charges.,164.63,,,,,,,fee schedule,Payment capped at billed charges.,66.09,,,,,,,fee schedule,,82.61,,,,,,,fee schedule,Payment capped at billed charges.,102.28,,,,,,,fee schedule,Payment capped at billed charges.,50.99,,,,,,,fee schedule,Payment capped at billed charges.,81.29,,,,,,,fee schedule,Payment capped at billed charges.,97.56,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,66.09,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,155.55,,,,,,,percent of total billed charges,,118.95,,,,,,,percent of total billed charges,,76.32,,,,,,,fee schedule,Payment capped at 80% of billed charges.,129.7,,,,,,,fee schedule,Payment capped at billed charges.,155.99,,,,,,,fee schedule,Payment capped at billed charges.,45.23,,,,,,,fee schedule,,175.27,,,,,,,fee schedule,Payment capped at billed charges.,78.97,,,,,,,fee schedule,,78.68,,,,,,,fee schedule,Payment capped at billed charges.
OT THER ACT EA 15 MIN,93400737,CDM,0430,RC,97530,CPT,11,Local,GO  ,outpatient,professional,,,102,102,31.17,98.75,,39.86,,,,,,,fee schedule,Payment capped at billed charges.,98.75,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,38.7,,,,,,,fee schedule,Payment capped at billed charges.,42.5,,,,,,,fee schedule,Payment capped at billed charges.,39.86,,,,,,,fee schedule,Payment capped at billed charges.,89.29,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,,41.3,,,,,,,fee schedule,Payment capped at billed charges.,51.13,,,,,,,fee schedule,Payment capped at billed charges.,35.14,,,,,,,fee schedule,Payment capped at billed charges.,40.64,,,,,,,fee schedule,Payment capped at billed charges.,48.77,,,,,,,fee schedule,Payment capped at billed charges.,38.04,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,86.7,,,,,,,percent of total billed charges,,66.3,,,,,,,percent of total billed charges,,38.15,,,,,,,fee schedule,Payment capped at 80% of billed charges.,68.41,,,,,,,fee schedule,Payment capped at billed charges.,82.27,,,,,,,fee schedule,Payment capped at billed charges.,31.17,,,,,,,fee schedule,,92.44,,,,,,,fee schedule,Payment capped at billed charges.,39.47,,,,,,,fee schedule,,39.33,,,,,,,fee schedule,Payment capped at billed charges.
OT SENSORY INTEGRATION EA15MIN,93400745,CDM,0430,RC,97533,CPT,11,Local,GO  ,outpatient,professional,,,172,172,23.32,172.37,,70.95,,,,,,,fee schedule,Payment capped at billed charges.,172.37,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,49.69,,,,,,,fee schedule,Payment capped at billed charges.,68.88,,,,,,,fee schedule,Payment capped at billed charges.,55.21,,,,,,,fee schedule,Payment capped at billed charges.,70.95,,,,,,,fee schedule,Payment capped at billed charges.,158.57,,,,,,,fee schedule,Payment capped at billed charges.,86,,,,,,,fee schedule,,73.5,,,,,,,fee schedule,Payment capped at billed charges.,91,,,,,,,fee schedule,Payment capped at billed charges.,26.29,,,,,,,fee schedule,Payment capped at billed charges.,72.32,,,,,,,fee schedule,Payment capped at billed charges.,86.8,,,,,,,fee schedule,Payment capped at billed charges.,66.46,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,146.2,,,,,,,percent of total billed charges,,111.8,,,,,,,percent of total billed charges,,67.9,,,,,,,fee schedule,Payment capped at 80% of billed charges.,118.27,,,,,,,fee schedule,Payment capped at billed charges.,142.25,,,,,,,fee schedule,Payment capped at billed charges.,23.32,,,,,,,fee schedule,,159.83,,,,,,,fee schedule,Payment capped at billed charges.,70.26,,,,,,,fee schedule,,70,,,,,,,fee schedule,Payment capped at billed charges.
OT ADL SELF CARE/HOME MGT 15M,93400752,CDM,0430,RC,97535,CPT,11,Local,GO  ,outpatient,professional,,,86,86,27.98,90,,36.69,,,,,,,fee schedule,Payment capped at billed charges.,86.43,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,35.62,,,,,,,fee schedule,Payment capped at billed charges.,39.26,,,,,,,fee schedule,Payment capped at billed charges.,36.69,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,,38.01,,,,,,,fee schedule,Payment capped at billed charges.,47.06,,,,,,,fee schedule,Payment capped at billed charges.,31.54,,,,,,,fee schedule,Payment capped at billed charges.,37.4,,,,,,,fee schedule,Payment capped at billed charges.,44.89,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,30.41,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,73.1,,,,,,,percent of total billed charges,,55.9,,,,,,,percent of total billed charges,,35.11,,,,,,,fee schedule,Payment capped at 80% of billed charges.,60.51,,,,,,,fee schedule,Payment capped at billed charges.,72.78,,,,,,,fee schedule,Payment capped at billed charges.,27.98,,,,,,,fee schedule,,81.77,,,,,,,fee schedule,Payment capped at billed charges.,36.33,,,,,,,fee schedule,,36.2,,,,,,,fee schedule,Payment capped at billed charges.
OT COM/WORK REINTEG 15M,93400760,CDM,0430,RC,97537,CPT,11,Local,GO  ,outpatient,professional,,,84,84,24.2,90,,36.16,,,,,,,fee schedule,Payment capped at billed charges.,83.26,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,35.11,,,,,,,fee schedule,Payment capped at billed charges.,39.26,,,,,,,fee schedule,Payment capped at billed charges.,36.16,,,,,,,fee schedule,Payment capped at billed charges.,74.98,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,,37.46,,,,,,,fee schedule,Payment capped at billed charges.,46.38,,,,,,,fee schedule,Payment capped at billed charges.,27.29,,,,,,,fee schedule,Payment capped at billed charges.,36.86,,,,,,,fee schedule,Payment capped at billed charges.,44.24,,,,,,,fee schedule,Payment capped at billed charges.,33.39,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,71.4,,,,,,,percent of total billed charges,,54.6,,,,,,,percent of total billed charges,,67.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,58.34,,,,,,,fee schedule,Payment capped at billed charges.,70.17,,,,,,,fee schedule,Payment capped at billed charges.,24.2,,,,,,,fee schedule,,78.84,,,,,,,fee schedule,Payment capped at billed charges.,35.81,,,,,,,fee schedule,,35.68,,,,,,,fee schedule,Payment capped at billed charges.
OT WHEELCHAIR MGMT EA 15MIN,93400778,CDM,0430,RC,97542,CPT,11,Local,GO  ,outpatient,professional,,,83,83,27.74,90,,35,,,,,,,fee schedule,Payment capped at billed charges.,83.26,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,29.68,,,,,,,fee schedule,Payment capped at billed charges.,33.98,,,,,,,fee schedule,Payment capped at billed charges.,32.56,,,,,,,fee schedule,Payment capped at billed charges.,35,,,,,,,fee schedule,Payment capped at billed charges.,74.98,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,,36.26,,,,,,,fee schedule,Payment capped at billed charges.,44.89,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,35.68,,,,,,,fee schedule,Payment capped at billed charges.,42.82,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,70.55,,,,,,,percent of total billed charges,,53.95,,,,,,,percent of total billed charges,,33.49,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,27.74,,,,,,,fee schedule,,,,,,,,,,service not payable,34.66,,,,,,,fee schedule,,34.53,,,,,,,fee schedule,Payment capped at billed charges.
OT WORK HARDENING,93400786,CDM,0430,RC,97545,CPT,11,Local,GO  ,outpatient,professional,,,413,413,10.61,413,,136.09,,,,,,,fee schedule,Payment capped at billed charges.,326.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,326.53,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,362.8,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,412.96,,,,,,,fee schedule,Payment capped at billed charges.,206.5,,,,,,,fee schedule,,,,,,,,,,,268.45,,,,,,,fee schedule,Payment capped at billed charges.,12.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,351.05,,,,,,,percent of total billed charges,,268.45,,,,,,,percent of total billed charges,,330.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,313.44,,,,,,,fee schedule,Payment capped at billed charges.,376.98,,,,,,,fee schedule,Payment capped at billed charges.,10.61,,,,,,,fee schedule,,413,,,,,,,fee schedule,Payment capped at billed charges.,144.55,,,,,,,fee schedule,,263.01,,,,,,,fee schedule,Payment capped at billed charges.
OT WORK HARDENING ADD ON,93400794,CDM,0430,RC,97546,CPT,11,Local,GO  ,outpatient,professional,,,184,184,54.22,181.41,,54.22,,,,,,,fee schedule,Payment capped at billed charges.,130,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,163.27,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,181.41,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,163.16,,,,,,,fee schedule,Payment capped at billed charges.,92,,,,,,,fee schedule,,,,,,,,,,,119.6,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,156.4,,,,,,,percent of total billed charges,,119.6,,,,,,,percent of total billed charges,,147.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,124.99,,,,,,,fee schedule,Payment capped at billed charges.,150.33,,,,,,,fee schedule,Payment capped at billed charges.,62.56,,,,,,,fee schedule,,168.91,,,,,,,fee schedule,Payment capped at billed charges.,64.4,,,,,,,fee schedule,,77.76,,,,,,,fee schedule,Payment capped at billed charges.
OT SELECT DEBRID 1ST20SQCMLESS,93400802,CDM,0430,RC,97597,CPT,11,Local,GO  ,outpatient,professional,,,273,273,60,273,,113.39,,,,,,,fee schedule,Payment capped at billed charges.,273,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,94.83,,,,,,,fee schedule,Payment capped at billed charges.,110.09,,,,,,,fee schedule,Payment capped at billed charges.,105.38,,,,,,,fee schedule,Payment capped at billed charges.,113.39,,,,,,,fee schedule,Payment capped at billed charges.,251.6,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,,117.47,,,,,,,fee schedule,Payment capped at billed charges.,145.44,,,,,,,fee schedule,Payment capped at billed charges.,68.79,,,,,,,fee schedule,Payment capped at billed charges.,115.59,,,,,,,fee schedule,Payment capped at billed charges.,138.73,,,,,,,fee schedule,Payment capped at billed charges.,106.27,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,232.05,,,,,,,percent of total billed charges,,177.45,,,,,,,percent of total billed charges,,108.53,,,,,,,fee schedule,Payment capped at 80% of billed charges.,191.65,,,,,,,fee schedule,Payment capped at billed charges.,230.5,,,,,,,fee schedule,Payment capped at billed charges.,60.42,,,,,,,fee schedule,,258.99,,,,,,,fee schedule,Payment capped at billed charges.,112.29,,,,,,,fee schedule,,111.88,,,,,,,fee schedule,Payment capped at billed charges.
OT SELECT DEBRIDE EA ADD20SQCM,93400810,CDM,0430,RC,97598,CPT,11,Local,GO  ,outpatient,professional,,,138,138,25.94,133.51,,50.11,,,,,,,fee schedule,Payment capped at billed charges.,119.66,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,120.17,,,,,,,fee schedule,Payment capped at billed charges.,48.65,,,,,,,fee schedule,Payment capped at billed charges.,133.51,,,,,,,fee schedule,Payment capped at billed charges.,50.11,,,,,,,fee schedule,Payment capped at billed charges.,110.28,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,,51.91,,,,,,,fee schedule,Payment capped at billed charges.,64.27,,,,,,,fee schedule,Payment capped at billed charges.,29.53,,,,,,,fee schedule,Payment capped at billed charges.,51.08,,,,,,,fee schedule,Payment capped at billed charges.,61.31,,,,,,,fee schedule,Payment capped at billed charges.,47.63,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,117.3,,,,,,,percent of total billed charges,,89.7,,,,,,,percent of total billed charges,,47.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,84.19,,,,,,,fee schedule,Payment capped at billed charges.,101.26,,,,,,,fee schedule,Payment capped at billed charges.,25.94,,,,,,,fee schedule,,113.77,,,,,,,fee schedule,Payment capped at billed charges.,49.62,,,,,,,fee schedule,,49.44,,,,,,,fee schedule,Payment capped at billed charges.
OT PHYSICAL PERF TEST EA 15MIN,93400828,CDM,0430,RC,97750,CPT,11,Local,GO  ,outpatient,professional,,,90,90,26.23,90,,38.25,,,,,,,fee schedule,Payment capped at billed charges.,89.26,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,54.58,,,,,,,fee schedule,Payment capped at billed charges.,37.14,,,,,,,fee schedule,Payment capped at billed charges.,60.32,,,,,,,fee schedule,Payment capped at billed charges.,38.25,,,,,,,fee schedule,Payment capped at billed charges.,79.68,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,,39.63,,,,,,,fee schedule,Payment capped at billed charges.,49.06,,,,,,,fee schedule,Payment capped at billed charges.,29.58,,,,,,,fee schedule,Payment capped at billed charges.,38.99,,,,,,,fee schedule,Payment capped at billed charges.,46.8,,,,,,,fee schedule,Payment capped at billed charges.,36.61,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,76.5,,,,,,,percent of total billed charges,,58.5,,,,,,,percent of total billed charges,,36.61,,,,,,,fee schedule,Payment capped at 80% of billed charges.,63.12,,,,,,,fee schedule,Payment capped at billed charges.,75.92,,,,,,,fee schedule,Payment capped at billed charges.,26.23,,,,,,,fee schedule,,85.3,,,,,,,fee schedule,Payment capped at billed charges.,37.88,,,,,,,fee schedule,,37.74,,,,,,,fee schedule,Payment capped at billed charges.
OT EVAL ENVIR ASSES,93400836,CDM,0430,RC,97755,CPT,11,Local,GO  ,outpatient,professional,,,100,100,28.23,100.32,,42.57,,,,,,,fee schedule,Payment capped at billed charges.,100.32,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,64.84,,,,,,,fee schedule,Payment capped at billed charges.,41.33,,,,,,,fee schedule,Payment capped at billed charges.,72.04,,,,,,,fee schedule,Payment capped at billed charges.,42.57,,,,,,,fee schedule,Payment capped at billed charges.,88.72,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,,44.1,,,,,,,fee schedule,Payment capped at billed charges.,54.6,,,,,,,fee schedule,Payment capped at billed charges.,31.83,,,,,,,fee schedule,Payment capped at billed charges.,43.39,,,,,,,fee schedule,Payment capped at billed charges.,52.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,35.28,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,85,,,,,,,percent of total billed charges,,65,,,,,,,percent of total billed charges,,40.74,,,,,,,fee schedule,Payment capped at 80% of billed charges.,70.33,,,,,,,fee schedule,Payment capped at billed charges.,84.59,,,,,,,fee schedule,Payment capped at billed charges.,28.23,,,,,,,fee schedule,,95.04,,,,,,,fee schedule,Payment capped at billed charges.,42.15,,,,,,,fee schedule,,42,,,,,,,fee schedule,Payment capped at billed charges.
OT ORTH FIT/TRAIN INIT EA15MIN,93400844,CDM,0430,RC,97760,CPT,11,Local,GO  ,outpatient,professional,,,130,130,42.87,129.92,,53.27,,,,,,,fee schedule,Payment capped at billed charges.,129.92,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,48.3,,,,,,,fee schedule,Payment capped at billed charges.,51.72,,,,,,,fee schedule,Payment capped at billed charges.,53.68,,,,,,,fee schedule,Payment capped at billed charges.,53.27,,,,,,,fee schedule,Payment capped at billed charges.,117.81,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,,55.19,,,,,,,fee schedule,Payment capped at billed charges.,68.33,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,54.3,,,,,,,fee schedule,Payment capped at billed charges.,65.17,,,,,,,fee schedule,Payment capped at billed charges.,50.48,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,110.5,,,,,,,percent of total billed charges,,84.5,,,,,,,percent of total billed charges,,50.98,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,42.87,,,,,,,fee schedule,,,,,,,,,,service not payable,52.75,,,,,,,fee schedule,,52.56,,,,,,,fee schedule,Payment capped at billed charges.
OT PROSTH TRAIN INIT EA 15MIN,93400851,CDM,0430,RC,97761,CPT,11,Local,GO  ,outpatient,professional,,,111,111,36.5,111.16,,46.63,,,,,,,fee schedule,Payment capped at billed charges.,111.16,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,48.01,,,,,,,fee schedule,Payment capped at billed charges.,45.27,,,,,,,fee schedule,Payment capped at billed charges.,53.33,,,,,,,fee schedule,Payment capped at billed charges.,46.63,,,,,,,fee schedule,Payment capped at billed charges.,99.72,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,,48.31,,,,,,,fee schedule,Payment capped at billed charges.,59.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,47.54,,,,,,,fee schedule,Payment capped at billed charges.,57.05,,,,,,,fee schedule,Payment capped at billed charges.,44.42,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,94.35,,,,,,,percent of total billed charges,,72.15,,,,,,,percent of total billed charges,,44.62,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,36.5,,,,,,,fee schedule,,,,,,,,,,service not payable,46.18,,,,,,,fee schedule,,46.01,,,,,,,fee schedule,Payment capped at billed charges.
OT ORTH/PROS SUBS ENC EA15MIN,93400869,CDM,0430,RC,97763,CPT,11,Local,GO  ,outpatient,professional,,,144,144,47.77,143.3,,58.44,,,,,,,fee schedule,Payment capped at billed charges.,143.3,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,67.68,,,,,,,fee schedule,Payment capped at billed charges.,56.74,,,,,,,fee schedule,Payment capped at billed charges.,75.2,,,,,,,fee schedule,Payment capped at billed charges.,58.44,,,,,,,fee schedule,Payment capped at billed charges.,131.86,,,,,,,fee schedule,Payment capped at billed charges.,72,,,,,,,fee schedule,,60.54,,,,,,,fee schedule,Payment capped at billed charges.,74.96,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,59.57,,,,,,,fee schedule,Payment capped at billed charges.,71.5,,,,,,,fee schedule,Payment capped at billed charges.,55.1,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,122.4,,,,,,,percent of total billed charges,,93.6,,,,,,,percent of total billed charges,,55.93,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,47.77,,,,,,,fee schedule,,,,,,,,,,service not payable,57.87,,,,,,,fee schedule,,57.66,,,,,,,fee schedule,Payment capped at billed charges.
OT DRIVING EVAL,93400877,CDM,0430,RC,97799,CPT,11,Local,GO  ,outpatient,professional,,,350,350,20.2,350,,,,,,,,,,service not payable,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.5,,,,,,,fee schedule,Payment capped at billed charges.,175,,,,,,,fee schedule,,,,,,,,,,,227.5,,,,,,,fee schedule,Payment capped at billed charges.,23,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,297.5,,,,,,,percent of total billed charges,,227.5,,,,,,,percent of total billed charges,,280,,,,,,,fee schedule,Payment capped at 80% of billed charges.,227.5,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,20.2,,,,,,,fee schedule,,,,,,,,,,,122.5,,,,,,,fee schedule,,350,,,,,,,fee schedule,Payment capped at billed charges.
SP BIOFEEDBACK TRAINING,93400885,CDM,0440,RC,90901,CPT,11,Local,GN  ,outpatient,professional,,,141,141,28.82,120.85,,45.84,,,,,,,fee schedule,Payment capped at billed charges.,109.44,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,72,,,,,,,fee schedule,Payment capped at billed charges.,44.51,,,,,,,fee schedule,Payment capped at billed charges.,80.01,,,,,,,fee schedule,Payment capped at billed charges.,45.84,,,,,,,fee schedule,Payment capped at billed charges.,120.5,,,,,,,fee schedule,Payment capped at billed charges.,70.5,,,,,,,fee schedule,,47.49,,,,,,,fee schedule,Payment capped at billed charges.,45.23,,,,,,,fee schedule,Payment capped at billed charges.,32.81,,,,,,,fee schedule,Payment capped at billed charges.,46.73,,,,,,,fee schedule,Payment capped at billed charges.,56.09,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,38.45,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,119.85,,,,,,,percent of total billed charges,,91.65,,,,,,,percent of total billed charges,,43.87,,,,,,,fee schedule,Payment capped at 80% of billed charges.,89.43,,,,,,,fee schedule,Payment capped at billed charges.,107.56,,,,,,,fee schedule,Payment capped at billed charges.,28.82,,,,,,,fee schedule,,120.85,,,,,,,fee schedule,Payment capped at billed charges.,45.4,,,,,,,fee schedule,,45.23,,,,,,,fee schedule,Payment capped at billed charges.
SP COMM/COG/LANG TX,93400893,CDM,0440,RC,92507,CPT,11,Local,GN  ,outpatient,professional,,,275,275,60,233.75,,84.88,,,,,,,fee schedule,Payment capped at billed charges.,198.04,,,,,,,fee schedule,Payment capped at billed charges.,70.35,,,,,,,fee schedule,Payment capped at billed charges.,70.35,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,66.47,,,,,,,fee schedule,Payment capped at billed charges.,82.41,,,,,,,fee schedule,Payment capped at billed charges.,73.86,,,,,,,fee schedule,Payment capped at billed charges.,84.88,,,,,,,fee schedule,Payment capped at billed charges.,218.78,,,,,,,fee schedule,Payment capped at billed charges.,70.35,,,,,,,fee schedule,,87.94,,,,,,,fee schedule,Payment capped at billed charges.,83.75,,,,,,,fee schedule,Payment capped at billed charges.,73.59,,,,,,,fee schedule,Payment capped at billed charges.,86.53,,,,,,,fee schedule,Payment capped at billed charges.,103.85,,,,,,,fee schedule,Payment capped at billed charges.,82.46,,,,,,,fee schedule,Payment capped at billed charges.,70.35,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,233.75,,,,,,,percent of total billed charges,,178.75,,,,,,,percent of total billed charges,,81.24,,,,,,,fee schedule,Payment capped at 80% of billed charges.,161.91,,,,,,,fee schedule,Payment capped at billed charges.,194.73,,,,,,,fee schedule,Payment capped at billed charges.,65.27,,,,,,,fee schedule,,218.8,,,,,,,fee schedule,Payment capped at billed charges.,84.06,,,,,,,fee schedule,,83.75,,,,,,,fee schedule,Payment capped at billed charges.
SP LANGUAGE TX GROUP,93400901,CDM,0443,RC,92508,CPT,11,Local,GN  ,outpatient,professional,,,68,68,22.43,90,,27.06,,,,,,,fee schedule,Payment capped at billed charges.,62.59,,,,,,,fee schedule,Payment capped at billed charges.,22.43,,,,,,,fee schedule,Payment capped at billed charges.,22.43,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.35,,,,,,,fee schedule,Payment capped at billed charges.,26.27,,,,,,,fee schedule,Payment capped at billed charges.,43.74,,,,,,,fee schedule,Payment capped at billed charges.,27.06,,,,,,,fee schedule,Payment capped at billed charges.,68,,,,,,,fee schedule,Payment capped at billed charges.,22.43,,,,,,,fee schedule,,28.04,,,,,,,fee schedule,Payment capped at billed charges.,26.7,,,,,,,fee schedule,Payment capped at billed charges.,29.49,,,,,,,fee schedule,Payment capped at billed charges.,27.59,,,,,,,fee schedule,Payment capped at billed charges.,33.11,,,,,,,fee schedule,Payment capped at billed charges.,25.95,,,,,,,fee schedule,Payment capped at billed charges.,22.43,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,57.8,,,,,,,percent of total billed charges,,44.2,,,,,,,percent of total billed charges,,25.89,,,,,,,fee schedule,Payment capped at 80% of billed charges.,52.33,,,,,,,fee schedule,Payment capped at billed charges.,62.93,,,,,,,fee schedule,Payment capped at billed charges.,26.19,,,,,,,fee schedule,,68,,,,,,,fee schedule,Payment capped at billed charges.,26.8,,,,,,,fee schedule,,26.7,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL OF SPEECH FLUENCY,93400919,CDM,0444,RC,92521,CPT,11,Local,GN  ,outpatient,professional,,,378,378,60,378,,147.92,,,,,,,fee schedule,Payment capped at billed charges.,344.17,,,,,,,fee schedule,Payment capped at billed charges.,122.6,,,,,,,fee schedule,Payment capped at billed charges.,122.6,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,158.98,,,,,,,fee schedule,Payment capped at billed charges.,143.61,,,,,,,fee schedule,Payment capped at billed charges.,176.64,,,,,,,fee schedule,Payment capped at billed charges.,147.92,,,,,,,fee schedule,Payment capped at billed charges.,378,,,,,,,fee schedule,Payment capped at billed charges.,122.6,,,,,,,fee schedule,,153.25,,,,,,,fee schedule,Payment capped at billed charges.,145.95,,,,,,,fee schedule,Payment capped at billed charges.,105.05,,,,,,,fee schedule,Payment capped at billed charges.,150.8,,,,,,,fee schedule,Payment capped at billed charges.,180.98,,,,,,,fee schedule,Payment capped at billed charges.,143.6,,,,,,,fee schedule,Payment capped at billed charges.,122.6,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,321.3,,,,,,,percent of total billed charges,,245.7,,,,,,,percent of total billed charges,,141.57,,,,,,,fee schedule,Payment capped at 80% of billed charges.,282.3,,,,,,,fee schedule,Payment capped at billed charges.,339.52,,,,,,,fee schedule,Payment capped at billed charges.,93.18,,,,,,,fee schedule,,378,,,,,,,fee schedule,Payment capped at billed charges.,146.49,,,,,,,fee schedule,,145.95,,,,,,,fee schedule,Payment capped at billed charges.
SP EVALUATE SPEECH PRODUCTION,93400927,CDM,0444,RC,92522,CPT,11,Local,GN  ,outpatient,professional,,,316,316,60,316,,122.76,,,,,,,fee schedule,Payment capped at billed charges.,287.12,,,,,,,fee schedule,Payment capped at billed charges.,101.75,,,,,,,fee schedule,Payment capped at billed charges.,101.75,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,133.21,,,,,,,fee schedule,Payment capped at billed charges.,119.18,,,,,,,fee schedule,Payment capped at billed charges.,148.01,,,,,,,fee schedule,Payment capped at billed charges.,122.76,,,,,,,fee schedule,Payment capped at billed charges.,316,,,,,,,fee schedule,Payment capped at billed charges.,101.75,,,,,,,fee schedule,,127.18,,,,,,,fee schedule,Payment capped at billed charges.,121.12,,,,,,,fee schedule,Payment capped at billed charges.,85.1,,,,,,,fee schedule,Payment capped at billed charges.,125.14,,,,,,,fee schedule,Payment capped at billed charges.,150.19,,,,,,,fee schedule,Payment capped at billed charges.,119.43,,,,,,,fee schedule,Payment capped at billed charges.,101.75,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,268.6,,,,,,,percent of total billed charges,,205.4,,,,,,,percent of total billed charges,,117.49,,,,,,,fee schedule,Payment capped at 80% of billed charges.,235.9,,,,,,,fee schedule,Payment capped at billed charges.,283.71,,,,,,,fee schedule,Payment capped at billed charges.,75.48,,,,,,,fee schedule,,316,,,,,,,fee schedule,Payment capped at billed charges.,121.57,,,,,,,fee schedule,,121.12,,,,,,,fee schedule,Payment capped at billed charges.
SP SOUND LANG COMPREHEN,93400935,CDM,0444,RC,92523,CPT,11,Local,GN  ,outpatient,professional,,,644,644,60,644,,252.95,,,,,,,fee schedule,Payment capped at billed charges.,590.13,,,,,,,fee schedule,Payment capped at billed charges.,209.64,,,,,,,fee schedule,Payment capped at billed charges.,209.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,271.14,,,,,,,fee schedule,Payment capped at billed charges.,245.59,,,,,,,fee schedule,Payment capped at billed charges.,301.29,,,,,,,fee schedule,Payment capped at billed charges.,252.95,,,,,,,fee schedule,Payment capped at billed charges.,644,,,,,,,fee schedule,Payment capped at billed charges.,209.64,,,,,,,fee schedule,,262.06,,,,,,,fee schedule,Payment capped at billed charges.,249.58,,,,,,,fee schedule,Payment capped at billed charges.,177.07,,,,,,,fee schedule,Payment capped at billed charges.,257.87,,,,,,,fee schedule,Payment capped at billed charges.,309.48,,,,,,,fee schedule,Payment capped at billed charges.,245.61,,,,,,,fee schedule,Payment capped at billed charges.,209.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,547.4,,,,,,,percent of total billed charges,,418.6,,,,,,,percent of total billed charges,,242.09,,,,,,,fee schedule,Payment capped at 80% of billed charges.,483.96,,,,,,,fee schedule,Payment capped at billed charges.,582.06,,,,,,,fee schedule,Payment capped at billed charges.,157.05,,,,,,,fee schedule,,644,,,,,,,fee schedule,Payment capped at billed charges.,250.5,,,,,,,fee schedule,,249.58,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL OF VOICE/RESONANCE,93400943,CDM,0444,RC,92524,CPT,11,Local,GN  ,outpatient,professional,,,311,311,60,311,,120.43,,,,,,,fee schedule,Payment capped at billed charges.,283.38,,,,,,,fee schedule,Payment capped at billed charges.,99.81,,,,,,,fee schedule,Payment capped at billed charges.,99.81,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,130.99,,,,,,,fee schedule,Payment capped at billed charges.,116.92,,,,,,,fee schedule,Payment capped at billed charges.,145.54,,,,,,,fee schedule,Payment capped at billed charges.,120.43,,,,,,,fee schedule,Payment capped at billed charges.,311,,,,,,,fee schedule,Payment capped at billed charges.,99.81,,,,,,,fee schedule,,124.76,,,,,,,fee schedule,Payment capped at billed charges.,118.82,,,,,,,fee schedule,Payment capped at billed charges.,89.01,,,,,,,fee schedule,Payment capped at billed charges.,122.76,,,,,,,fee schedule,Payment capped at billed charges.,147.34,,,,,,,fee schedule,Payment capped at billed charges.,117.3,,,,,,,fee schedule,Payment capped at billed charges.,99.81,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,264.35,,,,,,,percent of total billed charges,,202.15,,,,,,,percent of total billed charges,,115.25,,,,,,,fee schedule,Payment capped at 80% of billed charges.,232.12,,,,,,,fee schedule,Payment capped at billed charges.,279.18,,,,,,,fee schedule,Payment capped at billed charges.,78.95,,,,,,,fee schedule,,311,,,,,,,fee schedule,Payment capped at billed charges.,119.26,,,,,,,fee schedule,,118.82,,,,,,,fee schedule,Payment capped at billed charges.
SP SWALLOW TX,93400950,CDM,0440,RC,92526,CPT,11,Local,GN  ,outpatient,professional,,,245,245,60,244.56,,94.09,,,,,,,fee schedule,Payment capped at billed charges.,221,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,138.21,,,,,,,fee schedule,Payment capped at billed charges.,91.34,,,,,,,fee schedule,Payment capped at billed charges.,153.56,,,,,,,fee schedule,Payment capped at billed charges.,94.09,,,,,,,fee schedule,Payment capped at billed charges.,244.56,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,,97.47,,,,,,,fee schedule,Payment capped at billed charges.,92.83,,,,,,,fee schedule,Payment capped at billed charges.,92.98,,,,,,,fee schedule,Payment capped at billed charges.,95.91,,,,,,,fee schedule,Payment capped at billed charges.,115.11,,,,,,,fee schedule,Payment capped at billed charges.,91,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,208.25,,,,,,,percent of total billed charges,,159.25,,,,,,,percent of total billed charges,,90.05,,,,,,,fee schedule,Payment capped at 80% of billed charges.,180.46,,,,,,,fee schedule,Payment capped at billed charges.,217.04,,,,,,,fee schedule,Payment capped at billed charges.,82.47,,,,,,,fee schedule,,243.87,,,,,,,fee schedule,Payment capped at billed charges.,93.17,,,,,,,fee schedule,,92.83,,,,,,,fee schedule,Payment capped at billed charges.
SP VOICE PROSTHESIS EVAL,93400968,CDM,0444,RC,92597,CPT,11,Local,GN  ,outpatient,professional,,,444,444,60,377.4,,80.36,,,,,,,fee schedule,Payment capped at billed charges.,185.39,,,,,,,fee schedule,Payment capped at billed charges.,66.6,,,,,,,fee schedule,Payment capped at billed charges.,66.6,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,158.93,,,,,,,fee schedule,Payment capped at billed charges.,78.02,,,,,,,fee schedule,Payment capped at billed charges.,176.58,,,,,,,fee schedule,Payment capped at billed charges.,80.36,,,,,,,fee schedule,Payment capped at billed charges.,205.76,,,,,,,fee schedule,Payment capped at billed charges.,66.6,,,,,,,fee schedule,,83.25,,,,,,,fee schedule,Payment capped at billed charges.,79.29,,,,,,,fee schedule,Payment capped at billed charges.,80.41,,,,,,,fee schedule,Payment capped at billed charges.,81.92,,,,,,,fee schedule,Payment capped at billed charges.,98.32,,,,,,,fee schedule,Payment capped at billed charges.,83.74,,,,,,,fee schedule,Payment capped at billed charges.,66.6,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,377.4,,,,,,,percent of total billed charges,,288.6,,,,,,,percent of total billed charges,,76.91,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,71.32,,,,,,,fee schedule,,,,,,,,,,service not payable,79.58,,,,,,,fee schedule,,79.29,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL-SP GEN DEV1ST HR,93400976,CDM,0444,RC,92607,CPT,11,Local,GN  ,outpatient,professional,,,527,527,60,447.95,,137.93,,,,,,,fee schedule,Payment capped at billed charges.,323.58,,,,,,,fee schedule,Payment capped at billed charges.,115.68,,,,,,,fee schedule,Payment capped at billed charges.,115.68,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,194.53,,,,,,,fee schedule,Payment capped at billed charges.,133.91,,,,,,,fee schedule,Payment capped at billed charges.,216.15,,,,,,,fee schedule,Payment capped at billed charges.,137.93,,,,,,,fee schedule,Payment capped at billed charges.,358.27,,,,,,,fee schedule,Payment capped at billed charges.,263.5,,,,,,,fee schedule,,142.89,,,,,,,fee schedule,Payment capped at billed charges.,136.09,,,,,,,fee schedule,Payment capped at billed charges.,140,,,,,,,fee schedule,Payment capped at billed charges.,140.61,,,,,,,fee schedule,Payment capped at billed charges.,168.75,,,,,,,fee schedule,Payment capped at billed charges.,132.94,,,,,,,fee schedule,Payment capped at billed charges.,115.68,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,447.95,,,,,,,percent of total billed charges,,342.55,,,,,,,percent of total billed charges,,132.02,,,,,,,fee schedule,Payment capped at 80% of billed charges.,265.25,,,,,,,fee schedule,Payment capped at billed charges.,319.01,,,,,,,fee schedule,Payment capped at billed charges.,124.17,,,,,,,fee schedule,,358.44,,,,,,,fee schedule,Payment capped at billed charges.,136.59,,,,,,,fee schedule,,136.09,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL-SP GEN DEVADDL 30 MIN,93400984,CDM,0444,RC,92608,CPT,11,Local,GN  ,outpatient,professional,,,275,275,38.19,233.75,,54.33,,,,,,,fee schedule,Payment capped at billed charges.,127.5,,,,,,,fee schedule,Payment capped at billed charges.,45.57,,,,,,,fee schedule,Payment capped at billed charges.,45.57,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,38.19,,,,,,,fee schedule,Payment capped at billed charges.,52.75,,,,,,,fee schedule,Payment capped at billed charges.,42.42,,,,,,,fee schedule,Payment capped at billed charges.,54.33,,,,,,,fee schedule,Payment capped at billed charges.,142.48,,,,,,,fee schedule,Payment capped at billed charges.,137.5,,,,,,,fee schedule,,56.29,,,,,,,fee schedule,Payment capped at billed charges.,53.61,,,,,,,fee schedule,Payment capped at billed charges.,47.76,,,,,,,fee schedule,Payment capped at billed charges.,55.39,,,,,,,fee schedule,Payment capped at billed charges.,66.48,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,45.57,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,233.75,,,,,,,percent of total billed charges,,178.75,,,,,,,percent of total billed charges,,52,,,,,,,fee schedule,Payment capped at 80% of billed charges.,104.33,,,,,,,fee schedule,Payment capped at billed charges.,125.47,,,,,,,fee schedule,Payment capped at billed charges.,41.95,,,,,,,fee schedule,,140.98,,,,,,,fee schedule,Payment capped at billed charges.,53.81,,,,,,,fee schedule,,53.61,,,,,,,fee schedule,Payment capped at billed charges.
SP TRAINING/FITTING SLP GEN DV,93400992,CDM,0440,RC,92609,CPT,11,Local,GN  ,outpatient,professional,,,306,306,60,301.34,,115.26,,,,,,,fee schedule,Payment capped at billed charges.,270.63,,,,,,,fee schedule,Payment capped at billed charges.,96.66,,,,,,,fee schedule,Payment capped at billed charges.,96.66,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,105.33,,,,,,,fee schedule,Payment capped at billed charges.,111.9,,,,,,,fee schedule,Payment capped at billed charges.,117.03,,,,,,,fee schedule,Payment capped at billed charges.,115.26,,,,,,,fee schedule,Payment capped at billed charges.,301.34,,,,,,,fee schedule,Payment capped at billed charges.,153,,,,,,,fee schedule,,119.41,,,,,,,fee schedule,Payment capped at billed charges.,113.72,,,,,,,fee schedule,Payment capped at billed charges.,99.2,,,,,,,fee schedule,Payment capped at billed charges.,117.5,,,,,,,fee schedule,Payment capped at billed charges.,141.01,,,,,,,fee schedule,Payment capped at billed charges.,110.9,,,,,,,fee schedule,Payment capped at billed charges.,96.66,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,260.1,,,,,,,percent of total billed charges,,198.9,,,,,,,percent of total billed charges,,110.31,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,87.99,,,,,,,fee schedule,,,,,,,,,,service not payable,114.14,,,,,,,fee schedule,,113.72,,,,,,,fee schedule,Payment capped at billed charges.
SP CLINICAL SWALLOW EVAL,93401008,CDM,0444,RC,92610,CPT,11,Local,GN  ,outpatient,professional,,,273,273,60,269.82,,95.04,,,,,,,fee schedule,Payment capped at billed charges.,221.48,,,,,,,fee schedule,Payment capped at billed charges.,79.7,,,,,,,fee schedule,Payment capped at billed charges.,79.7,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,242.84,,,,,,,fee schedule,Payment capped at billed charges.,92.27,,,,,,,fee schedule,Payment capped at billed charges.,269.82,,,,,,,fee schedule,Payment capped at billed charges.,95.04,,,,,,,fee schedule,Payment capped at billed charges.,246.34,,,,,,,fee schedule,Payment capped at billed charges.,136.5,,,,,,,fee schedule,,98.46,,,,,,,fee schedule,Payment capped at billed charges.,93.77,,,,,,,fee schedule,Payment capped at billed charges.,93.64,,,,,,,fee schedule,Payment capped at billed charges.,96.88,,,,,,,fee schedule,Payment capped at billed charges.,116.27,,,,,,,fee schedule,Payment capped at billed charges.,91.7,,,,,,,fee schedule,Payment capped at billed charges.,79.7,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,232.05,,,,,,,percent of total billed charges,,177.45,,,,,,,percent of total billed charges,,90.95,,,,,,,fee schedule,Payment capped at 80% of billed charges.,182.29,,,,,,,fee schedule,Payment capped at billed charges.,219.24,,,,,,,fee schedule,Payment capped at billed charges.,82.24,,,,,,,fee schedule,,246.34,,,,,,,fee schedule,Payment capped at billed charges.,94.12,,,,,,,fee schedule,,93.77,,,,,,,fee schedule,Payment capped at billed charges.
SP MOD BARIUM SWALLOWING STUDY,93401016,CDM,0440,RC,92611,CPT,11,Local,GN  ,outpatient,professional,,,264,264,60,264,,101.49,,,,,,,fee schedule,Payment capped at billed charges.,239.81,,,,,,,fee schedule,Payment capped at billed charges.,85.12,,,,,,,fee schedule,Payment capped at billed charges.,85.12,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,86.23,,,,,,,fee schedule,Payment capped at billed charges.,98.54,,,,,,,fee schedule,Payment capped at billed charges.,95.83,,,,,,,fee schedule,Payment capped at billed charges.,101.49,,,,,,,fee schedule,Payment capped at billed charges.,264,,,,,,,fee schedule,Payment capped at billed charges.,132,,,,,,,fee schedule,,105.15,,,,,,,fee schedule,Payment capped at billed charges.,100.14,,,,,,,fee schedule,Payment capped at billed charges.,101.87,,,,,,,fee schedule,Payment capped at billed charges.,103.46,,,,,,,fee schedule,Payment capped at billed charges.,124.17,,,,,,,fee schedule,Payment capped at billed charges.,97.75,,,,,,,fee schedule,Payment capped at billed charges.,85.12,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,224.4,,,,,,,percent of total billed charges,,171.6,,,,,,,percent of total billed charges,,97.14,,,,,,,fee schedule,Payment capped at 80% of billed charges.,197.04,,,,,,,fee schedule,Payment capped at billed charges.,236.98,,,,,,,fee schedule,Payment capped at billed charges.,89.47,,,,,,,fee schedule,,264,,,,,,,fee schedule,Payment capped at billed charges.,100.51,,,,,,,fee schedule,,100.14,,,,,,,fee schedule,Payment capped at billed charges.
SP FEES W/CINE OR VIDEO RECORD,93401024,CDM,0444,RC,92612,CPT,11,Local,GN  ,outpatient,professional,,,586,586,60,586,,228.03,,,,,,,fee schedule,Payment capped at billed charges.,536.1,,,,,,,fee schedule,Payment capped at billed charges.,191.24,,,,,,,fee schedule,Payment capped at billed charges.,191.24,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,336.96,,,,,,,fee schedule,Payment capped at billed charges.,221.39,,,,,,,fee schedule,Payment capped at billed charges.,374.4,,,,,,,fee schedule,Payment capped at billed charges.,228.03,,,,,,,fee schedule,Payment capped at billed charges.,586,,,,,,,fee schedule,Payment capped at billed charges.,293,,,,,,,fee schedule,,236.24,,,,,,,fee schedule,Payment capped at billed charges.,224.99,,,,,,,fee schedule,Payment capped at billed charges.,172.49,,,,,,,fee schedule,Payment capped at billed charges.,232.46,,,,,,,fee schedule,Payment capped at billed charges.,278.99,,,,,,,fee schedule,Payment capped at billed charges.,212.56,,,,,,,fee schedule,Payment capped at billed charges.,191.24,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,498.1,,,,,,,percent of total billed charges,,380.9,,,,,,,percent of total billed charges,,218.23,,,,,,,fee schedule,Payment capped at 80% of billed charges.,439.5,,,,,,,fee schedule,Payment capped at billed charges.,528.59,,,,,,,fee schedule,Payment capped at billed charges.,151.49,,,,,,,fee schedule,,586,,,,,,,fee schedule,Payment capped at billed charges.,225.82,,,,,,,fee schedule,,224.99,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL AUD REHAB STATUS 1STHR,93401032,CDM,0440,RC,92626,CPT,11,Local,GN  ,outpatient,professional,,,444,444,60,377.4,,94.59,,,,,,,fee schedule,Payment capped at billed charges.,225.9,,,,,,,fee schedule,Payment capped at billed charges.,78.39,,,,,,,fee schedule,Payment capped at billed charges.,78.39,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,183.25,,,,,,,fee schedule,Payment capped at billed charges.,91.84,,,,,,,fee schedule,Payment capped at billed charges.,203.6,,,,,,,fee schedule,Payment capped at billed charges.,94.59,,,,,,,fee schedule,Payment capped at billed charges.,253.13,,,,,,,fee schedule,Payment capped at billed charges.,78.39,,,,,,,fee schedule,,98,,,,,,,fee schedule,Payment capped at billed charges.,93.33,,,,,,,fee schedule,Payment capped at billed charges.,80.74,,,,,,,fee schedule,Payment capped at billed charges.,96.43,,,,,,,fee schedule,Payment capped at billed charges.,115.73,,,,,,,fee schedule,Payment capped at billed charges.,91.7,,,,,,,fee schedule,Payment capped at billed charges.,78.39,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,377.4,,,,,,,percent of total billed charges,,288.6,,,,,,,percent of total billed charges,,90.53,,,,,,,fee schedule,Payment capped at 80% of billed charges.,182.96,,,,,,,fee schedule,Payment capped at billed charges.,220.04,,,,,,,fee schedule,Payment capped at billed charges.,70.91,,,,,,,fee schedule,,247.24,,,,,,,fee schedule,Payment capped at billed charges.,93.67,,,,,,,fee schedule,,93.33,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL AUD REHAB STAT ADD 15M,93401040,CDM,0440,RC,92627,CPT,11,Local,GN  ,outpatient,professional,,,110,110,17.54,93.5,,22.37,,,,,,,fee schedule,Payment capped at billed charges.,53.19,,,,,,,fee schedule,Payment capped at billed charges.,18.54,,,,,,,fee schedule,Payment capped at billed charges.,18.54,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,46.32,,,,,,,fee schedule,Payment capped at billed charges.,21.72,,,,,,,fee schedule,Payment capped at billed charges.,51.48,,,,,,,fee schedule,Payment capped at billed charges.,22.37,,,,,,,fee schedule,Payment capped at billed charges.,59.35,,,,,,,fee schedule,Payment capped at billed charges.,18.54,,,,,,,fee schedule,,23.17,,,,,,,fee schedule,Payment capped at billed charges.,22.07,,,,,,,fee schedule,Payment capped at billed charges.,19.98,,,,,,,fee schedule,Payment capped at billed charges.,22.8,,,,,,,fee schedule,Payment capped at billed charges.,27.37,,,,,,,fee schedule,Payment capped at billed charges.,21.69,,,,,,,fee schedule,Payment capped at billed charges.,18.54,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,93.5,,,,,,,percent of total billed charges,,71.5,,,,,,,percent of total billed charges,,21.41,,,,,,,fee schedule,Payment capped at 80% of billed charges.,43.26,,,,,,,fee schedule,Payment capped at billed charges.,52.03,,,,,,,fee schedule,Payment capped at billed charges.,17.54,,,,,,,fee schedule,,58.46,,,,,,,fee schedule,Payment capped at billed charges.,22.15,,,,,,,fee schedule,,22.07,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL APHASIA 60 MIN,93401057,CDM,0444,RC,96105,CPT,11,Local,GN  ,outpatient,professional,,,281,281,60,278.57,,105.54,,,,,,,fee schedule,Payment capped at billed charges.,250.78,,,,,,,fee schedule,Payment capped at billed charges.,87.47,,,,,,,fee schedule,Payment capped at billed charges.,87.47,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,195.07,,,,,,,fee schedule,Payment capped at billed charges.,102.46,,,,,,,fee schedule,Payment capped at billed charges.,201.7,,,,,,,fee schedule,Payment capped at billed charges.,105.54,,,,,,,fee schedule,Payment capped at billed charges.,278.57,,,,,,,fee schedule,Payment capped at billed charges.,87.47,,,,,,,fee schedule,,109.34,,,,,,,fee schedule,Payment capped at billed charges.,104.13,,,,,,,fee schedule,Payment capped at billed charges.,96.12,,,,,,,fee schedule,Payment capped at billed charges.,107.59,,,,,,,fee schedule,Payment capped at billed charges.,129.12,,,,,,,fee schedule,Payment capped at billed charges.,103.07,,,,,,,fee schedule,Payment capped at billed charges.,87.47,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,238.85,,,,,,,percent of total billed charges,,182.65,,,,,,,percent of total billed charges,,101,,,,,,,fee schedule,Payment capped at 80% of billed charges.,202.58,,,,,,,fee schedule,Payment capped at billed charges.,243.65,,,,,,,fee schedule,Payment capped at billed charges.,84.42,,,,,,,fee schedule,,273.76,,,,,,,fee schedule,Payment capped at billed charges.,104.51,,,,,,,fee schedule,,104.13,,,,,,,fee schedule,Payment capped at billed charges.
SP DEVEL TEST ADMIN 1ST HR,93401065,CDM,0440,RC,96112,CPT,11,Local,GN  ,outpatient,professional,,,378,378,60,354.81,,142.13,,,,,,,fee schedule,Payment capped at billed charges.,319.72,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,235.55,,,,,,,fee schedule,Payment capped at billed charges.,137.99,,,,,,,fee schedule,Payment capped at billed charges.,261.71,,,,,,,fee schedule,Payment capped at billed charges.,142.13,,,,,,,fee schedule,Payment capped at billed charges.,354.81,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,,147.24,,,,,,,fee schedule,Payment capped at billed charges.,140.23,,,,,,,fee schedule,Payment capped at billed charges.,133.03,,,,,,,fee schedule,Payment capped at billed charges.,144.89,,,,,,,fee schedule,Payment capped at billed charges.,173.89,,,,,,,fee schedule,Payment capped at billed charges.,173.96,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,321.3,,,,,,,percent of total billed charges,,245.7,,,,,,,percent of total billed charges,,136.01,,,,,,,fee schedule,Payment capped at 80% of billed charges.,259.02,,,,,,,fee schedule,Payment capped at billed charges.,311.53,,,,,,,fee schedule,Payment capped at billed charges.,116.84,,,,,,,fee schedule,,350.03,,,,,,,fee schedule,Payment capped at billed charges.,140.75,,,,,,,fee schedule,,140.23,,,,,,,fee schedule,Payment capped at billed charges.
SP DEVEL TEST ADMIN EA ADD 30M,93401073,CDM,0440,RC,96113,CPT,11,Local,GN  ,outpatient,professional,,,169,169,49.16,169,,59.31,,,,,,,fee schedule,Payment capped at billed charges.,151.94,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,110.86,,,,,,,fee schedule,Payment capped at billed charges.,57.58,,,,,,,fee schedule,Payment capped at billed charges.,123.18,,,,,,,fee schedule,Payment capped at billed charges.,59.31,,,,,,,fee schedule,Payment capped at billed charges.,168.24,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,,61.45,,,,,,,fee schedule,Payment capped at billed charges.,58.52,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,60.46,,,,,,,fee schedule,Payment capped at billed charges.,72.56,,,,,,,fee schedule,Payment capped at billed charges.,73.04,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,143.65,,,,,,,percent of total billed charges,,109.85,,,,,,,percent of total billed charges,,56.76,,,,,,,fee schedule,Payment capped at 80% of billed charges.,126.01,,,,,,,fee schedule,Payment capped at billed charges.,151.55,,,,,,,fee schedule,Payment capped at billed charges.,55.66,,,,,,,fee schedule,,169,,,,,,,fee schedule,Payment capped at billed charges.,58.74,,,,,,,fee schedule,,58.52,,,,,,,fee schedule,Payment capped at billed charges.
SP COGNITIVE PERF TEST PER HR,93401081,CDM,0444,RC,96125,CPT,11,Local,GN  ,outpatient,professional,,,305,305,60,297.27,,112.79,,,,,,,fee schedule,Payment capped at billed charges.,265.41,,,,,,,fee schedule,Payment capped at billed charges.,94.6,,,,,,,fee schedule,Payment capped at billed charges.,94.6,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,226.03,,,,,,,fee schedule,Payment capped at billed charges.,109.51,,,,,,,fee schedule,Payment capped at billed charges.,251.15,,,,,,,fee schedule,Payment capped at billed charges.,112.79,,,,,,,fee schedule,Payment capped at billed charges.,297.27,,,,,,,fee schedule,Payment capped at billed charges.,152.5,,,,,,,fee schedule,,116.85,,,,,,,fee schedule,Payment capped at billed charges.,111.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,114.98,,,,,,,fee schedule,Payment capped at billed charges.,138,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,94.6,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,259.25,,,,,,,percent of total billed charges,,198.25,,,,,,,percent of total billed charges,,107.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,217.4,,,,,,,fee schedule,Payment capped at billed charges.,261.46,,,,,,,fee schedule,Payment capped at billed charges.,90.19,,,,,,,fee schedule,,293.78,,,,,,,fee schedule,Payment capped at billed charges.,111.7,,,,,,,fee schedule,,111.29,,,,,,,fee schedule,Payment capped at billed charges.
SP THERAPUTIC EXERCISE 15MIN,93401099,CDM,0440,RC,97110,CPT,11,Local,GN  ,outpatient,professional,,,80,80,27.16,90,,32.78,,,,,,,fee schedule,Payment capped at billed charges.,77.07,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,31.82,,,,,,,fee schedule,Payment capped at billed charges.,42.31,,,,,,,fee schedule,Payment capped at billed charges.,32.78,,,,,,,fee schedule,Payment capped at billed charges.,69.34,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,,33.96,,,,,,,fee schedule,Payment capped at billed charges.,32.34,,,,,,,fee schedule,Payment capped at billed charges.,33.38,,,,,,,fee schedule,Payment capped at billed charges.,33.41,,,,,,,fee schedule,Payment capped at billed charges.,40.1,,,,,,,fee schedule,Payment capped at billed charges.,31.64,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,68,,,,,,,percent of total billed charges,,52,,,,,,,percent of total billed charges,,31.37,,,,,,,fee schedule,Payment capped at 80% of billed charges.,54.01,,,,,,,fee schedule,Payment capped at billed charges.,64.95,,,,,,,fee schedule,Payment capped at billed charges.,29.61,,,,,,,fee schedule,,72.98,,,,,,,fee schedule,Payment capped at billed charges.,32.46,,,,,,,fee schedule,,32.34,,,,,,,fee schedule,Payment capped at billed charges.
SP COGNITIVE FUNC INTRV 1ST15M,93401107,CDM,0440,RC,97129,CPT,11,Local,GN  ,outpatient,professional,,,72,72,20.09,90,,23.96,,,,,,,fee schedule,Payment capped at billed charges.,56.75,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.09,,,,,,,fee schedule,Payment capped at billed charges.,23.26,,,,,,,fee schedule,Payment capped at billed charges.,41.21,,,,,,,fee schedule,Payment capped at billed charges.,23.96,,,,,,,fee schedule,Payment capped at billed charges.,51.47,,,,,,,fee schedule,Payment capped at billed charges.,36,,,,,,,fee schedule,,24.82,,,,,,,fee schedule,Payment capped at billed charges.,23.64,,,,,,,fee schedule,Payment capped at billed charges.,23.58,,,,,,,fee schedule,Payment capped at billed charges.,24.42,,,,,,,fee schedule,Payment capped at billed charges.,29.31,,,,,,,fee schedule,Payment capped at billed charges.,23.81,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,61.2,,,,,,,percent of total billed charges,,46.8,,,,,,,percent of total billed charges,,22.93,,,,,,,fee schedule,Payment capped at 80% of billed charges.,39.95,,,,,,,fee schedule,Payment capped at billed charges.,48.05,,,,,,,fee schedule,Payment capped at billed charges.,20.71,,,,,,,fee schedule,,53.99,,,,,,,fee schedule,Payment capped at billed charges.,23.73,,,,,,,fee schedule,,23.64,,,,,,,fee schedule,Payment capped at billed charges.
SP COGNITIVE FUNC INTRV ADD15M,93401115,CDM,0440,RC,97130,CPT,11,Local,GN  ,outpatient,professional,,,72,72,19.18,90,,22.88,,,,,,,fee schedule,Payment capped at billed charges.,54.18,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,22.21,,,,,,,fee schedule,Payment capped at billed charges.,39.37,,,,,,,fee schedule,Payment capped at billed charges.,22.88,,,,,,,fee schedule,Payment capped at billed charges.,50,,,,,,,fee schedule,Payment capped at billed charges.,36,,,,,,,fee schedule,,23.7,,,,,,,fee schedule,Payment capped at billed charges.,22.57,,,,,,,fee schedule,Payment capped at billed charges.,22.53,,,,,,,fee schedule,Payment capped at billed charges.,23.32,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,22.75,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,61.2,,,,,,,percent of total billed charges,,46.8,,,,,,,percent of total billed charges,,21.89,,,,,,,fee schedule,Payment capped at 80% of billed charges.,38.15,,,,,,,fee schedule,Payment capped at billed charges.,45.88,,,,,,,fee schedule,Payment capped at billed charges.,19.79,,,,,,,fee schedule,,51.55,,,,,,,fee schedule,Payment capped at billed charges.,22.65,,,,,,,fee schedule,,22.57,,,,,,,fee schedule,Payment capped at billed charges.
SP OTHER THERA PROC 1 -15MIN,93401123,CDM,0440,RC,97139,CPT,11,Local,GN  ,outpatient,professional,,,65,65,6.23,90,,14.1,,,,,,,fee schedule,Payment capped at billed charges.,33.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.85,,,,,,,fee schedule,Payment capped at billed charges.,32.5,,,,,,,fee schedule,,,,,,,,,,,42.25,,,,,,,fee schedule,Payment capped at billed charges.,15.39,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,6.23,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,55.25,,,,,,,percent of total billed charges,,42.25,,,,,,,percent of total billed charges,,52,,,,,,,fee schedule,Payment capped at 80% of billed charges.,42.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,13.51,,,,,,,fee schedule,,,,,,,,,,,22.75,,,,,,,fee schedule,,65,,,,,,,fee schedule,Payment capped at billed charges.
SP THER ACT EA 15 MIN,93401131,CDM,0440,RC,97530,CPT,11,Local,GN  ,outpatient,professional,,,102,102,31.17,98.75,,39.86,,,,,,,fee schedule,Payment capped at billed charges.,98.75,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,38.7,,,,,,,fee schedule,Payment capped at billed charges.,42.5,,,,,,,fee schedule,Payment capped at billed charges.,39.86,,,,,,,fee schedule,Payment capped at billed charges.,89.29,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,,41.3,,,,,,,fee schedule,Payment capped at billed charges.,39.33,,,,,,,fee schedule,Payment capped at billed charges.,35.14,,,,,,,fee schedule,Payment capped at billed charges.,40.64,,,,,,,fee schedule,Payment capped at billed charges.,48.77,,,,,,,fee schedule,Payment capped at billed charges.,38.04,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,86.7,,,,,,,percent of total billed charges,,66.3,,,,,,,percent of total billed charges,,38.15,,,,,,,fee schedule,Payment capped at 80% of billed charges.,68.41,,,,,,,fee schedule,Payment capped at billed charges.,82.27,,,,,,,fee schedule,Payment capped at billed charges.,31.17,,,,,,,fee schedule,,92.44,,,,,,,fee schedule,Payment capped at billed charges.,39.47,,,,,,,fee schedule,,39.33,,,,,,,fee schedule,Payment capped at billed charges.
AFO MOLDED TP PATIENT PLASTI,93401156,CDM,0274,RC,L1940,HCPCS,11,Local,NU  ,outpatient,professional,,,571,571,60,571,,230.17,,,,,,,fee schedule,Payment capped at billed charges.,551.83,,,,,,,fee schedule,Payment capped at billed charges.,468.01,,,,,,,fee schedule,Payment capped at billed charges.,468.01,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,299,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,299,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,371.15,,,,,,,fee schedule,Payment capped at billed charges.,468.01,,,,,,,fee schedule,,,,,,,,,,,371.15,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,571,,,,,,,fee schedule,Payment capped at billed charges.,468.01,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,485.35,,,,,,,percent of total billed charges,,371.15,,,,,,,percent of total billed charges,,456.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,432.66,,,,,,,fee schedule,Payment capped at billed charges.,520.36,,,,,,,fee schedule,Payment capped at billed charges.,194.14,,,,,,,fee schedule,,571,,,,,,,fee schedule,Payment capped at billed charges.,199.85,,,,,,,fee schedule,,571,,,,,,,fee schedule,Payment capped at billed charges.
AFO TIB FX CAST MOLDED TO PT,93401164,CDM,0274,RC,L2108,HCPCS,11,Local,NU  ,outpatient,professional,,,1234,1234,60,1321.01,,551,,,,,,,fee schedule,Payment capped at billed charges.,1321.01,,,,,,,fee schedule,Payment capped at billed charges.,1120.33,,,,,,,fee schedule,Payment capped at billed charges.,1120.33,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,715,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,715,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,802.1,,,,,,,fee schedule,Payment capped at billed charges.,1120.33,,,,,,,fee schedule,,,,,,,,,,,802.1,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234,,,,,,,fee schedule,Payment capped at billed charges.,1120.33,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,1048.9,,,,,,,percent of total billed charges,,802.1,,,,,,,percent of total billed charges,,987.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1035.69,,,,,,,fee schedule,Payment capped at billed charges.,1234,,,,,,,fee schedule,Payment capped at billed charges.,419.56,,,,,,,fee schedule,,1234,,,,,,,fee schedule,Payment capped at billed charges.,431.9,,,,,,,fee schedule,,1234,,,,,,,fee schedule,Payment capped at billed charges.
KAFO FEM FX CAST MOLDED TO PT,93401172,CDM,0274,RC,L2128,HCPCS,11,Local,NU  ,outpatient,professional,,,1981,1981,60,2077.11,,866.38,,,,,,,fee schedule,Payment capped at billed charges.,2077.11,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,1124,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,1124,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,1287.65,,,,,,,fee schedule,Payment capped at billed charges.,990.5,,,,,,,fee schedule,,,,,,,,,,,1287.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1981,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1683.85,,,,,,,percent of total billed charges,,1287.65,,,,,,,percent of total billed charges,,1584.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1628.5,,,,,,,fee schedule,Payment capped at billed charges.,1958.6,,,,,,,fee schedule,Payment capped at billed charges.,673.54,,,,,,,fee schedule,,1981,,,,,,,fee schedule,Payment capped at billed charges.,693.35,,,,,,,fee schedule,,1981,,,,,,,fee schedule,Payment capped at billed charges.
FOOT LONGITUDE METATARSAL SUP,93401180,CDM,0274,RC,L3020,HCPCS,11,Local,NU  ,outpatient,professional,,,239,239,60,239,,96.39,,,,,,,fee schedule,Payment capped at billed charges.,231.09,,,,,,,fee schedule,Payment capped at billed charges.,195.97,,,,,,,fee schedule,Payment capped at billed charges.,195.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,130.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,130.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,155.35,,,,,,,fee schedule,Payment capped at billed charges.,195.97,,,,,,,fee schedule,,,,,,,,,,,155.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,239,,,,,,,fee schedule,Payment capped at billed charges.,195.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,203.15,,,,,,,percent of total billed charges,,155.35,,,,,,,percent of total billed charges,,191.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,181.17,,,,,,,fee schedule,Payment capped at billed charges.,217.89,,,,,,,fee schedule,Payment capped at billed charges.,81.26,,,,,,,fee schedule,,239,,,,,,,fee schedule,Payment capped at billed charges.,83.65,,,,,,,fee schedule,,239,,,,,,,fee schedule,Payment capped at billed charges.
SO CAP DESIGN W/O JNTS CF,93401198,CDM,0274,RC,L3671,HCPCS,11,Local,NU  ,outpatient,professional,,,905,905,60,955.2,,398.42,,,,,,,fee schedule,Payment capped at billed charges.,955.2,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,586.7,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,586.7,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,588.25,,,,,,,fee schedule,Payment capped at billed charges.,452.5,,,,,,,fee schedule,,,,,,,,,,,588.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,905,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,769.25,,,,,,,percent of total billed charges,,588.25,,,,,,,percent of total billed charges,,724,,,,,,,fee schedule,Payment capped at 80% of billed charges.,748.89,,,,,,,fee schedule,Payment capped at billed charges.,900.69,,,,,,,fee schedule,Payment capped at billed charges.,307.7,,,,,,,fee schedule,,905,,,,,,,fee schedule,Payment capped at billed charges.,316.75,,,,,,,fee schedule,,905,,,,,,,fee schedule,Payment capped at billed charges.
SO AIRPLANE W/WO JOINT CF,93401206,CDM,0274,RC,L3674,HCPCS,11,Local,NU  ,outpatient,professional,,,1187,1187,60,1253,,522.64,,,,,,,fee schedule,Payment capped at billed charges.,1253,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,797.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,797.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,771.55,,,,,,,fee schedule,Payment capped at billed charges.,593.5,,,,,,,fee schedule,,,,,,,,,,,771.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1187,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1008.95,,,,,,,percent of total billed charges,,771.55,,,,,,,percent of total billed charges,,949.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,982.37,,,,,,,fee schedule,Payment capped at billed charges.,1181.5,,,,,,,fee schedule,Payment capped at billed charges.,403.58,,,,,,,fee schedule,,1187,,,,,,,fee schedule,Payment capped at billed charges.,415.45,,,,,,,fee schedule,,1187,,,,,,,fee schedule,Payment capped at billed charges.
EO ELBOW STATIC CUST FIT ADJ,93401214,CDM,0274,RC,L3702,HCPCS,11,Local,NU  ,outpatient,professional,,,328,328,60,328,,127.67,,,,,,,fee schedule,Payment capped at billed charges.,306.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,188,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,188,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,213.2,,,,,,,fee schedule,Payment capped at billed charges.,164,,,,,,,fee schedule,,,,,,,,,,,213.2,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,328,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,278.8,,,,,,,percent of total billed charges,,213.2,,,,,,,percent of total billed charges,,262.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,239.97,,,,,,,fee schedule,Payment capped at billed charges.,288.62,,,,,,,fee schedule,Payment capped at billed charges.,111.52,,,,,,,fee schedule,,324.29,,,,,,,fee schedule,Payment capped at billed charges.,114.8,,,,,,,fee schedule,,328,,,,,,,fee schedule,Payment capped at billed charges.
EO ELB STAT PROG DBL HING CUST,93401222,CDM,0274,RC,L3730,HCPCS,11,Local,NU  ,outpatient,professional,,,1019,1019,60,1019,,410.55,,,,,,,fee schedule,Payment capped at billed charges.,984.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,533,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,533,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,662.35,,,,,,,fee schedule,Payment capped at billed charges.,509.5,,,,,,,fee schedule,,,,,,,,,,,662.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1019,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,866.15,,,,,,,percent of total billed charges,,662.35,,,,,,,percent of total billed charges,,815.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,771.71,,,,,,,fee schedule,Payment capped at billed charges.,928.14,,,,,,,fee schedule,Payment capped at billed charges.,346.46,,,,,,,fee schedule,,1019,,,,,,,fee schedule,Payment capped at billed charges.,356.65,,,,,,,fee schedule,,1019,,,,,,,fee schedule,Payment capped at billed charges.
EO STAT CUSTOM F A,93401230,CDM,0274,RC,L3740,HCPCS,11,Local,NU  ,outpatient,professional,,,1208,1208,60,1208,,486.75,,,,,,,fee schedule,Payment capped at billed charges.,1166.97,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,632,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,632,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,785.2,,,,,,,fee schedule,Payment capped at billed charges.,604,,,,,,,fee schedule,,,,,,,,,,,785.2,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1208,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1026.8,,,,,,,percent of total billed charges,,785.2,,,,,,,percent of total billed charges,,966.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,914.93,,,,,,,fee schedule,Payment capped at billed charges.,1100.39,,,,,,,fee schedule,Payment capped at billed charges.,410.72,,,,,,,fee schedule,,1208,,,,,,,fee schedule,Payment capped at billed charges.,422.8,,,,,,,fee schedule,,1208,,,,,,,fee schedule,Payment capped at billed charges.
EWHO ELB WRIST HD STAT CUSTFIT,93401248,CDM,0274,RC,L3763,HCPCS,11,Local,NU  ,outpatient,professional,,,739,739,60,744.08,,310.36,,,,,,,fee schedule,Payment capped at billed charges.,744.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,457.04,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,457.04,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,480.35,,,,,,,fee schedule,Payment capped at billed charges.,369.5,,,,,,,fee schedule,,,,,,,,,,,480.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,739,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,628.15,,,,,,,percent of total billed charges,,480.35,,,,,,,percent of total billed charges,,591.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,583.37,,,,,,,fee schedule,Payment capped at billed charges.,701.62,,,,,,,fee schedule,Payment capped at billed charges.,251.26,,,,,,,fee schedule,,739,,,,,,,fee schedule,Payment capped at billed charges.,258.65,,,,,,,fee schedule,,739,,,,,,,fee schedule,Payment capped at billed charges.
EWHO W/JOINT(S) CF,93401255,CDM,0274,RC,L3764,HCPCS,11,Local,NU  ,outpatient,professional,,,841,841,60,971.19,,405.09,,,,,,,fee schedule,Payment capped at billed charges.,971.19,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,596.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,596.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,546.65,,,,,,,fee schedule,Payment capped at billed charges.,420.5,,,,,,,fee schedule,,,,,,,,,,,546.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,841,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,714.85,,,,,,,percent of total billed charges,,546.65,,,,,,,percent of total billed charges,,672.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,761.45,,,,,,,fee schedule,Payment capped at billed charges.,841,,,,,,,fee schedule,Payment capped at billed charges.,285.94,,,,,,,fee schedule,,841,,,,,,,fee schedule,Payment capped at billed charges.,294.35,,,,,,,fee schedule,,841,,,,,,,fee schedule,Payment capped at billed charges.
EWHFO STATIC CUSTOM FIT   ADJ,93401263,CDM,0274,RC,L3765,HCPCS,11,Local,NU  ,outpatient,professional,,,1288,1288,60,1359.22,,566.94,,,,,,,fee schedule,Payment capped at billed charges.,1359.22,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,876.61,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,876.61,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,837.2,,,,,,,fee schedule,Payment capped at billed charges.,644,,,,,,,fee schedule,,,,,,,,,,,837.2,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1288,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1094.8,,,,,,,percent of total billed charges,,837.2,,,,,,,percent of total billed charges,,1030.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1065.65,,,,,,,fee schedule,Payment capped at billed charges.,1281.66,,,,,,,fee schedule,Payment capped at billed charges.,437.92,,,,,,,fee schedule,,1288,,,,,,,fee schedule,Payment capped at billed charges.,450.8,,,,,,,fee schedule,,1288,,,,,,,fee schedule,Payment capped at billed charges.
EWHFO W/JOINT(S) CF,93401271,CDM,0274,RC,L3766,HCPCS,11,Local,NU  ,outpatient,professional,,,1363,1363,60,1439.32,,600.35,,,,,,,fee schedule,Payment capped at billed charges.,1439.32,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,928.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,928.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,885.95,,,,,,,fee schedule,Payment capped at billed charges.,681.5,,,,,,,fee schedule,,,,,,,,,,,885.95,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1363,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1158.55,,,,,,,percent of total billed charges,,885.95,,,,,,,percent of total billed charges,,1090.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1128.45,,,,,,,fee schedule,Payment capped at billed charges.,1357.19,,,,,,,fee schedule,Payment capped at billed charges.,463.42,,,,,,,fee schedule,,1363,,,,,,,fee schedule,Payment capped at billed charges.,477.05,,,,,,,fee schedule,,1363,,,,,,,fee schedule,Payment capped at billed charges.
WHFO STAT PROG DYN CUSTOM FIT,93401289,CDM,0274,RC,L3806,HCPCS,11,Local,NU  ,outpatient,professional,,,518,518,60,518,,200.85,,,,,,,fee schedule,Payment capped at billed charges.,481.53,,,,,,,fee schedule,Payment capped at billed charges.,408.39,,,,,,,fee schedule,Payment capped at billed charges.,408.39,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,310.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,310.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,336.7,,,,,,,fee schedule,Payment capped at billed charges.,408.39,,,,,,,fee schedule,,,,,,,,,,,336.7,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,518,,,,,,,fee schedule,Payment capped at billed charges.,408.39,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,440.3,,,,,,,percent of total billed charges,,336.7,,,,,,,percent of total billed charges,,414.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,377.53,,,,,,,fee schedule,Payment capped at billed charges.,454.06,,,,,,,fee schedule,Payment capped at billed charges.,176.12,,,,,,,fee schedule,,510.18,,,,,,,fee schedule,Payment capped at billed charges.,181.3,,,,,,,fee schedule,,518,,,,,,,fee schedule,Payment capped at billed charges.
WHFO STATIC CUSTOM FIT   ADJ,93401297,CDM,0274,RC,L3808,HCPCS,11,Local,NU  ,outpatient,professional,,,374,374,60,396.4,,165.34,,,,,,,fee schedule,Payment capped at billed charges.,396.4,,,,,,,fee schedule,Payment capped at billed charges.,336.19,,,,,,,fee schedule,Payment capped at billed charges.,336.19,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,243.47,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,243.47,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,243.1,,,,,,,fee schedule,Payment capped at billed charges.,336.19,,,,,,,fee schedule,,,,,,,,,,,243.1,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,374,,,,,,,fee schedule,Payment capped at billed charges.,336.19,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,317.9,,,,,,,percent of total billed charges,,243.1,,,,,,,percent of total billed charges,,299.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,310.79,,,,,,,fee schedule,Payment capped at billed charges.,373.78,,,,,,,fee schedule,Payment capped at billed charges.,127.16,,,,,,,fee schedule,,374,,,,,,,fee schedule,Payment capped at billed charges.,130.9,,,,,,,fee schedule,,374,,,,,,,fee schedule,Payment capped at billed charges.
TENODESIS SPLINT CUST FIT ADJ,93401305,CDM,0274,RC,L3900,HCPCS,11,Local,NU  ,outpatient,professional,,,1463,1463,60,1545.65,,644.7,,,,,,,fee schedule,Payment capped at billed charges.,1545.65,,,,,,,fee schedule,Payment capped at billed charges.,1310.85,,,,,,,fee schedule,Payment capped at billed charges.,1310.85,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,837,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,837,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,950.95,,,,,,,fee schedule,Payment capped at billed charges.,1310.85,,,,,,,fee schedule,,,,,,,,,,,950.95,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463,,,,,,,fee schedule,Payment capped at billed charges.,1310.85,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,1243.55,,,,,,,percent of total billed charges,,950.95,,,,,,,percent of total billed charges,,1170.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1211.82,,,,,,,fee schedule,Payment capped at billed charges.,1457.46,,,,,,,fee schedule,Payment capped at billed charges.,497.42,,,,,,,fee schedule,,1463,,,,,,,fee schedule,Payment capped at billed charges.,512.05,,,,,,,fee schedule,,1463,,,,,,,fee schedule,Payment capped at billed charges.
WHO STATIC PROG DYN CUSTOM FIT,93401313,CDM,0274,RC,L3905,HCPCS,11,Local,NU  ,outpatient,professional,,,996,996,60,1051.25,,438.48,,,,,,,fee schedule,Payment capped at billed charges.,1051.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,645.71,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,645.71,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,647.4,,,,,,,fee schedule,Payment capped at billed charges.,498,,,,,,,fee schedule,,,,,,,,,,,647.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,996,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,846.6,,,,,,,percent of total billed charges,,647.4,,,,,,,percent of total billed charges,,796.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,824.2,,,,,,,fee schedule,Payment capped at billed charges.,991.27,,,,,,,fee schedule,Payment capped at billed charges.,338.64,,,,,,,fee schedule,,996,,,,,,,fee schedule,Payment capped at billed charges.,348.6,,,,,,,fee schedule,,996,,,,,,,fee schedule,Payment capped at billed charges.
WHO STATIC CUSTOM FIT   ADJ,93401321,CDM,0274,RC,L3906,HCPCS,11,Local,NU  ,outpatient,professional,,,447,447,60,466.75,,194.68,,,,,,,fee schedule,Payment capped at billed charges.,466.75,,,,,,,fee schedule,Payment capped at billed charges.,395.84,,,,,,,fee schedule,Payment capped at billed charges.,395.84,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,253,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,253,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,290.55,,,,,,,fee schedule,Payment capped at billed charges.,395.84,,,,,,,fee schedule,,,,,,,,,,,290.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,447,,,,,,,fee schedule,Payment capped at billed charges.,395.84,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,379.95,,,,,,,percent of total billed charges,,290.55,,,,,,,percent of total billed charges,,357.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,365.94,,,,,,,fee schedule,Payment capped at billed charges.,440.11,,,,,,,fee schedule,Payment capped at billed charges.,151.98,,,,,,,fee schedule,,447,,,,,,,fee schedule,Payment capped at billed charges.,156.45,,,,,,,fee schedule,,447,,,,,,,fee schedule,Payment capped at billed charges.
HFO STATIC CUSTOM FIT   ADJ,93401339,CDM,0274,RC,L3913,HCPCS,11,Local,NU  ,outpatient,professional,,,285,285,60,287.11,,119.76,,,,,,,fee schedule,Payment capped at billed charges.,287.11,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,176.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,176.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,185.25,,,,,,,fee schedule,Payment capped at billed charges.,142.5,,,,,,,fee schedule,,,,,,,,,,,185.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,285,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,242.25,,,,,,,percent of total billed charges,,185.25,,,,,,,percent of total billed charges,,228,,,,,,,fee schedule,Payment capped at 80% of billed charges.,225.09,,,,,,,fee schedule,Payment capped at billed charges.,270.72,,,,,,,fee schedule,Payment capped at billed charges.,96.9,,,,,,,fee schedule,,285,,,,,,,fee schedule,Payment capped at billed charges.,99.75,,,,,,,fee schedule,,285,,,,,,,fee schedule,Payment capped at billed charges.
HO HAND ORTHO STAT CUST FIT,93401347,CDM,0274,RC,L3919,HCPCS,11,Local,NU  ,outpatient,professional,,,272,272,60,287.11,,119.76,,,,,,,fee schedule,Payment capped at billed charges.,287.11,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,176.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,176.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,176.8,,,,,,,fee schedule,Payment capped at billed charges.,136,,,,,,,fee schedule,,,,,,,,,,,176.8,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,272,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,231.2,,,,,,,percent of total billed charges,,176.8,,,,,,,percent of total billed charges,,217.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,225.09,,,,,,,fee schedule,Payment capped at billed charges.,270.72,,,,,,,fee schedule,Payment capped at billed charges.,92.48,,,,,,,fee schedule,,272,,,,,,,fee schedule,Payment capped at billed charges.,95.2,,,,,,,fee schedule,,272,,,,,,,fee schedule,Payment capped at billed charges.
HFO STATIC PROG/DYN CUSTOM FIT,93401354,CDM,0274,RC,L3921,HCPCS,11,Local,NU  ,outpatient,professional,,,345,345,60,345,,142.02,,,,,,,fee schedule,Payment capped at billed charges.,340.49,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,209.15,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,209.15,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,224.25,,,,,,,fee schedule,Payment capped at billed charges.,172.5,,,,,,,fee schedule,,,,,,,,,,,224.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,345,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,293.25,,,,,,,percent of total billed charges,,224.25,,,,,,,percent of total billed charges,,276,,,,,,,fee schedule,Payment capped at 80% of billed charges.,266.96,,,,,,,fee schedule,Payment capped at billed charges.,321.07,,,,,,,fee schedule,Payment capped at billed charges.,117.3,,,,,,,fee schedule,,345,,,,,,,fee schedule,Payment capped at billed charges.,120.75,,,,,,,fee schedule,,345,,,,,,,fee schedule,Payment capped at billed charges.
FO FINGR STATIC CUST ORTHO FIT,93401362,CDM,0274,RC,L3933,HCPCS,11,Local,NU  ,outpatient,professional,,,214,214,60,226.15,,94.33,,,,,,,fee schedule,Payment capped at billed charges.,226.15,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,138.92,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,138.92,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,139.1,,,,,,,fee schedule,Payment capped at billed charges.,107,,,,,,,fee schedule,,,,,,,,,,,139.1,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,214,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,181.9,,,,,,,percent of total billed charges,,139.1,,,,,,,percent of total billed charges,,171.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,177.3,,,,,,,fee schedule,Payment capped at billed charges.,213.24,,,,,,,fee schedule,Payment capped at billed charges.,72.76,,,,,,,fee schedule,,214,,,,,,,fee schedule,Payment capped at billed charges.,74.9,,,,,,,fee schedule,,214,,,,,,,fee schedule,Payment capped at billed charges.
FO STAT PROG/DYN CUST ORTH FIT,93401370,CDM,0274,RC,L3935,HCPCS,11,Local,NU  ,outpatient,professional,,,222,222,60,234.16,,97.67,,,,,,,fee schedule,Payment capped at billed charges.,234.16,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,143.84,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,143.84,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,144.3,,,,,,,fee schedule,Payment capped at billed charges.,111,,,,,,,fee schedule,,,,,,,,,,,144.3,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,222,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,188.7,,,,,,,percent of total billed charges,,144.3,,,,,,,percent of total billed charges,,177.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,183.59,,,,,,,fee schedule,Payment capped at billed charges.,220.8,,,,,,,fee schedule,Payment capped at billed charges.,75.48,,,,,,,fee schedule,,222,,,,,,,fee schedule,Payment capped at billed charges.,77.7,,,,,,,fee schedule,,222,,,,,,,fee schedule,Payment capped at billed charges.
SEWHO CAP DESIGN W/O JNTS CF,93401388,CDM,0274,RC,L3961,HCPCS,11,Local,NU  ,outpatient,professional,,,1688,1688,60,1780.97,,742.86,,,,,,,fee schedule,Payment capped at billed charges.,1780.97,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,1148.61,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,1148.61,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,1097.2,,,,,,,fee schedule,Payment capped at billed charges.,844,,,,,,,fee schedule,,,,,,,,,,,1097.2,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1688,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1434.8,,,,,,,percent of total billed charges,,1097.2,,,,,,,percent of total billed charges,,1350.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1396.32,,,,,,,fee schedule,Payment capped at billed charges.,1679.36,,,,,,,fee schedule,Payment capped at billed charges.,573.92,,,,,,,fee schedule,,1688,,,,,,,fee schedule,Payment capped at billed charges.,590.8,,,,,,,fee schedule,,1688,,,,,,,fee schedule,Payment capped at billed charges.
SP LARYNGEAL FUNCTION STUDIES,93401396,CDM,0440,RC,92520,CPT,11,Local,GN  ,outpatient,professional,,,285,285,60,259.88,,102.56,,,,,,,fee schedule,Payment capped at billed charges.,229.14,,,,,,,fee schedule,Payment capped at billed charges.,85,,,,,,,fee schedule,Payment capped at billed charges.,85,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,108.47,,,,,,,fee schedule,Payment capped at billed charges.,99.57,,,,,,,fee schedule,Payment capped at billed charges.,120.51,,,,,,,fee schedule,Payment capped at billed charges.,102.56,,,,,,,fee schedule,Payment capped at billed charges.,245.25,,,,,,,fee schedule,Payment capped at billed charges.,85,,,,,,,fee schedule,,106.25,,,,,,,fee schedule,Payment capped at billed charges.,101.19,,,,,,,fee schedule,Payment capped at billed charges.,69.05,,,,,,,fee schedule,Payment capped at billed charges.,104.55,,,,,,,fee schedule,Payment capped at billed charges.,125.48,,,,,,,fee schedule,Payment capped at billed charges.,96.33,,,,,,,fee schedule,Payment capped at billed charges.,85,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,242.25,,,,,,,percent of total billed charges,,185.25,,,,,,,percent of total billed charges,,98.15,,,,,,,fee schedule,Payment capped at 80% of billed charges.,192.31,,,,,,,fee schedule,Payment capped at billed charges.,231.29,,,,,,,fee schedule,Payment capped at billed charges.,60.64,,,,,,,fee schedule,,259.88,,,,,,,fee schedule,Payment capped at billed charges.,101.56,,,,,,,fee schedule,,101.19,,,,,,,fee schedule,Payment capped at billed charges.
PT CAREGIVER TRAING 1ST 30 MIN,93401412,CDM,0420,RC,97550,CPT,11,Local,GP  ,outpatient,professional,,,155,155,48.46,152.56,,58.47,,,,,,,fee schedule,Payment capped at billed charges.,117.13,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,79.45,,,,,,,fee schedule,Payment capped at billed charges.,56.77,,,,,,,fee schedule,Payment capped at billed charges.,88.28,,,,,,,fee schedule,Payment capped at billed charges.,58.47,,,,,,,fee schedule,Payment capped at billed charges.,152.56,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,,60.57,,,,,,,fee schedule,Payment capped at billed charges.,57.69,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,59.61,,,,,,,fee schedule,Payment capped at billed charges.,71.54,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,131.75,,,,,,,percent of total billed charges,,100.75,,,,,,,percent of total billed charges,,55.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,111.57,,,,,,,fee schedule,Payment capped at billed charges.,134.19,,,,,,,fee schedule,Payment capped at billed charges.,54.49,,,,,,,fee schedule,,150.77,,,,,,,fee schedule,Payment capped at billed charges.,57.9,,,,,,,fee schedule,,57.69,,,,,,,fee schedule,Payment capped at billed charges.
PT CAREGIVER TRAING EA ADDL 15,93401420,CDM,0420,RC,97551,CPT,11,Local,GP  ,outpatient,professional,,,76,76,23.59,90,,28.47,,,,,,,fee schedule,Payment capped at billed charges.,57.81,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.22,,,,,,,fee schedule,Payment capped at billed charges.,27.64,,,,,,,fee schedule,Payment capped at billed charges.,43.57,,,,,,,fee schedule,Payment capped at billed charges.,28.47,,,,,,,fee schedule,Payment capped at billed charges.,75.11,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,29.49,,,,,,,fee schedule,Payment capped at billed charges.,28.09,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.02,,,,,,,fee schedule,Payment capped at billed charges.,34.83,,,,,,,fee schedule,Payment capped at billed charges.,28.08,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,64.6,,,,,,,percent of total billed charges,,49.4,,,,,,,percent of total billed charges,,27.25,,,,,,,fee schedule,Payment capped at 80% of billed charges.,55.07,,,,,,,fee schedule,Payment capped at billed charges.,66.23,,,,,,,fee schedule,Payment capped at billed charges.,26.61,,,,,,,fee schedule,,74.42,,,,,,,fee schedule,Payment capped at billed charges.,28.19,,,,,,,fee schedule,,28.09,,,,,,,fee schedule,Payment capped at billed charges.
PT GROUP CAREGIVER TRAINING,93401438,CDM,0420,RC,97552,CPT,11,Local,GP  ,outpatient,professional,,,68,68,21.18,90,,25.55,,,,,,,fee schedule,Payment capped at billed charges.,51.09,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,34.64,,,,,,,fee schedule,Payment capped at billed charges.,24.81,,,,,,,fee schedule,Payment capped at billed charges.,38.49,,,,,,,fee schedule,Payment capped at billed charges.,25.55,,,,,,,fee schedule,Payment capped at billed charges.,67.25,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,,26.47,,,,,,,fee schedule,Payment capped at billed charges.,25.21,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,26.05,,,,,,,fee schedule,Payment capped at billed charges.,31.26,,,,,,,fee schedule,Payment capped at billed charges.,24.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,57.8,,,,,,,percent of total billed charges,,44.2,,,,,,,percent of total billed charges,,24.45,,,,,,,fee schedule,Payment capped at 80% of billed charges.,48.65,,,,,,,fee schedule,Payment capped at billed charges.,58.51,,,,,,,fee schedule,Payment capped at billed charges.,23.35,,,,,,,fee schedule,,65.74,,,,,,,fee schedule,Payment capped at billed charges.,25.3,,,,,,,fee schedule,,25.21,,,,,,,fee schedule,Payment capped at billed charges.
OT CAREGIVER TRAING 1ST 30 MIN,93401446,CDM,0430,RC,97550,CPT,11,Local,GO  ,outpatient,professional,,,155,155,48.46,152.56,,58.47,,,,,,,fee schedule,Payment capped at billed charges.,117.13,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,79.45,,,,,,,fee schedule,Payment capped at billed charges.,56.77,,,,,,,fee schedule,Payment capped at billed charges.,88.28,,,,,,,fee schedule,Payment capped at billed charges.,58.47,,,,,,,fee schedule,Payment capped at billed charges.,152.56,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,,60.57,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,59.61,,,,,,,fee schedule,Payment capped at billed charges.,71.54,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,131.75,,,,,,,percent of total billed charges,,100.75,,,,,,,percent of total billed charges,,55.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,111.57,,,,,,,fee schedule,Payment capped at billed charges.,134.19,,,,,,,fee schedule,Payment capped at billed charges.,54.49,,,,,,,fee schedule,,150.77,,,,,,,fee schedule,Payment capped at billed charges.,57.9,,,,,,,fee schedule,,57.69,,,,,,,fee schedule,Payment capped at billed charges.
OT CAREGIVER TRAING EA ADDL 15,93401453,CDM,0430,RC,97551,CPT,11,Local,GO  ,outpatient,professional,,,76,76,23.59,90,,28.47,,,,,,,fee schedule,Payment capped at billed charges.,57.81,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.22,,,,,,,fee schedule,Payment capped at billed charges.,27.64,,,,,,,fee schedule,Payment capped at billed charges.,43.57,,,,,,,fee schedule,Payment capped at billed charges.,28.47,,,,,,,fee schedule,Payment capped at billed charges.,75.11,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,29.49,,,,,,,fee schedule,Payment capped at billed charges.,36.52,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.02,,,,,,,fee schedule,Payment capped at billed charges.,34.83,,,,,,,fee schedule,Payment capped at billed charges.,28.08,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,64.6,,,,,,,percent of total billed charges,,49.4,,,,,,,percent of total billed charges,,27.25,,,,,,,fee schedule,Payment capped at 80% of billed charges.,55.07,,,,,,,fee schedule,Payment capped at billed charges.,66.23,,,,,,,fee schedule,Payment capped at billed charges.,26.61,,,,,,,fee schedule,,74.42,,,,,,,fee schedule,Payment capped at billed charges.,28.19,,,,,,,fee schedule,,28.09,,,,,,,fee schedule,Payment capped at billed charges.
OT GROUP CAREGIVER TRAINING,93401461,CDM,0430,RC,97552,CPT,11,Local,GO  ,outpatient,professional,,,68,68,21.18,90,,25.55,,,,,,,fee schedule,Payment capped at billed charges.,51.09,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,34.64,,,,,,,fee schedule,Payment capped at billed charges.,24.81,,,,,,,fee schedule,Payment capped at billed charges.,38.49,,,,,,,fee schedule,Payment capped at billed charges.,25.55,,,,,,,fee schedule,Payment capped at billed charges.,67.25,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,,26.47,,,,,,,fee schedule,Payment capped at billed charges.,32.77,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,26.05,,,,,,,fee schedule,Payment capped at billed charges.,31.26,,,,,,,fee schedule,Payment capped at billed charges.,24.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,57.8,,,,,,,percent of total billed charges,,44.2,,,,,,,percent of total billed charges,,24.45,,,,,,,fee schedule,Payment capped at 80% of billed charges.,48.65,,,,,,,fee schedule,Payment capped at billed charges.,58.51,,,,,,,fee schedule,Payment capped at billed charges.,23.35,,,,,,,fee schedule,,65.74,,,,,,,fee schedule,Payment capped at billed charges.,25.3,,,,,,,fee schedule,,25.21,,,,,,,fee schedule,Payment capped at billed charges.
SP CAREGIVER TRAING 1ST 30 MIN,93401479,CDM,0440,RC,97550,CPT,11,Local,GN  ,outpatient,professional,,,155,155,48.46,152.56,,58.47,,,,,,,fee schedule,Payment capped at billed charges.,117.13,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,79.45,,,,,,,fee schedule,Payment capped at billed charges.,56.77,,,,,,,fee schedule,Payment capped at billed charges.,88.28,,,,,,,fee schedule,Payment capped at billed charges.,58.47,,,,,,,fee schedule,Payment capped at billed charges.,152.56,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,,60.57,,,,,,,fee schedule,Payment capped at billed charges.,57.69,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,59.61,,,,,,,fee schedule,Payment capped at billed charges.,71.54,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,131.75,,,,,,,percent of total billed charges,,100.75,,,,,,,percent of total billed charges,,55.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,111.57,,,,,,,fee schedule,Payment capped at billed charges.,134.19,,,,,,,fee schedule,Payment capped at billed charges.,54.49,,,,,,,fee schedule,,150.77,,,,,,,fee schedule,Payment capped at billed charges.,57.9,,,,,,,fee schedule,,57.69,,,,,,,fee schedule,Payment capped at billed charges.
SP CAREGIVER TRAING EA ADDL 15,93401487,CDM,0440,RC,97551,CPT,11,Local,GN  ,outpatient,professional,,,76,76,23.59,90,,28.47,,,,,,,fee schedule,Payment capped at billed charges.,57.81,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.22,,,,,,,fee schedule,Payment capped at billed charges.,27.64,,,,,,,fee schedule,Payment capped at billed charges.,43.57,,,,,,,fee schedule,Payment capped at billed charges.,28.47,,,,,,,fee schedule,Payment capped at billed charges.,75.11,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,29.49,,,,,,,fee schedule,Payment capped at billed charges.,28.09,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.02,,,,,,,fee schedule,Payment capped at billed charges.,34.83,,,,,,,fee schedule,Payment capped at billed charges.,28.08,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,64.6,,,,,,,percent of total billed charges,,49.4,,,,,,,percent of total billed charges,,27.25,,,,,,,fee schedule,Payment capped at 80% of billed charges.,55.07,,,,,,,fee schedule,Payment capped at billed charges.,66.23,,,,,,,fee schedule,Payment capped at billed charges.,26.61,,,,,,,fee schedule,,74.42,,,,,,,fee schedule,Payment capped at billed charges.,28.19,,,,,,,fee schedule,,28.09,,,,,,,fee schedule,Payment capped at billed charges.
SP GROUP CAREGIVER TRAINING,93401495,CDM,0440,RC,97552,CPT,11,Local,GN  ,outpatient,professional,,,68,68,21.18,90,,25.55,,,,,,,fee schedule,Payment capped at billed charges.,51.09,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,34.64,,,,,,,fee schedule,Payment capped at billed charges.,24.81,,,,,,,fee schedule,Payment capped at billed charges.,38.49,,,,,,,fee schedule,Payment capped at billed charges.,25.55,,,,,,,fee schedule,Payment capped at billed charges.,67.25,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,,26.47,,,,,,,fee schedule,Payment capped at billed charges.,25.21,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,26.05,,,,,,,fee schedule,Payment capped at billed charges.,31.26,,,,,,,fee schedule,Payment capped at billed charges.,24.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,57.8,,,,,,,percent of total billed charges,,44.2,,,,,,,percent of total billed charges,,24.45,,,,,,,fee schedule,Payment capped at 80% of billed charges.,48.65,,,,,,,fee schedule,Payment capped at billed charges.,58.51,,,,,,,fee schedule,Payment capped at billed charges.,23.35,,,,,,,fee schedule,,65.74,,,,,,,fee schedule,Payment capped at billed charges.,25.3,,,,,,,fee schedule,,25.21,,,,,,,fee schedule,Payment capped at billed charges.
PT RTM INITIAL SETUP,93401503,CDM,0940,RC,98975,CPT,11,Local,GP  ,outpatient,professional,,,258,258,19.97,219.3,,23.82,,,,,,,fee schedule,Payment capped at billed charges.,53.49,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.28,,,,,,,fee schedule,Payment capped at billed charges.,23.12,,,,,,,fee schedule,Payment capped at billed charges.,43.64,,,,,,,fee schedule,Payment capped at billed charges.,23.82,,,,,,,fee schedule,Payment capped at billed charges.,59.25,,,,,,,fee schedule,Payment capped at billed charges.,129,,,,,,,fee schedule,,24.68,,,,,,,fee schedule,Payment capped at billed charges.,23.5,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,24.28,,,,,,,fee schedule,Payment capped at billed charges.,29.14,,,,,,,fee schedule,Payment capped at billed charges.,21.69,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,219.3,,,,,,,percent of total billed charges,,167.7,,,,,,,percent of total billed charges,,206.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,45.43,,,,,,,fee schedule,Payment capped at billed charges.,21.42,,,,,,,fee schedule,,51.05,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,23.5,,,,,,,fee schedule,Payment capped at billed charges.
PT RTM DATA COLLECTION,93401511,CDM,0940,RC,98977,CPT,11,Local,GP  ,outpatient,professional,,,75,75,37.5,90,,51.96,,,,,,,fee schedule,Payment capped at billed charges.,77.03,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,75,,,,,,,fee schedule,Payment capped at billed charges.,50.45,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,51.96,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,37.5,,,,,,,fee schedule,,53.83,,,,,,,fee schedule,Payment capped at billed charges.,51.27,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,52.97,,,,,,,fee schedule,Payment capped at billed charges.,63.57,,,,,,,fee schedule,Payment capped at billed charges.,47.27,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,63.75,,,,,,,percent of total billed charges,,48.75,,,,,,,percent of total billed charges,,60,,,,,,,fee schedule,Payment capped at 80% of billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,46.45,,,,,,,fee schedule,,75,,,,,,,fee schedule,Payment capped at billed charges.,51.46,,,,,,,fee schedule,,51.27,,,,,,,fee schedule,Payment capped at billed charges.
PT RTM INITIAL 20 MINS CONSULT,93401529,CDM,0940,RC,98980,CPT,11,Local,GP  ,outpatient,professional,,,106,106,48.47,108.86,,57.79,,,,,,,fee schedule,Payment capped at billed charges.,108.86,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,95.29,,,,,,,fee schedule,Payment capped at billed charges.,56.11,,,,,,,fee schedule,Payment capped at billed charges.,105.88,,,,,,,fee schedule,Payment capped at billed charges.,57.79,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53,,,,,,,fee schedule,,59.87,,,,,,,fee schedule,Payment capped at billed charges.,57.02,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,58.91,,,,,,,fee schedule,Payment capped at billed charges.,70.7,,,,,,,fee schedule,Payment capped at billed charges.,55.1,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,90.1,,,,,,,percent of total billed charges,,68.9,,,,,,,percent of total billed charges,,84.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,91.29,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53.18,,,,,,,fee schedule,,106,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,,57.02,,,,,,,fee schedule,Payment capped at billed charges.
PT RTM ADDL 20 MINS CONSULT,93401537,CDM,0940,RC,98981,CPT,11,Local,GP  ,outpatient,professional,,,83,83,37.37,90,,44.55,,,,,,,fee schedule,Payment capped at billed charges.,85.24,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,76.5,,,,,,,fee schedule,Payment capped at billed charges.,43.26,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,44.55,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.5,,,,,,,fee schedule,,46.16,,,,,,,fee schedule,Payment capped at billed charges.,43.96,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,45.42,,,,,,,fee schedule,Payment capped at billed charges.,54.51,,,,,,,fee schedule,Payment capped at billed charges.,43.01,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,70.55,,,,,,,percent of total billed charges,,53.95,,,,,,,percent of total billed charges,,66.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,71.2,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.35,,,,,,,fee schedule,,83,,,,,,,fee schedule,Payment capped at billed charges.,44.12,,,,,,,fee schedule,,43.96,,,,,,,fee schedule,Payment capped at billed charges.
OT RTM INITIAL SETUP,93401545,CDM,0940,RC,98975,CPT,11,Local,GO  ,outpatient,professional,,,258,258,19.97,219.3,,23.82,,,,,,,fee schedule,Payment capped at billed charges.,53.49,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.28,,,,,,,fee schedule,Payment capped at billed charges.,23.12,,,,,,,fee schedule,Payment capped at billed charges.,43.64,,,,,,,fee schedule,Payment capped at billed charges.,23.82,,,,,,,fee schedule,Payment capped at billed charges.,59.25,,,,,,,fee schedule,Payment capped at billed charges.,129,,,,,,,fee schedule,,24.68,,,,,,,fee schedule,Payment capped at billed charges.,30.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,24.28,,,,,,,fee schedule,Payment capped at billed charges.,29.14,,,,,,,fee schedule,Payment capped at billed charges.,21.69,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,219.3,,,,,,,percent of total billed charges,,167.7,,,,,,,percent of total billed charges,,206.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,45.43,,,,,,,fee schedule,Payment capped at billed charges.,21.42,,,,,,,fee schedule,,51.05,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,23.5,,,,,,,fee schedule,Payment capped at billed charges.
OT RTM DATA COLLECTION,93401552,CDM,0940,RC,98977,CPT,11,Local,GO  ,outpatient,professional,,,75,75,37.5,90,,51.96,,,,,,,fee schedule,Payment capped at billed charges.,77.03,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,75,,,,,,,fee schedule,Payment capped at billed charges.,50.45,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,51.96,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,37.5,,,,,,,fee schedule,,53.83,,,,,,,fee schedule,Payment capped at billed charges.,66.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,52.97,,,,,,,fee schedule,Payment capped at billed charges.,63.57,,,,,,,fee schedule,Payment capped at billed charges.,47.27,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,63.75,,,,,,,percent of total billed charges,,48.75,,,,,,,percent of total billed charges,,60,,,,,,,fee schedule,Payment capped at 80% of billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,46.45,,,,,,,fee schedule,,75,,,,,,,fee schedule,Payment capped at billed charges.,51.46,,,,,,,fee schedule,,51.27,,,,,,,fee schedule,Payment capped at billed charges.
OT RTM INITIAL 20 MINS CONSULT,93401560,CDM,0940,RC,98980,CPT,11,Local,GO  ,outpatient,professional,,,106,106,48.47,108.86,,57.79,,,,,,,fee schedule,Payment capped at billed charges.,108.86,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,95.29,,,,,,,fee schedule,Payment capped at billed charges.,56.11,,,,,,,fee schedule,Payment capped at billed charges.,105.88,,,,,,,fee schedule,Payment capped at billed charges.,57.79,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53,,,,,,,fee schedule,,59.87,,,,,,,fee schedule,Payment capped at billed charges.,74.13,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,58.91,,,,,,,fee schedule,Payment capped at billed charges.,70.7,,,,,,,fee schedule,Payment capped at billed charges.,55.1,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,90.1,,,,,,,percent of total billed charges,,68.9,,,,,,,percent of total billed charges,,84.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,91.29,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53.18,,,,,,,fee schedule,,106,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,,57.02,,,,,,,fee schedule,Payment capped at billed charges.
OT RTM ADDL 20 MINS CONSULT,93401578,CDM,0940,RC,98981,CPT,11,Local,GO  ,outpatient,professional,,,83,83,37.37,90,,44.55,,,,,,,fee schedule,Payment capped at billed charges.,85.24,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,76.5,,,,,,,fee schedule,Payment capped at billed charges.,43.26,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,44.55,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.5,,,,,,,fee schedule,,46.16,,,,,,,fee schedule,Payment capped at billed charges.,57.15,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,45.42,,,,,,,fee schedule,Payment capped at billed charges.,54.51,,,,,,,fee schedule,Payment capped at billed charges.,43.01,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,70.55,,,,,,,percent of total billed charges,,53.95,,,,,,,percent of total billed charges,,66.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,71.2,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.35,,,,,,,fee schedule,,83,,,,,,,fee schedule,Payment capped at billed charges.,44.12,,,,,,,fee schedule,,43.96,,,,,,,fee schedule,Payment capped at billed charges.
SP RTM INITIAL SETUP,93401586,CDM,0940,RC,98975,CPT,11,Local,GN  ,outpatient,professional,,,258,258,19.97,219.3,,23.82,,,,,,,fee schedule,Payment capped at billed charges.,53.49,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.28,,,,,,,fee schedule,Payment capped at billed charges.,23.12,,,,,,,fee schedule,Payment capped at billed charges.,43.64,,,,,,,fee schedule,Payment capped at billed charges.,23.82,,,,,,,fee schedule,Payment capped at billed charges.,59.25,,,,,,,fee schedule,Payment capped at billed charges.,129,,,,,,,fee schedule,,24.68,,,,,,,fee schedule,Payment capped at billed charges.,23.5,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,24.28,,,,,,,fee schedule,Payment capped at billed charges.,29.14,,,,,,,fee schedule,Payment capped at billed charges.,21.69,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,219.3,,,,,,,percent of total billed charges,,167.7,,,,,,,percent of total billed charges,,206.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,45.43,,,,,,,fee schedule,Payment capped at billed charges.,21.42,,,,,,,fee schedule,,51.05,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,23.5,,,,,,,fee schedule,Payment capped at billed charges.
SP RTM DATA COLLECTION,93401594,CDM,0940,RC,98977,CPT,11,Local,GN  ,outpatient,professional,,,75,75,37.5,90,,51.96,,,,,,,fee schedule,Payment capped at billed charges.,77.03,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,75,,,,,,,fee schedule,Payment capped at billed charges.,50.45,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,51.96,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,37.5,,,,,,,fee schedule,,53.83,,,,,,,fee schedule,Payment capped at billed charges.,51.27,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,52.97,,,,,,,fee schedule,Payment capped at billed charges.,63.57,,,,,,,fee schedule,Payment capped at billed charges.,47.27,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,63.75,,,,,,,percent of total billed charges,,48.75,,,,,,,percent of total billed charges,,60,,,,,,,fee schedule,Payment capped at 80% of billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,46.45,,,,,,,fee schedule,,75,,,,,,,fee schedule,Payment capped at billed charges.,51.46,,,,,,,fee schedule,,51.27,,,,,,,fee schedule,Payment capped at billed charges.
SP RTM INITIAL 20 MINS CONSULT,93401602,CDM,0940,RC,98980,CPT,11,Local,GN  ,outpatient,professional,,,106,106,48.47,108.86,,57.79,,,,,,,fee schedule,Payment capped at billed charges.,108.86,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,95.29,,,,,,,fee schedule,Payment capped at billed charges.,56.11,,,,,,,fee schedule,Payment capped at billed charges.,105.88,,,,,,,fee schedule,Payment capped at billed charges.,57.79,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53,,,,,,,fee schedule,,59.87,,,,,,,fee schedule,Payment capped at billed charges.,57.02,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,58.91,,,,,,,fee schedule,Payment capped at billed charges.,70.7,,,,,,,fee schedule,Payment capped at billed charges.,55.1,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,90.1,,,,,,,percent of total billed charges,,68.9,,,,,,,percent of total billed charges,,84.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,91.29,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53.18,,,,,,,fee schedule,,106,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,,57.02,,,,,,,fee schedule,Payment capped at billed charges.
SP RTM ADDL 20 MINS CONSULT,93401610,CDM,0940,RC,98981,CPT,11,Local,GN  ,outpatient,professional,,,83,83,37.37,90,,44.55,,,,,,,fee schedule,Payment capped at billed charges.,85.24,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,76.5,,,,,,,fee schedule,Payment capped at billed charges.,43.26,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,44.55,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.5,,,,,,,fee schedule,,46.16,,,,,,,fee schedule,Payment capped at billed charges.,43.96,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,45.42,,,,,,,fee schedule,Payment capped at billed charges.,54.51,,,,,,,fee schedule,Payment capped at billed charges.,43.01,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,70.55,,,,,,,percent of total billed charges,,53.95,,,,,,,percent of total billed charges,,66.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,71.2,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.35,,,,,,,fee schedule,,83,,,,,,,fee schedule,Payment capped at billed charges.,44.12,,,,,,,fee schedule,,43.96,,,,,,,fee schedule,Payment capped at billed charges.
PT NDL INS W/O NJX 1 OR 2 MUSC,93500015,CDM,0420,RC,20560,CPT,11,Local,GP  ,outpatient,professional,,,137,137,23.03,116.45,,28.27,,,,,,,fee schedule,Payment capped at billed charges.,68.33,,,,,,,fee schedule,Payment capped at billed charges.,23.71,,,,,,,fee schedule,Payment capped at billed charges.,23.71,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,54.1,,,,,,,fee schedule,Payment capped at billed charges.,27.44,,,,,,,fee schedule,Payment capped at billed charges.,60.11,,,,,,,fee schedule,Payment capped at billed charges.,28.27,,,,,,,fee schedule,Payment capped at billed charges.,73.63,,,,,,,fee schedule,Payment capped at billed charges.,68.5,,,,,,,fee schedule,,29.28,,,,,,,fee schedule,Payment capped at billed charges.,27.89,,,,,,,fee schedule,Payment capped at billed charges.,26.22,,,,,,,fee schedule,Payment capped at billed charges.,28.82,,,,,,,fee schedule,Payment capped at billed charges.,34.58,,,,,,,fee schedule,Payment capped at billed charges.,27.01,,,,,,,fee schedule,Payment capped at billed charges.,23.71,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,116.45,,,,,,,percent of total billed charges,,89.05,,,,,,,percent of total billed charges,,109.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,53.01,,,,,,,fee schedule,Payment capped at billed charges.,63.76,,,,,,,fee schedule,Payment capped at billed charges.,23.03,,,,,,,fee schedule,,71.64,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,,27.89,,,,,,,fee schedule,Payment capped at billed charges.
PT NDL INSJ W/O NJX 3  MUSC,93500023,CDM,0420,RC,20561,CPT,11,Local,GP  ,outpatient,professional,,,137,137,34.25,116.45,,41.23,,,,,,,fee schedule,Payment capped at billed charges.,99.22,,,,,,,fee schedule,Payment capped at billed charges.,34.58,,,,,,,fee schedule,Payment capped at billed charges.,34.58,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,76.7,,,,,,,fee schedule,Payment capped at billed charges.,40.03,,,,,,,fee schedule,Payment capped at billed charges.,85.22,,,,,,,fee schedule,Payment capped at billed charges.,41.23,,,,,,,fee schedule,Payment capped at billed charges.,104.39,,,,,,,fee schedule,Payment capped at billed charges.,68.5,,,,,,,fee schedule,,42.71,,,,,,,fee schedule,Payment capped at billed charges.,40.68,,,,,,,fee schedule,Payment capped at billed charges.,39,,,,,,,fee schedule,Payment capped at billed charges.,42.03,,,,,,,fee schedule,Payment capped at billed charges.,50.44,,,,,,,fee schedule,Payment capped at billed charges.,39.45,,,,,,,fee schedule,Payment capped at billed charges.,34.58,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,116.45,,,,,,,percent of total billed charges,,89.05,,,,,,,percent of total billed charges,,109.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,76.25,,,,,,,fee schedule,Payment capped at billed charges.,91.71,,,,,,,fee schedule,Payment capped at billed charges.,34.25,,,,,,,fee schedule,,103.04,,,,,,,fee schedule,Payment capped at billed charges.,40.83,,,,,,,fee schedule,,40.68,,,,,,,fee schedule,Payment capped at billed charges.
PT BIOFEEDBACK TRAINING,93500031,CDM,0420,RC,90901,CPT,11,Local,GP  ,outpatient,professional,,,141,141,28.82,120.85,,45.84,,,,,,,fee schedule,Payment capped at billed charges.,109.44,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,72,,,,,,,fee schedule,Payment capped at billed charges.,44.51,,,,,,,fee schedule,Payment capped at billed charges.,80.01,,,,,,,fee schedule,Payment capped at billed charges.,45.84,,,,,,,fee schedule,Payment capped at billed charges.,120.5,,,,,,,fee schedule,Payment capped at billed charges.,70.5,,,,,,,fee schedule,,47.49,,,,,,,fee schedule,Payment capped at billed charges.,45.23,,,,,,,fee schedule,Payment capped at billed charges.,32.81,,,,,,,fee schedule,Payment capped at billed charges.,46.73,,,,,,,fee schedule,Payment capped at billed charges.,56.09,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,38.45,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,119.85,,,,,,,percent of total billed charges,,91.65,,,,,,,percent of total billed charges,,43.87,,,,,,,fee schedule,Payment capped at 80% of billed charges.,89.43,,,,,,,fee schedule,Payment capped at billed charges.,107.56,,,,,,,fee schedule,Payment capped at billed charges.,28.82,,,,,,,fee schedule,,120.85,,,,,,,fee schedule,Payment capped at billed charges.,45.4,,,,,,,fee schedule,,45.23,,,,,,,fee schedule,Payment capped at billed charges.
PT BIOFEEDBACK INCONT 1ST15MIN,93500049,CDM,0420,RC,90912,CPT,11,Local,GP  ,outpatient,professional,,,237,237,60,237,,89.78,,,,,,,fee schedule,Payment capped at billed charges.,214.19,,,,,,,fee schedule,Payment capped at billed charges.,75.29,,,,,,,fee schedule,Payment capped at billed charges.,75.29,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,135.24,,,,,,,fee schedule,Payment capped at billed charges.,87.16,,,,,,,fee schedule,Payment capped at billed charges.,150.27,,,,,,,fee schedule,Payment capped at billed charges.,89.78,,,,,,,fee schedule,Payment capped at billed charges.,237,,,,,,,fee schedule,Payment capped at billed charges.,118.5,,,,,,,fee schedule,,93.01,,,,,,,fee schedule,Payment capped at billed charges.,88.58,,,,,,,fee schedule,Payment capped at billed charges.,80.3,,,,,,,fee schedule,Payment capped at billed charges.,91.52,,,,,,,fee schedule,Payment capped at billed charges.,109.84,,,,,,,fee schedule,Payment capped at billed charges.,106.24,,,,,,,fee schedule,Payment capped at billed charges.,75.29,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,201.45,,,,,,,percent of total billed charges,,154.05,,,,,,,percent of total billed charges,,85.91,,,,,,,fee schedule,Payment capped at 80% of billed charges.,175.13,,,,,,,fee schedule,Payment capped at billed charges.,210.63,,,,,,,fee schedule,Payment capped at billed charges.,70.53,,,,,,,fee schedule,,236.66,,,,,,,fee schedule,Payment capped at billed charges.,88.91,,,,,,,fee schedule,,88.58,,,,,,,fee schedule,Payment capped at billed charges.
PT BIOFEEDBACK INCONT ADD15MIN,93500056,CDM,0420,RC,90913,CPT,11,Local,GP  ,outpatient,professional,,,91,91,28.38,91,,35.67,,,,,,,fee schedule,Payment capped at billed charges.,83.99,,,,,,,fee schedule,Payment capped at billed charges.,29.91,,,,,,,fee schedule,Payment capped at billed charges.,29.91,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,53.66,,,,,,,fee schedule,Payment capped at billed charges.,34.63,,,,,,,fee schedule,Payment capped at billed charges.,59.61,,,,,,,fee schedule,Payment capped at billed charges.,35.67,,,,,,,fee schedule,Payment capped at billed charges.,91,,,,,,,fee schedule,Payment capped at billed charges.,45.5,,,,,,,fee schedule,,36.95,,,,,,,fee schedule,Payment capped at billed charges.,35.19,,,,,,,fee schedule,Payment capped at billed charges.,32.32,,,,,,,fee schedule,Payment capped at billed charges.,36.36,,,,,,,fee schedule,Payment capped at billed charges.,43.64,,,,,,,fee schedule,Payment capped at billed charges.,42.94,,,,,,,fee schedule,Payment capped at billed charges.,29.91,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,77.35,,,,,,,percent of total billed charges,,59.15,,,,,,,percent of total billed charges,,34.14,,,,,,,fee schedule,Payment capped at 80% of billed charges.,68.23,,,,,,,fee schedule,Payment capped at billed charges.,82.06,,,,,,,fee schedule,Payment capped at billed charges.,28.38,,,,,,,fee schedule,,91,,,,,,,fee schedule,Payment capped at billed charges.,35.32,,,,,,,fee schedule,,35.19,,,,,,,fee schedule,Payment capped at billed charges.
PT CANALITH REPOSITIONING,93500064,CDM,0420,RC,95992,CPT,11,Local,GP  ,outpatient,professional,,,124,124,33.84,120.98,,46.29,,,,,,,fee schedule,Payment capped at billed charges.,111.9,,,,,,,fee schedule,Payment capped at billed charges.,38.37,,,,,,,fee schedule,Payment capped at billed charges.,38.37,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,80.39,,,,,,,fee schedule,Payment capped at billed charges.,44.94,,,,,,,fee schedule,Payment capped at billed charges.,89.32,,,,,,,fee schedule,Payment capped at billed charges.,46.29,,,,,,,fee schedule,Payment capped at billed charges.,100.95,,,,,,,fee schedule,Payment capped at billed charges.,38.37,,,,,,,fee schedule,,47.95,,,,,,,fee schedule,Payment capped at billed charges.,45.67,,,,,,,fee schedule,Payment capped at billed charges.,38.53,,,,,,,fee schedule,Payment capped at billed charges.,47.19,,,,,,,fee schedule,Payment capped at billed charges.,56.63,,,,,,,fee schedule,Payment capped at billed charges.,45.14,,,,,,,fee schedule,Payment capped at billed charges.,38.37,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,105.4,,,,,,,percent of total billed charges,,80.6,,,,,,,percent of total billed charges,,44.3,,,,,,,fee schedule,Payment capped at 80% of billed charges.,89.53,,,,,,,fee schedule,Payment capped at billed charges.,107.67,,,,,,,fee schedule,Payment capped at billed charges.,33.84,,,,,,,fee schedule,,120.98,,,,,,,fee schedule,Payment capped at billed charges.,45.84,,,,,,,fee schedule,,45.67,,,,,,,fee schedule,Payment capped at billed charges.
PT DEVEL TEST ADMIN 1ST HR,93500072,CDM,0420,RC,96112,CPT,11,Local,GP  ,outpatient,professional,,,378,378,60,354.81,,142.13,,,,,,,fee schedule,Payment capped at billed charges.,319.72,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,235.55,,,,,,,fee schedule,Payment capped at billed charges.,137.99,,,,,,,fee schedule,Payment capped at billed charges.,261.71,,,,,,,fee schedule,Payment capped at billed charges.,142.13,,,,,,,fee schedule,Payment capped at billed charges.,354.81,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,,147.24,,,,,,,fee schedule,Payment capped at billed charges.,140.23,,,,,,,fee schedule,Payment capped at billed charges.,133.03,,,,,,,fee schedule,Payment capped at billed charges.,144.89,,,,,,,fee schedule,Payment capped at billed charges.,173.89,,,,,,,fee schedule,Payment capped at billed charges.,173.96,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,321.3,,,,,,,percent of total billed charges,,245.7,,,,,,,percent of total billed charges,,136.01,,,,,,,fee schedule,Payment capped at 80% of billed charges.,259.02,,,,,,,fee schedule,Payment capped at billed charges.,311.53,,,,,,,fee schedule,Payment capped at billed charges.,116.84,,,,,,,fee schedule,,350.03,,,,,,,fee schedule,Payment capped at billed charges.,140.75,,,,,,,fee schedule,,140.23,,,,,,,fee schedule,Payment capped at billed charges.
PT DEVEL TEST ADMIN EA ADD 30M,93500080,CDM,0420,RC,96113,CPT,11,Local,GP  ,outpatient,professional,,,169,169,49.16,169,,59.31,,,,,,,fee schedule,Payment capped at billed charges.,151.94,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,110.86,,,,,,,fee schedule,Payment capped at billed charges.,57.58,,,,,,,fee schedule,Payment capped at billed charges.,123.18,,,,,,,fee schedule,Payment capped at billed charges.,59.31,,,,,,,fee schedule,Payment capped at billed charges.,168.24,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,,61.45,,,,,,,fee schedule,Payment capped at billed charges.,58.52,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,60.46,,,,,,,fee schedule,Payment capped at billed charges.,72.56,,,,,,,fee schedule,Payment capped at billed charges.,73.04,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,143.65,,,,,,,percent of total billed charges,,109.85,,,,,,,percent of total billed charges,,56.76,,,,,,,fee schedule,Payment capped at 80% of billed charges.,126.01,,,,,,,fee schedule,Payment capped at billed charges.,151.55,,,,,,,fee schedule,Payment capped at billed charges.,55.66,,,,,,,fee schedule,,169,,,,,,,fee schedule,Payment capped at billed charges.,58.74,,,,,,,fee schedule,,58.52,,,,,,,fee schedule,Payment capped at billed charges.
PT TRACTION MECHANICAL,93500098,CDM,0420,RC,97012,CPT,11,Local,GP  ,outpatient,professional,,,41,41,12.92,90,,16.08,,,,,,,fee schedule,Payment capped at billed charges.,37.3,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.64,,,,,,,fee schedule,Payment capped at billed charges.,15.62,,,,,,,fee schedule,Payment capped at billed charges.,24.03,,,,,,,fee schedule,Payment capped at billed charges.,16.08,,,,,,,fee schedule,Payment capped at billed charges.,33.06,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,,16.66,,,,,,,fee schedule,Payment capped at billed charges.,15.87,,,,,,,fee schedule,Payment capped at billed charges.,14.57,,,,,,,fee schedule,Payment capped at billed charges.,16.4,,,,,,,fee schedule,Payment capped at billed charges.,19.68,,,,,,,fee schedule,Payment capped at billed charges.,15.64,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,34.85,,,,,,,percent of total billed charges,,26.65,,,,,,,percent of total billed charges,,15.38,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.08,,,,,,,fee schedule,Payment capped at billed charges.,31.36,,,,,,,fee schedule,Payment capped at billed charges.,12.92,,,,,,,fee schedule,,35.24,,,,,,,fee schedule,Payment capped at billed charges.,15.93,,,,,,,fee schedule,,15.87,,,,,,,fee schedule,Payment capped at billed charges.
PT E-STIM UNATT,93500106,CDM,0420,RC,97014,CPT,11,Local,GP  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,13.86,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
PT E-STIM WOUND CARE UNATTEND,93500114,CDM,0420,RC,97014,CPT,11,Local,GP  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,13.86,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
PT ELEC STIM UNATTENDED,93500122,CDM,0420,RC,97014,CPT,11,Local,GP  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,13.86,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
PT VASOPNEUMATIC DEVICES,93500130,CDM,0420,RC,97016,CPT,11,Local,GP  ,outpatient,professional,,,49,49,10.99,90,,13.27,,,,,,,fee schedule,Payment capped at billed charges.,30.65,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,31.6,,,,,,,fee schedule,Payment capped at billed charges.,12.88,,,,,,,fee schedule,Payment capped at billed charges.,34.95,,,,,,,fee schedule,Payment capped at billed charges.,13.27,,,,,,,fee schedule,Payment capped at billed charges.,27.92,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,,13.74,,,,,,,fee schedule,Payment capped at billed charges.,13.09,,,,,,,fee schedule,Payment capped at billed charges.,14.13,,,,,,,fee schedule,Payment capped at billed charges.,13.52,,,,,,,fee schedule,Payment capped at billed charges.,16.23,,,,,,,fee schedule,Payment capped at billed charges.,12.8,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,41.65,,,,,,,percent of total billed charges,,31.85,,,,,,,percent of total billed charges,,12.69,,,,,,,fee schedule,Payment capped at 80% of billed charges.,21.95,,,,,,,fee schedule,Payment capped at billed charges.,26.4,,,,,,,fee schedule,Payment capped at billed charges.,13.19,,,,,,,fee schedule,,29.66,,,,,,,fee schedule,Payment capped at billed charges.,13.14,,,,,,,fee schedule,,13.09,,,,,,,fee schedule,Payment capped at billed charges.
PT PARAFFIN BATH,93500148,CDM,0420,RC,97018,CPT,11,Local,GP  ,outpatient,professional,,,50,50,5.93,90,,7.16,,,,,,,fee schedule,Payment capped at billed charges.,15.23,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,27.77,,,,,,,fee schedule,Payment capped at billed charges.,6.95,,,,,,,fee schedule,Payment capped at billed charges.,31.12,,,,,,,fee schedule,Payment capped at billed charges.,7.16,,,,,,,fee schedule,Payment capped at billed charges.,13.92,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,,7.41,,,,,,,fee schedule,Payment capped at billed charges.,7.06,,,,,,,fee schedule,Payment capped at billed charges.,6.97,,,,,,,fee schedule,Payment capped at billed charges.,7.29,,,,,,,fee schedule,Payment capped at billed charges.,8.75,,,,,,,fee schedule,Payment capped at billed charges.,6.75,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,42.5,,,,,,,percent of total billed charges,,32.5,,,,,,,percent of total billed charges,,6.85,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,6.51,,,,,,,fee schedule,,,,,,,,,,service not payable,7.09,,,,,,,fee schedule,,7.06,,,,,,,fee schedule,Payment capped at billed charges.
PT MODALTY WHIRLPOOL,93500155,CDM,0420,RC,97022,CPT,11,Local,GP  ,outpatient,professional,,,62,62,14.92,90,,18,,,,,,,fee schedule,Payment capped at billed charges.,45.78,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,29.68,,,,,,,fee schedule,Payment capped at billed charges.,17.48,,,,,,,fee schedule,Payment capped at billed charges.,32.56,,,,,,,fee schedule,Payment capped at billed charges.,18,,,,,,,fee schedule,Payment capped at billed charges.,41.82,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,,18.65,,,,,,,fee schedule,Payment capped at billed charges.,17.76,,,,,,,fee schedule,Payment capped at billed charges.,20.76,,,,,,,fee schedule,Payment capped at billed charges.,18.35,,,,,,,fee schedule,Payment capped at billed charges.,22.02,,,,,,,fee schedule,Payment capped at billed charges.,17.06,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,52.7,,,,,,,percent of total billed charges,,40.3,,,,,,,percent of total billed charges,,17.23,,,,,,,fee schedule,Payment capped at 80% of billed charges.,32.68,,,,,,,fee schedule,Payment capped at billed charges.,39.3,,,,,,,fee schedule,Payment capped at billed charges.,19.19,,,,,,,fee schedule,,44.16,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,17.76,,,,,,,fee schedule,Payment capped at billed charges.
PT E-STIM ATTENDED PER 15 MIN,93500163,CDM,0420,RC,97032,CPT,11,Local,GP  ,outpatient,professional,,,48,48,13.34,90,,16.08,,,,,,,fee schedule,Payment capped at billed charges.,37.3,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,19.61,,,,,,,fee schedule,Payment capped at billed charges.,15.62,,,,,,,fee schedule,Payment capped at billed charges.,21.77,,,,,,,fee schedule,Payment capped at billed charges.,16.08,,,,,,,fee schedule,Payment capped at billed charges.,33.93,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,,16.66,,,,,,,fee schedule,Payment capped at billed charges.,15.87,,,,,,,fee schedule,Payment capped at billed charges.,17.2,,,,,,,fee schedule,Payment capped at billed charges.,16.4,,,,,,,fee schedule,Payment capped at billed charges.,19.68,,,,,,,fee schedule,Payment capped at billed charges.,15.64,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,40.8,,,,,,,percent of total billed charges,,31.2,,,,,,,percent of total billed charges,,15.38,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.75,,,,,,,fee schedule,Payment capped at billed charges.,32.17,,,,,,,fee schedule,Payment capped at billed charges.,15.26,,,,,,,fee schedule,,36.15,,,,,,,fee schedule,Payment capped at billed charges.,15.93,,,,,,,fee schedule,,15.87,,,,,,,fee schedule,Payment capped at billed charges.
PT IONTOPHORESIS EACH 15 M,93500171,CDM,0420,RC,97033,CPT,11,Local,GP  ,outpatient,professional,,,59,59,17.83,90,,21.51,,,,,,,fee schedule,Payment capped at billed charges.,52.19,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,28.38,,,,,,,fee schedule,Payment capped at billed charges.,20.88,,,,,,,fee schedule,Payment capped at billed charges.,31.54,,,,,,,fee schedule,Payment capped at billed charges.,21.51,,,,,,,fee schedule,Payment capped at billed charges.,46.72,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,22.28,,,,,,,fee schedule,Payment capped at billed charges.,21.22,,,,,,,fee schedule,Payment capped at billed charges.,20.1,,,,,,,fee schedule,Payment capped at billed charges.,21.92,,,,,,,fee schedule,Payment capped at billed charges.,26.31,,,,,,,fee schedule,Payment capped at billed charges.,20.61,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,50.15,,,,,,,percent of total billed charges,,38.35,,,,,,,percent of total billed charges,,20.58,,,,,,,fee schedule,Payment capped at 80% of billed charges.,36.67,,,,,,,fee schedule,Payment capped at billed charges.,44.11,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,49.56,,,,,,,fee schedule,Payment capped at billed charges.,21.3,,,,,,,fee schedule,,21.22,,,,,,,fee schedule,Payment capped at billed charges.
PT CONTRAST BATH 1-15MIN,93500189,CDM,0420,RC,97034,CPT,11,Local,GP  ,outpatient,professional,,,45,45,12.83,90,,15.48,,,,,,,fee schedule,Payment capped at billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,18.92,,,,,,,fee schedule,Payment capped at billed charges.,15.03,,,,,,,fee schedule,Payment capped at billed charges.,21.03,,,,,,,fee schedule,Payment capped at billed charges.,15.48,,,,,,,fee schedule,Payment capped at billed charges.,34.43,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,,16.03,,,,,,,fee schedule,Payment capped at billed charges.,15.27,,,,,,,fee schedule,Payment capped at billed charges.,16.3,,,,,,,fee schedule,Payment capped at billed charges.,15.78,,,,,,,fee schedule,Payment capped at billed charges.,18.93,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,38.25,,,,,,,percent of total billed charges,,29.25,,,,,,,percent of total billed charges,,14.81,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.38,,,,,,,fee schedule,Payment capped at billed charges.,31.73,,,,,,,fee schedule,Payment capped at billed charges.,14.45,,,,,,,fee schedule,,35.65,,,,,,,fee schedule,Payment capped at billed charges.,15.33,,,,,,,fee schedule,,15.27,,,,,,,fee schedule,Payment capped at billed charges.
PT ULTRASOUND 15MIN,93500197,CDM,0420,RC,97035,CPT,11,Local,GP  ,outpatient,professional,,,37,37,10.1,90,,15.86,,,,,,,fee schedule,Payment capped at billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,19.26,,,,,,,fee schedule,Payment capped at billed charges.,15.4,,,,,,,fee schedule,Payment capped at billed charges.,21.41,,,,,,,fee schedule,Payment capped at billed charges.,15.86,,,,,,,fee schedule,Payment capped at billed charges.,33.56,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,,16.43,,,,,,,fee schedule,Payment capped at billed charges.,15.65,,,,,,,fee schedule,Payment capped at billed charges.,11.39,,,,,,,fee schedule,Payment capped at billed charges.,16.17,,,,,,,fee schedule,Payment capped at billed charges.,19.41,,,,,,,fee schedule,Payment capped at billed charges.,15.29,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,31.45,,,,,,,percent of total billed charges,,24.05,,,,,,,percent of total billed charges,,15.19,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.38,,,,,,,fee schedule,Payment capped at billed charges.,31.73,,,,,,,fee schedule,Payment capped at billed charges.,10.1,,,,,,,fee schedule,,35.65,,,,,,,fee schedule,Payment capped at billed charges.,15.71,,,,,,,fee schedule,,15.65,,,,,,,fee schedule,Payment capped at billed charges.
PT THER EX EA 15 MIN,93500205,CDM,0420,RC,97110,CPT,11,Local,GP  ,outpatient,professional,,,80,80,27.16,90,,32.78,,,,,,,fee schedule,Payment capped at billed charges.,77.07,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,31.82,,,,,,,fee schedule,Payment capped at billed charges.,42.31,,,,,,,fee schedule,Payment capped at billed charges.,32.78,,,,,,,fee schedule,Payment capped at billed charges.,69.34,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,,33.96,,,,,,,fee schedule,Payment capped at billed charges.,32.34,,,,,,,fee schedule,Payment capped at billed charges.,33.38,,,,,,,fee schedule,Payment capped at billed charges.,33.41,,,,,,,fee schedule,Payment capped at billed charges.,40.1,,,,,,,fee schedule,Payment capped at billed charges.,31.64,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,68,,,,,,,percent of total billed charges,,52,,,,,,,percent of total billed charges,,31.37,,,,,,,fee schedule,Payment capped at 80% of billed charges.,54.01,,,,,,,fee schedule,Payment capped at billed charges.,64.95,,,,,,,fee schedule,Payment capped at billed charges.,29.61,,,,,,,fee schedule,,72.98,,,,,,,fee schedule,Payment capped at billed charges.,32.46,,,,,,,fee schedule,,32.34,,,,,,,fee schedule,Payment capped at billed charges.
PT NEURO RE-ED BAL 15MIN,93500213,CDM,0420,RC,97112,CPT,11,Local,GP  ,outpatient,professional,,,90,90,27.11,90,,36.47,,,,,,,fee schedule,Payment capped at billed charges.,88.64,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,34.24,,,,,,,fee schedule,Payment capped at billed charges.,35.4,,,,,,,fee schedule,Payment capped at billed charges.,40.29,,,,,,,fee schedule,Payment capped at billed charges.,36.47,,,,,,,fee schedule,Payment capped at billed charges.,80.77,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,,37.78,,,,,,,fee schedule,Payment capped at billed charges.,35.98,,,,,,,fee schedule,Payment capped at billed charges.,30.57,,,,,,,fee schedule,Payment capped at billed charges.,37.17,,,,,,,fee schedule,Payment capped at billed charges.,44.62,,,,,,,fee schedule,Payment capped at billed charges.,35.19,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,76.5,,,,,,,percent of total billed charges,,58.5,,,,,,,percent of total billed charges,,34.9,,,,,,,fee schedule,Payment capped at 80% of billed charges.,62.1,,,,,,,fee schedule,Payment capped at billed charges.,74.69,,,,,,,fee schedule,Payment capped at billed charges.,27.11,,,,,,,fee schedule,,83.92,,,,,,,fee schedule,Payment capped at billed charges.,36.11,,,,,,,fee schedule,,35.98,,,,,,,fee schedule,Payment capped at billed charges.
PT AQUA THER W/EXERCISE 15 MIN,93500221,CDM,0420,RC,97113,CPT,11,Local,GP  ,outpatient,professional,,,108,108,34.66,97.33,,42.03,,,,,,,fee schedule,Payment capped at billed charges.,97.33,,,,,,,fee schedule,Payment capped at billed charges.,34.84,,,,,,,fee schedule,Payment capped at billed charges.,34.84,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,47.72,,,,,,,fee schedule,Payment capped at billed charges.,40.81,,,,,,,fee schedule,Payment capped at billed charges.,53.03,,,,,,,fee schedule,Payment capped at billed charges.,42.03,,,,,,,fee schedule,Payment capped at billed charges.,87.92,,,,,,,fee schedule,Payment capped at billed charges.,34.84,,,,,,,fee schedule,,43.54,,,,,,,fee schedule,Payment capped at billed charges.,41.47,,,,,,,fee schedule,Payment capped at billed charges.,39.08,,,,,,,fee schedule,Payment capped at billed charges.,42.85,,,,,,,fee schedule,Payment capped at billed charges.,51.42,,,,,,,fee schedule,Payment capped at billed charges.,40.16,,,,,,,fee schedule,Payment capped at billed charges.,34.84,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,91.8,,,,,,,percent of total billed charges,,70.2,,,,,,,percent of total billed charges,,40.22,,,,,,,fee schedule,Payment capped at 80% of billed charges.,68.11,,,,,,,fee schedule,Payment capped at billed charges.,81.92,,,,,,,fee schedule,Payment capped at billed charges.,34.66,,,,,,,fee schedule,,92.04,,,,,,,fee schedule,Payment capped at billed charges.,41.62,,,,,,,fee schedule,,41.47,,,,,,,fee schedule,Payment capped at billed charges.
PT GAIT TRAINING EA 15 MIN,93500239,CDM,0420,RC,97116,CPT,11,Local,GP  ,outpatient,professional,,,76,76,22.52,90,,32.78,,,,,,,fee schedule,Payment capped at billed charges.,77.07,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,32.08,,,,,,,fee schedule,Payment capped at billed charges.,31.82,,,,,,,fee schedule,Payment capped at billed charges.,35.91,,,,,,,fee schedule,Payment capped at billed charges.,32.78,,,,,,,fee schedule,Payment capped at billed charges.,69.34,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,,33.96,,,,,,,fee schedule,Payment capped at billed charges.,32.34,,,,,,,fee schedule,Payment capped at billed charges.,25.39,,,,,,,fee schedule,Payment capped at billed charges.,33.41,,,,,,,fee schedule,Payment capped at billed charges.,40.1,,,,,,,fee schedule,Payment capped at billed charges.,31.64,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,64.6,,,,,,,percent of total billed charges,,49.4,,,,,,,percent of total billed charges,,31.37,,,,,,,fee schedule,Payment capped at 80% of billed charges.,54.01,,,,,,,fee schedule,Payment capped at billed charges.,64.95,,,,,,,fee schedule,Payment capped at billed charges.,22.52,,,,,,,fee schedule,,72.98,,,,,,,fee schedule,Payment capped at billed charges.,32.46,,,,,,,fee schedule,,32.34,,,,,,,fee schedule,Payment capped at billed charges.
PT COGNITIVE FUNC INTRV 1ST15M,93500247,CDM,0420,RC,97129,CPT,11,Local,GP  ,outpatient,professional,,,72,72,20.09,90,,23.96,,,,,,,fee schedule,Payment capped at billed charges.,56.75,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.09,,,,,,,fee schedule,Payment capped at billed charges.,23.26,,,,,,,fee schedule,Payment capped at billed charges.,41.21,,,,,,,fee schedule,Payment capped at billed charges.,23.96,,,,,,,fee schedule,Payment capped at billed charges.,51.47,,,,,,,fee schedule,Payment capped at billed charges.,36,,,,,,,fee schedule,,24.82,,,,,,,fee schedule,Payment capped at billed charges.,23.64,,,,,,,fee schedule,Payment capped at billed charges.,23.58,,,,,,,fee schedule,Payment capped at billed charges.,24.42,,,,,,,fee schedule,Payment capped at billed charges.,29.31,,,,,,,fee schedule,Payment capped at billed charges.,23.81,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,61.2,,,,,,,percent of total billed charges,,46.8,,,,,,,percent of total billed charges,,22.93,,,,,,,fee schedule,Payment capped at 80% of billed charges.,39.95,,,,,,,fee schedule,Payment capped at billed charges.,48.05,,,,,,,fee schedule,Payment capped at billed charges.,20.71,,,,,,,fee schedule,,53.99,,,,,,,fee schedule,Payment capped at billed charges.,23.73,,,,,,,fee schedule,,23.64,,,,,,,fee schedule,Payment capped at billed charges.
PT UNLISTED PM R,93500254,CDM,0420,RC,97139,CPT,11,Local,GP  ,outpatient,professional,,,65,65,6.23,90,,14.1,,,,,,,fee schedule,Payment capped at billed charges.,33.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.85,,,,,,,fee schedule,Payment capped at billed charges.,32.5,,,,,,,fee schedule,,,,,,,,,,,42.25,,,,,,,fee schedule,Payment capped at billed charges.,15.39,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,6.23,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,55.25,,,,,,,percent of total billed charges,,42.25,,,,,,,percent of total billed charges,,52,,,,,,,fee schedule,Payment capped at 80% of billed charges.,42.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,13.51,,,,,,,fee schedule,,,,,,,,,,,22.75,,,,,,,fee schedule,,65,,,,,,,fee schedule,Payment capped at billed charges.
PT MANUAL THER EA 15 MIN,93500262,CDM,0420,RC,97140,CPT,11,Local,GP  ,outpatient,professional,,,74,74,23.92,90,,30.91,,,,,,,fee schedule,Payment capped at billed charges.,70.75,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.38,,,,,,,fee schedule,Payment capped at billed charges.,30.01,,,,,,,fee schedule,Payment capped at billed charges.,39.31,,,,,,,fee schedule,Payment capped at billed charges.,30.91,,,,,,,fee schedule,Payment capped at billed charges.,63.56,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,,32.02,,,,,,,fee schedule,Payment capped at billed charges.,30.5,,,,,,,fee schedule,Payment capped at billed charges.,26.97,,,,,,,fee schedule,Payment capped at billed charges.,31.51,,,,,,,fee schedule,Payment capped at billed charges.,37.82,,,,,,,fee schedule,Payment capped at billed charges.,29.86,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,62.9,,,,,,,percent of total billed charges,,48.1,,,,,,,percent of total billed charges,,29.59,,,,,,,fee schedule,Payment capped at 80% of billed charges.,49.59,,,,,,,fee schedule,Payment capped at billed charges.,59.64,,,,,,,fee schedule,Payment capped at billed charges.,23.92,,,,,,,fee schedule,,67.01,,,,,,,fee schedule,Payment capped at billed charges.,30.61,,,,,,,fee schedule,,30.5,,,,,,,fee schedule,Payment capped at billed charges.
PT THERAPEUTIC PROCEDURES GRP,93500270,CDM,0423,RC,97150,CPT,11,Local,GP  ,outpatient,professional,,,46,46,16.42,90,,19.81,,,,,,,fee schedule,Payment capped at billed charges.,46.2,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.54,,,,,,,fee schedule,Payment capped at billed charges.,19.24,,,,,,,fee schedule,Payment capped at billed charges.,23.94,,,,,,,fee schedule,Payment capped at billed charges.,19.81,,,,,,,fee schedule,Payment capped at billed charges.,41.18,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,,20.53,,,,,,,fee schedule,Payment capped at billed charges.,19.55,,,,,,,fee schedule,Payment capped at billed charges.,20.99,,,,,,,fee schedule,Payment capped at billed charges.,20.2,,,,,,,fee schedule,Payment capped at billed charges.,24.24,,,,,,,fee schedule,Payment capped at billed charges.,17.27,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,39.1,,,,,,,percent of total billed charges,,29.9,,,,,,,percent of total billed charges,,18.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,33.04,,,,,,,fee schedule,Payment capped at billed charges.,39.74,,,,,,,fee schedule,Payment capped at billed charges.,18.62,,,,,,,fee schedule,,44.65,,,,,,,fee schedule,Payment capped at billed charges.,19.62,,,,,,,fee schedule,,19.55,,,,,,,fee schedule,Payment capped at billed charges.
PT EVAL LOW COMPLEX,93500288,CDM,0424,RC,97161,CPT,11,Local,GP  ,outpatient,professional,,,262,262,60,262.63,,111.56,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,131.12,,,,,,,fee schedule,Payment capped at billed charges.,108.31,,,,,,,fee schedule,Payment capped at billed charges.,145.69,,,,,,,fee schedule,Payment capped at billed charges.,111.56,,,,,,,fee schedule,Payment capped at billed charges.,235.81,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,,115.57,,,,,,,fee schedule,Payment capped at billed charges.,110.07,,,,,,,fee schedule,Payment capped at billed charges.,79.58,,,,,,,fee schedule,Payment capped at billed charges.,113.72,,,,,,,fee schedule,Payment capped at billed charges.,136.49,,,,,,,fee schedule,Payment capped at billed charges.,107.7,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,106.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,184.7,,,,,,,fee schedule,Payment capped at billed charges.,222.14,,,,,,,fee schedule,Payment capped at billed charges.,70.58,,,,,,,fee schedule,,249.59,,,,,,,fee schedule,Payment capped at billed charges.,110.48,,,,,,,fee schedule,,110.07,,,,,,,fee schedule,Payment capped at billed charges.
PT EVAL MOD COMPLEX,93500296,CDM,0424,RC,97162,CPT,11,Local,GP  ,outpatient,professional,,,262,262,60,262.63,,111.56,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,134.89,,,,,,,fee schedule,Payment capped at billed charges.,108.31,,,,,,,fee schedule,Payment capped at billed charges.,149.89,,,,,,,fee schedule,Payment capped at billed charges.,111.56,,,,,,,fee schedule,Payment capped at billed charges.,235.81,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,,115.57,,,,,,,fee schedule,Payment capped at billed charges.,110.07,,,,,,,fee schedule,Payment capped at billed charges.,79.58,,,,,,,fee schedule,Payment capped at billed charges.,113.72,,,,,,,fee schedule,Payment capped at billed charges.,136.49,,,,,,,fee schedule,Payment capped at billed charges.,107.7,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,106.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,184.7,,,,,,,fee schedule,Payment capped at billed charges.,222.14,,,,,,,fee schedule,Payment capped at billed charges.,70.58,,,,,,,fee schedule,,249.59,,,,,,,fee schedule,Payment capped at billed charges.,110.48,,,,,,,fee schedule,,110.07,,,,,,,fee schedule,Payment capped at billed charges.
PT EVAL HIGH COMPLEX,93500304,CDM,0424,RC,97163,CPT,11,Local,GP  ,outpatient,professional,,,262,262,60,262.63,,111.56,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,142.82,,,,,,,fee schedule,Payment capped at billed charges.,108.31,,,,,,,fee schedule,Payment capped at billed charges.,158.7,,,,,,,fee schedule,Payment capped at billed charges.,111.56,,,,,,,fee schedule,Payment capped at billed charges.,235.81,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,,115.57,,,,,,,fee schedule,Payment capped at billed charges.,110.07,,,,,,,fee schedule,Payment capped at billed charges.,79.58,,,,,,,fee schedule,Payment capped at billed charges.,113.72,,,,,,,fee schedule,Payment capped at billed charges.,136.49,,,,,,,fee schedule,Payment capped at billed charges.,107.7,,,,,,,fee schedule,Payment capped at billed charges.,92.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,106.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,184.7,,,,,,,fee schedule,Payment capped at billed charges.,222.14,,,,,,,fee schedule,Payment capped at billed charges.,70.58,,,,,,,fee schedule,,249.59,,,,,,,fee schedule,Payment capped at billed charges.,110.48,,,,,,,fee schedule,,110.07,,,,,,,fee schedule,Payment capped at billed charges.
PT RE-EVAL EST PLAN CARE,93500312,CDM,0424,RC,97164,CPT,11,Local,GP  ,outpatient,professional,,,183,183,48.13,183.43,,77.41,,,,,,,fee schedule,Payment capped at billed charges.,183.43,,,,,,,fee schedule,Payment capped at billed charges.,64.16,,,,,,,fee schedule,Payment capped at billed charges.,64.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,91.06,,,,,,,fee schedule,Payment capped at billed charges.,75.16,,,,,,,fee schedule,Payment capped at billed charges.,101.19,,,,,,,fee schedule,Payment capped at billed charges.,77.41,,,,,,,fee schedule,Payment capped at billed charges.,163.77,,,,,,,fee schedule,Payment capped at billed charges.,64.16,,,,,,,fee schedule,,80.2,,,,,,,fee schedule,Payment capped at billed charges.,76.38,,,,,,,fee schedule,Payment capped at billed charges.,54.27,,,,,,,fee schedule,Payment capped at billed charges.,78.92,,,,,,,fee schedule,Payment capped at billed charges.,94.71,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,64.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,155.55,,,,,,,percent of total billed charges,,118.95,,,,,,,percent of total billed charges,,74.08,,,,,,,fee schedule,Payment capped at 80% of billed charges.,129.05,,,,,,,fee schedule,Payment capped at billed charges.,155.21,,,,,,,fee schedule,Payment capped at billed charges.,48.13,,,,,,,fee schedule,,174.39,,,,,,,fee schedule,Payment capped at billed charges.,76.66,,,,,,,fee schedule,,76.38,,,,,,,fee schedule,Payment capped at billed charges.
PT THER ACT EA 15 MIN,93500320,CDM,0420,RC,97530,CPT,11,Local,GP  ,outpatient,professional,,,102,102,31.17,98.75,,39.86,,,,,,,fee schedule,Payment capped at billed charges.,98.75,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,38.7,,,,,,,fee schedule,Payment capped at billed charges.,42.5,,,,,,,fee schedule,Payment capped at billed charges.,39.86,,,,,,,fee schedule,Payment capped at billed charges.,89.29,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,,41.3,,,,,,,fee schedule,Payment capped at billed charges.,39.33,,,,,,,fee schedule,Payment capped at billed charges.,35.14,,,,,,,fee schedule,Payment capped at billed charges.,40.64,,,,,,,fee schedule,Payment capped at billed charges.,48.77,,,,,,,fee schedule,Payment capped at billed charges.,38.04,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,86.7,,,,,,,percent of total billed charges,,66.3,,,,,,,percent of total billed charges,,38.15,,,,,,,fee schedule,Payment capped at 80% of billed charges.,68.41,,,,,,,fee schedule,Payment capped at billed charges.,82.27,,,,,,,fee schedule,Payment capped at billed charges.,31.17,,,,,,,fee schedule,,92.44,,,,,,,fee schedule,Payment capped at billed charges.,39.47,,,,,,,fee schedule,,39.33,,,,,,,fee schedule,Payment capped at billed charges.
PT SENSORY INTEGRATON EA15 MIN,93500338,CDM,0420,RC,97533,CPT,11,Local,GP  ,outpatient,professional,,,172,172,23.32,172.37,,70.95,,,,,,,fee schedule,Payment capped at billed charges.,172.37,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,49.69,,,,,,,fee schedule,Payment capped at billed charges.,68.88,,,,,,,fee schedule,Payment capped at billed charges.,55.21,,,,,,,fee schedule,Payment capped at billed charges.,70.95,,,,,,,fee schedule,Payment capped at billed charges.,158.57,,,,,,,fee schedule,Payment capped at billed charges.,86,,,,,,,fee schedule,,73.5,,,,,,,fee schedule,Payment capped at billed charges.,70,,,,,,,fee schedule,Payment capped at billed charges.,26.29,,,,,,,fee schedule,Payment capped at billed charges.,72.32,,,,,,,fee schedule,Payment capped at billed charges.,86.8,,,,,,,fee schedule,Payment capped at billed charges.,66.46,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,146.2,,,,,,,percent of total billed charges,,111.8,,,,,,,percent of total billed charges,,67.9,,,,,,,fee schedule,Payment capped at 80% of billed charges.,118.27,,,,,,,fee schedule,Payment capped at billed charges.,142.25,,,,,,,fee schedule,Payment capped at billed charges.,23.32,,,,,,,fee schedule,,159.83,,,,,,,fee schedule,Payment capped at billed charges.,70.26,,,,,,,fee schedule,,70,,,,,,,fee schedule,Payment capped at billed charges.
PT ADL SELF CARE/HOME IND 15M,93500346,CDM,0420,RC,97535,CPT,11,Local,GP  ,outpatient,professional,,,86,86,27.98,90,,36.69,,,,,,,fee schedule,Payment capped at billed charges.,86.43,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,35.62,,,,,,,fee schedule,Payment capped at billed charges.,39.26,,,,,,,fee schedule,Payment capped at billed charges.,36.69,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,,38.01,,,,,,,fee schedule,Payment capped at billed charges.,36.2,,,,,,,fee schedule,Payment capped at billed charges.,31.54,,,,,,,fee schedule,Payment capped at billed charges.,37.4,,,,,,,fee schedule,Payment capped at billed charges.,44.89,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,30.41,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,73.1,,,,,,,percent of total billed charges,,55.9,,,,,,,percent of total billed charges,,35.11,,,,,,,fee schedule,Payment capped at 80% of billed charges.,60.51,,,,,,,fee schedule,Payment capped at billed charges.,72.78,,,,,,,fee schedule,Payment capped at billed charges.,27.98,,,,,,,fee schedule,,81.77,,,,,,,fee schedule,Payment capped at billed charges.,36.33,,,,,,,fee schedule,,36.2,,,,,,,fee schedule,Payment capped at billed charges.
PT COM/WORK REINTEG 15M,93500353,CDM,0420,RC,97537,CPT,11,Local,GP  ,outpatient,professional,,,84,84,24.2,90,,36.16,,,,,,,fee schedule,Payment capped at billed charges.,83.26,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,35.11,,,,,,,fee schedule,Payment capped at billed charges.,39.26,,,,,,,fee schedule,Payment capped at billed charges.,36.16,,,,,,,fee schedule,Payment capped at billed charges.,74.98,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,,37.46,,,,,,,fee schedule,Payment capped at billed charges.,35.68,,,,,,,fee schedule,Payment capped at billed charges.,27.29,,,,,,,fee schedule,Payment capped at billed charges.,36.86,,,,,,,fee schedule,Payment capped at billed charges.,44.24,,,,,,,fee schedule,Payment capped at billed charges.,33.39,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,71.4,,,,,,,percent of total billed charges,,54.6,,,,,,,percent of total billed charges,,67.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,58.34,,,,,,,fee schedule,Payment capped at billed charges.,70.17,,,,,,,fee schedule,Payment capped at billed charges.,24.2,,,,,,,fee schedule,,78.84,,,,,,,fee schedule,Payment capped at billed charges.,35.81,,,,,,,fee schedule,,35.68,,,,,,,fee schedule,Payment capped at billed charges.
PT WHEELCHAIR MGMT 15M,93500361,CDM,0420,RC,97542,CPT,11,Local,GP  ,outpatient,professional,,,83,83,27.74,90,,35,,,,,,,fee schedule,Payment capped at billed charges.,83.26,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,29.68,,,,,,,fee schedule,Payment capped at billed charges.,33.98,,,,,,,fee schedule,Payment capped at billed charges.,32.56,,,,,,,fee schedule,Payment capped at billed charges.,35,,,,,,,fee schedule,Payment capped at billed charges.,74.98,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,,36.26,,,,,,,fee schedule,Payment capped at billed charges.,34.53,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,35.68,,,,,,,fee schedule,Payment capped at billed charges.,42.82,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,70.55,,,,,,,percent of total billed charges,,53.95,,,,,,,percent of total billed charges,,33.49,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,27.74,,,,,,,fee schedule,,,,,,,,,,service not payable,34.66,,,,,,,fee schedule,,34.53,,,,,,,fee schedule,Payment capped at billed charges.
PT WRK HARD CONDT 2 HRS,93500379,CDM,0420,RC,97545,CPT,11,Local,GP  ,outpatient,professional,,,413,413,10.61,413,,136.09,,,,,,,fee schedule,Payment capped at billed charges.,326.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,326.53,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,362.8,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,412.96,,,,,,,fee schedule,Payment capped at billed charges.,206.5,,,,,,,fee schedule,,,,,,,,,,,268.45,,,,,,,fee schedule,Payment capped at billed charges.,12.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,351.05,,,,,,,percent of total billed charges,,268.45,,,,,,,percent of total billed charges,,330.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,313.44,,,,,,,fee schedule,Payment capped at billed charges.,376.98,,,,,,,fee schedule,Payment capped at billed charges.,10.61,,,,,,,fee schedule,,413,,,,,,,fee schedule,Payment capped at billed charges.,144.55,,,,,,,fee schedule,,263.01,,,,,,,fee schedule,Payment capped at billed charges.
PT WORK HARD COND ADD HR,93500387,CDM,0420,RC,97546,CPT,11,Local,GP  ,outpatient,professional,,,184,184,54.22,181.41,,54.22,,,,,,,fee schedule,Payment capped at billed charges.,130,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,163.27,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,181.41,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,163.16,,,,,,,fee schedule,Payment capped at billed charges.,92,,,,,,,fee schedule,,,,,,,,,,,119.6,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,156.4,,,,,,,percent of total billed charges,,119.6,,,,,,,percent of total billed charges,,147.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,124.99,,,,,,,fee schedule,Payment capped at billed charges.,150.33,,,,,,,fee schedule,Payment capped at billed charges.,62.56,,,,,,,fee schedule,,168.91,,,,,,,fee schedule,Payment capped at billed charges.,64.4,,,,,,,fee schedule,,77.76,,,,,,,fee schedule,Payment capped at billed charges.
PT SELECT DEBRIDE1ST20SQCMLESS,93500395,CDM,0420,RC,97597,CPT,11,Local,GP  ,outpatient,professional,,,273,273,60,273,,113.39,,,,,,,fee schedule,Payment capped at billed charges.,273,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,94.83,,,,,,,fee schedule,Payment capped at billed charges.,110.09,,,,,,,fee schedule,Payment capped at billed charges.,105.38,,,,,,,fee schedule,Payment capped at billed charges.,113.39,,,,,,,fee schedule,Payment capped at billed charges.,251.6,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,,117.47,,,,,,,fee schedule,Payment capped at billed charges.,111.88,,,,,,,fee schedule,Payment capped at billed charges.,68.79,,,,,,,fee schedule,Payment capped at billed charges.,115.59,,,,,,,fee schedule,Payment capped at billed charges.,138.73,,,,,,,fee schedule,Payment capped at billed charges.,106.27,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,232.05,,,,,,,percent of total billed charges,,177.45,,,,,,,percent of total billed charges,,108.53,,,,,,,fee schedule,Payment capped at 80% of billed charges.,191.65,,,,,,,fee schedule,Payment capped at billed charges.,230.5,,,,,,,fee schedule,Payment capped at billed charges.,60.42,,,,,,,fee schedule,,258.99,,,,,,,fee schedule,Payment capped at billed charges.,112.29,,,,,,,fee schedule,,111.88,,,,,,,fee schedule,Payment capped at billed charges.
PT SELECT DEBRIDE EA ADD20SQCM,93500403,CDM,0420,RC,97598,CPT,11,Local,GP  ,outpatient,professional,,,138,138,25.94,133.51,,50.11,,,,,,,fee schedule,Payment capped at billed charges.,119.66,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,120.17,,,,,,,fee schedule,Payment capped at billed charges.,48.65,,,,,,,fee schedule,Payment capped at billed charges.,133.51,,,,,,,fee schedule,Payment capped at billed charges.,50.11,,,,,,,fee schedule,Payment capped at billed charges.,110.28,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,,51.91,,,,,,,fee schedule,Payment capped at billed charges.,49.44,,,,,,,fee schedule,Payment capped at billed charges.,29.53,,,,,,,fee schedule,Payment capped at billed charges.,51.08,,,,,,,fee schedule,Payment capped at billed charges.,61.31,,,,,,,fee schedule,Payment capped at billed charges.,47.63,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,117.3,,,,,,,percent of total billed charges,,89.7,,,,,,,percent of total billed charges,,47.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,84.19,,,,,,,fee schedule,Payment capped at billed charges.,101.26,,,,,,,fee schedule,Payment capped at billed charges.,25.94,,,,,,,fee schedule,,113.77,,,,,,,fee schedule,Payment capped at billed charges.,49.62,,,,,,,fee schedule,,49.44,,,,,,,fee schedule,Payment capped at billed charges.
PT PHYSICAL PERF TEST EA 15MIN,93500411,CDM,0420,RC,97750,CPT,11,Local,GP  ,outpatient,professional,,,90,90,26.23,90,,38.25,,,,,,,fee schedule,Payment capped at billed charges.,89.26,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,54.58,,,,,,,fee schedule,Payment capped at billed charges.,37.14,,,,,,,fee schedule,Payment capped at billed charges.,60.32,,,,,,,fee schedule,Payment capped at billed charges.,38.25,,,,,,,fee schedule,Payment capped at billed charges.,79.68,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,,39.63,,,,,,,fee schedule,Payment capped at billed charges.,37.74,,,,,,,fee schedule,Payment capped at billed charges.,29.58,,,,,,,fee schedule,Payment capped at billed charges.,38.99,,,,,,,fee schedule,Payment capped at billed charges.,46.8,,,,,,,fee schedule,Payment capped at billed charges.,36.61,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,76.5,,,,,,,percent of total billed charges,,58.5,,,,,,,percent of total billed charges,,36.61,,,,,,,fee schedule,Payment capped at 80% of billed charges.,63.12,,,,,,,fee schedule,Payment capped at billed charges.,75.92,,,,,,,fee schedule,Payment capped at billed charges.,26.23,,,,,,,fee schedule,,85.3,,,,,,,fee schedule,Payment capped at billed charges.,37.88,,,,,,,fee schedule,,37.74,,,,,,,fee schedule,Payment capped at billed charges.
PT ASSISTIVE TECHN ASSES 15MIN,93500429,CDM,0420,RC,97755,CPT,11,Local,GP  ,outpatient,professional,,,100,100,28.23,100.32,,42.57,,,,,,,fee schedule,Payment capped at billed charges.,100.32,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,64.84,,,,,,,fee schedule,Payment capped at billed charges.,41.33,,,,,,,fee schedule,Payment capped at billed charges.,72.04,,,,,,,fee schedule,Payment capped at billed charges.,42.57,,,,,,,fee schedule,Payment capped at billed charges.,88.72,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,,44.1,,,,,,,fee schedule,Payment capped at billed charges.,42,,,,,,,fee schedule,Payment capped at billed charges.,31.83,,,,,,,fee schedule,Payment capped at billed charges.,43.39,,,,,,,fee schedule,Payment capped at billed charges.,52.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,35.28,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,85,,,,,,,percent of total billed charges,,65,,,,,,,percent of total billed charges,,40.74,,,,,,,fee schedule,Payment capped at 80% of billed charges.,70.33,,,,,,,fee schedule,Payment capped at billed charges.,84.59,,,,,,,fee schedule,Payment capped at billed charges.,28.23,,,,,,,fee schedule,,95.04,,,,,,,fee schedule,Payment capped at billed charges.,42.15,,,,,,,fee schedule,,42,,,,,,,fee schedule,Payment capped at billed charges.
PT ORTH FIT/TRAIN INIT EA15MIN,93500437,CDM,0420,RC,97760,CPT,11,Local,GP  ,outpatient,professional,,,130,130,42.87,129.92,,53.27,,,,,,,fee schedule,Payment capped at billed charges.,129.92,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,48.3,,,,,,,fee schedule,Payment capped at billed charges.,51.72,,,,,,,fee schedule,Payment capped at billed charges.,53.68,,,,,,,fee schedule,Payment capped at billed charges.,53.27,,,,,,,fee schedule,Payment capped at billed charges.,117.81,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,,55.19,,,,,,,fee schedule,Payment capped at billed charges.,52.56,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,54.3,,,,,,,fee schedule,Payment capped at billed charges.,65.17,,,,,,,fee schedule,Payment capped at billed charges.,50.48,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,110.5,,,,,,,percent of total billed charges,,84.5,,,,,,,percent of total billed charges,,50.98,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,42.87,,,,,,,fee schedule,,,,,,,,,,service not payable,52.75,,,,,,,fee schedule,,52.56,,,,,,,fee schedule,Payment capped at billed charges.
PT PROSTH TRAIN INIT EA 15MIN,93500445,CDM,0420,RC,97761,CPT,11,Local,GP  ,outpatient,professional,,,111,111,36.5,111.16,,46.63,,,,,,,fee schedule,Payment capped at billed charges.,111.16,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,48.01,,,,,,,fee schedule,Payment capped at billed charges.,45.27,,,,,,,fee schedule,Payment capped at billed charges.,53.33,,,,,,,fee schedule,Payment capped at billed charges.,46.63,,,,,,,fee schedule,Payment capped at billed charges.,99.72,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,,48.31,,,,,,,fee schedule,Payment capped at billed charges.,46.01,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,47.54,,,,,,,fee schedule,Payment capped at billed charges.,57.05,,,,,,,fee schedule,Payment capped at billed charges.,44.42,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,94.35,,,,,,,percent of total billed charges,,72.15,,,,,,,percent of total billed charges,,44.62,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,36.5,,,,,,,fee schedule,,,,,,,,,,service not payable,46.18,,,,,,,fee schedule,,46.01,,,,,,,fee schedule,Payment capped at billed charges.
PT ORTH/PROS SUBS ENC EA15MIN,93500452,CDM,0420,RC,97763,CPT,11,Local,GP  ,outpatient,professional,,,144,144,47.77,143.3,,58.44,,,,,,,fee schedule,Payment capped at billed charges.,143.3,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,67.68,,,,,,,fee schedule,Payment capped at billed charges.,56.74,,,,,,,fee schedule,Payment capped at billed charges.,75.2,,,,,,,fee schedule,Payment capped at billed charges.,58.44,,,,,,,fee schedule,Payment capped at billed charges.,131.86,,,,,,,fee schedule,Payment capped at billed charges.,72,,,,,,,fee schedule,,60.54,,,,,,,fee schedule,Payment capped at billed charges.,57.66,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,59.57,,,,,,,fee schedule,Payment capped at billed charges.,71.5,,,,,,,fee schedule,Payment capped at billed charges.,55.1,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,122.4,,,,,,,percent of total billed charges,,93.6,,,,,,,percent of total billed charges,,55.93,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,47.77,,,,,,,fee schedule,,,,,,,,,,service not payable,57.87,,,,,,,fee schedule,,57.66,,,,,,,fee schedule,Payment capped at billed charges.
PT DRIVING EVAL,93500460,CDM,0420,RC,97799,CPT,11,Local,GP  ,outpatient,professional,,,350,350,20.2,350,,,,,,,,,,service not payable,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.5,,,,,,,fee schedule,Payment capped at billed charges.,175,,,,,,,fee schedule,,,,,,,,,,,227.5,,,,,,,fee schedule,Payment capped at billed charges.,23,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,297.5,,,,,,,percent of total billed charges,,227.5,,,,,,,percent of total billed charges,,280,,,,,,,fee schedule,Payment capped at 80% of billed charges.,227.5,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,20.2,,,,,,,fee schedule,,,,,,,,,,,122.5,,,,,,,fee schedule,,350,,,,,,,fee schedule,Payment capped at billed charges.
OT BIOFEEDBACK TRAIN ANY METH,93500478,CDM,0430,RC,90901,CPT,11,Local,GO  ,outpatient,professional,,,141,141,28.82,120.85,,45.84,,,,,,,fee schedule,Payment capped at billed charges.,109.44,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,72,,,,,,,fee schedule,Payment capped at billed charges.,44.51,,,,,,,fee schedule,Payment capped at billed charges.,80.01,,,,,,,fee schedule,Payment capped at billed charges.,45.84,,,,,,,fee schedule,Payment capped at billed charges.,120.5,,,,,,,fee schedule,Payment capped at billed charges.,70.5,,,,,,,fee schedule,,47.49,,,,,,,fee schedule,Payment capped at billed charges.,58.8,,,,,,,fee schedule,Payment capped at billed charges.,32.81,,,,,,,fee schedule,Payment capped at billed charges.,46.73,,,,,,,fee schedule,Payment capped at billed charges.,56.09,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,38.45,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,119.85,,,,,,,percent of total billed charges,,91.65,,,,,,,percent of total billed charges,,43.87,,,,,,,fee schedule,Payment capped at 80% of billed charges.,89.43,,,,,,,fee schedule,Payment capped at billed charges.,107.56,,,,,,,fee schedule,Payment capped at billed charges.,28.82,,,,,,,fee schedule,,120.85,,,,,,,fee schedule,Payment capped at billed charges.,45.4,,,,,,,fee schedule,,45.23,,,,,,,fee schedule,Payment capped at billed charges.
OT DEVEL TEST ADMIN 1ST HR,93500486,CDM,0430,RC,96112,CPT,11,Local,GO  ,outpatient,professional,,,378,378,60,354.81,,142.13,,,,,,,fee schedule,Payment capped at billed charges.,319.72,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,235.55,,,,,,,fee schedule,Payment capped at billed charges.,137.99,,,,,,,fee schedule,Payment capped at billed charges.,261.71,,,,,,,fee schedule,Payment capped at billed charges.,142.13,,,,,,,fee schedule,Payment capped at billed charges.,354.81,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,,147.24,,,,,,,fee schedule,Payment capped at billed charges.,182.3,,,,,,,fee schedule,Payment capped at billed charges.,133.03,,,,,,,fee schedule,Payment capped at billed charges.,144.89,,,,,,,fee schedule,Payment capped at billed charges.,173.89,,,,,,,fee schedule,Payment capped at billed charges.,173.96,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,321.3,,,,,,,percent of total billed charges,,245.7,,,,,,,percent of total billed charges,,136.01,,,,,,,fee schedule,Payment capped at 80% of billed charges.,259.02,,,,,,,fee schedule,Payment capped at billed charges.,311.53,,,,,,,fee schedule,Payment capped at billed charges.,116.84,,,,,,,fee schedule,,350.03,,,,,,,fee schedule,Payment capped at billed charges.,140.75,,,,,,,fee schedule,,140.23,,,,,,,fee schedule,Payment capped at billed charges.
OT DEVEL TEST ADMIN EA ADD 30M,93500494,CDM,0430,RC,96113,CPT,11,Local,GO  ,outpatient,professional,,,169,169,49.16,169,,59.31,,,,,,,fee schedule,Payment capped at billed charges.,151.94,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,110.86,,,,,,,fee schedule,Payment capped at billed charges.,57.58,,,,,,,fee schedule,Payment capped at billed charges.,123.18,,,,,,,fee schedule,Payment capped at billed charges.,59.31,,,,,,,fee schedule,Payment capped at billed charges.,168.24,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,,61.45,,,,,,,fee schedule,Payment capped at billed charges.,76.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,60.46,,,,,,,fee schedule,Payment capped at billed charges.,72.56,,,,,,,fee schedule,Payment capped at billed charges.,73.04,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,143.65,,,,,,,percent of total billed charges,,109.85,,,,,,,percent of total billed charges,,56.76,,,,,,,fee schedule,Payment capped at 80% of billed charges.,126.01,,,,,,,fee schedule,Payment capped at billed charges.,151.55,,,,,,,fee schedule,Payment capped at billed charges.,55.66,,,,,,,fee schedule,,169,,,,,,,fee schedule,Payment capped at billed charges.,58.74,,,,,,,fee schedule,,58.52,,,,,,,fee schedule,Payment capped at billed charges.
OT COG PERF TEST PER HR,93500502,CDM,0434,RC,96125,CPT,11,Local,GO  ,outpatient,professional,,,305,305,60,297.27,,112.79,,,,,,,fee schedule,Payment capped at billed charges.,265.41,,,,,,,fee schedule,Payment capped at billed charges.,94.6,,,,,,,fee schedule,Payment capped at billed charges.,94.6,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,226.03,,,,,,,fee schedule,Payment capped at billed charges.,109.51,,,,,,,fee schedule,Payment capped at billed charges.,251.15,,,,,,,fee schedule,Payment capped at billed charges.,112.79,,,,,,,fee schedule,Payment capped at billed charges.,297.27,,,,,,,fee schedule,Payment capped at billed charges.,152.5,,,,,,,fee schedule,,116.85,,,,,,,fee schedule,Payment capped at billed charges.,144.68,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,114.98,,,,,,,fee schedule,Payment capped at billed charges.,138,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,94.6,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,259.25,,,,,,,percent of total billed charges,,198.25,,,,,,,percent of total billed charges,,107.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,217.4,,,,,,,fee schedule,Payment capped at billed charges.,261.46,,,,,,,fee schedule,Payment capped at billed charges.,90.19,,,,,,,fee schedule,,293.78,,,,,,,fee schedule,Payment capped at billed charges.,111.7,,,,,,,fee schedule,,111.29,,,,,,,fee schedule,Payment capped at billed charges.
OT MECHANICAL TRACTION THERAPY,93500510,CDM,0430,RC,97012,CPT,11,Local,GO  ,outpatient,professional,,,41,41,12.92,90,,16.08,,,,,,,fee schedule,Payment capped at billed charges.,37.3,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.64,,,,,,,fee schedule,Payment capped at billed charges.,15.62,,,,,,,fee schedule,Payment capped at billed charges.,24.03,,,,,,,fee schedule,Payment capped at billed charges.,16.08,,,,,,,fee schedule,Payment capped at billed charges.,33.06,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,,16.66,,,,,,,fee schedule,Payment capped at billed charges.,20.63,,,,,,,fee schedule,Payment capped at billed charges.,14.57,,,,,,,fee schedule,Payment capped at billed charges.,16.4,,,,,,,fee schedule,Payment capped at billed charges.,19.68,,,,,,,fee schedule,Payment capped at billed charges.,15.64,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,34.85,,,,,,,percent of total billed charges,,26.65,,,,,,,percent of total billed charges,,15.38,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.08,,,,,,,fee schedule,Payment capped at billed charges.,31.36,,,,,,,fee schedule,Payment capped at billed charges.,12.92,,,,,,,fee schedule,,35.24,,,,,,,fee schedule,Payment capped at billed charges.,15.93,,,,,,,fee schedule,,15.87,,,,,,,fee schedule,Payment capped at billed charges.
OT E-STIM UNATT,93500528,CDM,0430,RC,97014,CPT,11,Local,GO  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,18.02,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
OT E-STIM WOUND CARE UNATTEND,93500536,CDM,0430,RC,97014,CPT,11,Local,GO  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,18.02,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
OT E-STIM NOT WND PART TX PLAN,93500544,CDM,0430,RC,97014,CPT,11,Local,GO  ,outpatient,professional,,,57,57,9.79,90,,9.79,,,,,,,fee schedule,Payment capped at billed charges.,9.96,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,23.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.63,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,,,,,,,,,,,18.02,,,,,,,fee schedule,Payment capped at billed charges.,14.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,13.51,,,,,,,fee schedule,Payment capped at billed charges.,11.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,48.45,,,,,,,percent of total billed charges,,37.05,,,,,,,percent of total billed charges,,13.44,,,,,,,fee schedule,Payment capped at 80% of billed charges.,23.27,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,12.65,,,,,,,fee schedule,,31.45,,,,,,,fee schedule,Payment capped at billed charges.,19.95,,,,,,,fee schedule,,18.03,,,,,,,fee schedule,Payment capped at billed charges.
OT VASOPNEUMATIC DEVICES,93500551,CDM,0430,RC,97016,CPT,11,Local,GO  ,outpatient,professional,,,49,49,10.99,90,,13.27,,,,,,,fee schedule,Payment capped at billed charges.,30.65,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,31.6,,,,,,,fee schedule,Payment capped at billed charges.,12.88,,,,,,,fee schedule,Payment capped at billed charges.,34.95,,,,,,,fee schedule,Payment capped at billed charges.,13.27,,,,,,,fee schedule,Payment capped at billed charges.,27.92,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,,13.74,,,,,,,fee schedule,Payment capped at billed charges.,17.02,,,,,,,fee schedule,Payment capped at billed charges.,14.13,,,,,,,fee schedule,Payment capped at billed charges.,13.52,,,,,,,fee schedule,Payment capped at billed charges.,16.23,,,,,,,fee schedule,Payment capped at billed charges.,12.8,,,,,,,fee schedule,Payment capped at billed charges.,10.99,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,41.65,,,,,,,percent of total billed charges,,31.85,,,,,,,percent of total billed charges,,12.69,,,,,,,fee schedule,Payment capped at 80% of billed charges.,21.95,,,,,,,fee schedule,Payment capped at billed charges.,26.4,,,,,,,fee schedule,Payment capped at billed charges.,13.19,,,,,,,fee schedule,,29.66,,,,,,,fee schedule,Payment capped at billed charges.,13.14,,,,,,,fee schedule,,13.09,,,,,,,fee schedule,Payment capped at billed charges.
OT PARAFFIN BATH,93500569,CDM,0430,RC,97018,CPT,11,Local,GO  ,outpatient,professional,,,50,50,5.93,90,,7.16,,,,,,,fee schedule,Payment capped at billed charges.,15.23,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,27.77,,,,,,,fee schedule,Payment capped at billed charges.,6.95,,,,,,,fee schedule,Payment capped at billed charges.,31.12,,,,,,,fee schedule,Payment capped at billed charges.,7.16,,,,,,,fee schedule,Payment capped at billed charges.,13.92,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,,7.41,,,,,,,fee schedule,Payment capped at billed charges.,9.18,,,,,,,fee schedule,Payment capped at billed charges.,6.97,,,,,,,fee schedule,Payment capped at billed charges.,7.29,,,,,,,fee schedule,Payment capped at billed charges.,8.75,,,,,,,fee schedule,Payment capped at billed charges.,6.75,,,,,,,fee schedule,Payment capped at billed charges.,5.93,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,42.5,,,,,,,percent of total billed charges,,32.5,,,,,,,percent of total billed charges,,6.85,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,6.51,,,,,,,fee schedule,,,,,,,,,,service not payable,7.09,,,,,,,fee schedule,,7.06,,,,,,,fee schedule,Payment capped at billed charges.
OT MODALTY WHIRLPOOL,93500577,CDM,0430,RC,97022,CPT,11,Local,GO  ,outpatient,professional,,,62,62,14.92,90,,18,,,,,,,fee schedule,Payment capped at billed charges.,45.78,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,29.68,,,,,,,fee schedule,Payment capped at billed charges.,17.48,,,,,,,fee schedule,Payment capped at billed charges.,32.56,,,,,,,fee schedule,Payment capped at billed charges.,18,,,,,,,fee schedule,Payment capped at billed charges.,41.82,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,,18.65,,,,,,,fee schedule,Payment capped at billed charges.,23.09,,,,,,,fee schedule,Payment capped at billed charges.,20.76,,,,,,,fee schedule,Payment capped at billed charges.,18.35,,,,,,,fee schedule,Payment capped at billed charges.,22.02,,,,,,,fee schedule,Payment capped at billed charges.,17.06,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,52.7,,,,,,,percent of total billed charges,,40.3,,,,,,,percent of total billed charges,,17.23,,,,,,,fee schedule,Payment capped at 80% of billed charges.,32.68,,,,,,,fee schedule,Payment capped at billed charges.,39.3,,,,,,,fee schedule,Payment capped at billed charges.,19.19,,,,,,,fee schedule,,44.16,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,17.76,,,,,,,fee schedule,Payment capped at billed charges.
OT E-STIM ATTENDED PER 15 MIN,93500585,CDM,0430,RC,97032,CPT,11,Local,GO  ,outpatient,professional,,,48,48,13.34,90,,16.08,,,,,,,fee schedule,Payment capped at billed charges.,37.3,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,19.61,,,,,,,fee schedule,Payment capped at billed charges.,15.62,,,,,,,fee schedule,Payment capped at billed charges.,21.77,,,,,,,fee schedule,Payment capped at billed charges.,16.08,,,,,,,fee schedule,Payment capped at billed charges.,33.93,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,,16.66,,,,,,,fee schedule,Payment capped at billed charges.,20.63,,,,,,,fee schedule,Payment capped at billed charges.,17.2,,,,,,,fee schedule,Payment capped at billed charges.,16.4,,,,,,,fee schedule,Payment capped at billed charges.,19.68,,,,,,,fee schedule,Payment capped at billed charges.,15.64,,,,,,,fee schedule,Payment capped at billed charges.,13.34,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,40.8,,,,,,,percent of total billed charges,,31.2,,,,,,,percent of total billed charges,,15.38,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.75,,,,,,,fee schedule,Payment capped at billed charges.,32.17,,,,,,,fee schedule,Payment capped at billed charges.,15.26,,,,,,,fee schedule,,36.15,,,,,,,fee schedule,Payment capped at billed charges.,15.93,,,,,,,fee schedule,,15.87,,,,,,,fee schedule,Payment capped at billed charges.
OT IONTOPHERESIS 15 MIN,93500593,CDM,0430,RC,97033,CPT,11,Local,GO  ,outpatient,professional,,,59,59,17.83,90,,21.51,,,,,,,fee schedule,Payment capped at billed charges.,52.19,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,28.38,,,,,,,fee schedule,Payment capped at billed charges.,20.88,,,,,,,fee schedule,Payment capped at billed charges.,31.54,,,,,,,fee schedule,Payment capped at billed charges.,21.51,,,,,,,fee schedule,Payment capped at billed charges.,46.72,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,22.28,,,,,,,fee schedule,Payment capped at billed charges.,27.59,,,,,,,fee schedule,Payment capped at billed charges.,20.1,,,,,,,fee schedule,Payment capped at billed charges.,21.92,,,,,,,fee schedule,Payment capped at billed charges.,26.31,,,,,,,fee schedule,Payment capped at billed charges.,20.61,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,50.15,,,,,,,percent of total billed charges,,38.35,,,,,,,percent of total billed charges,,20.58,,,,,,,fee schedule,Payment capped at 80% of billed charges.,36.67,,,,,,,fee schedule,Payment capped at billed charges.,44.11,,,,,,,fee schedule,Payment capped at billed charges.,17.83,,,,,,,fee schedule,,49.56,,,,,,,fee schedule,Payment capped at billed charges.,21.3,,,,,,,fee schedule,,21.22,,,,,,,fee schedule,Payment capped at billed charges.
OT CONTRAST BATH THERAPY,93500601,CDM,0430,RC,97034,CPT,11,Local,GO  ,outpatient,professional,,,45,45,12.83,90,,15.48,,,,,,,fee schedule,Payment capped at billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,18.92,,,,,,,fee schedule,Payment capped at billed charges.,15.03,,,,,,,fee schedule,Payment capped at billed charges.,21.03,,,,,,,fee schedule,Payment capped at billed charges.,15.48,,,,,,,fee schedule,Payment capped at billed charges.,34.43,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,,16.03,,,,,,,fee schedule,Payment capped at billed charges.,19.85,,,,,,,fee schedule,Payment capped at billed charges.,16.3,,,,,,,fee schedule,Payment capped at billed charges.,15.78,,,,,,,fee schedule,Payment capped at billed charges.,18.93,,,,,,,fee schedule,Payment capped at billed charges.,14.92,,,,,,,fee schedule,Payment capped at billed charges.,12.83,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,38.25,,,,,,,percent of total billed charges,,29.25,,,,,,,percent of total billed charges,,14.81,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.38,,,,,,,fee schedule,Payment capped at billed charges.,31.73,,,,,,,fee schedule,Payment capped at billed charges.,14.45,,,,,,,fee schedule,,35.65,,,,,,,fee schedule,Payment capped at billed charges.,15.33,,,,,,,fee schedule,,15.27,,,,,,,fee schedule,Payment capped at billed charges.
OT ULTRASOUND 15MIN,93500619,CDM,0430,RC,97035,CPT,11,Local,GO  ,outpatient,professional,,,37,37,10.1,90,,15.86,,,,,,,fee schedule,Payment capped at billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,19.26,,,,,,,fee schedule,Payment capped at billed charges.,15.4,,,,,,,fee schedule,Payment capped at billed charges.,21.41,,,,,,,fee schedule,Payment capped at billed charges.,15.86,,,,,,,fee schedule,Payment capped at billed charges.,33.56,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,,16.43,,,,,,,fee schedule,Payment capped at billed charges.,20.35,,,,,,,fee schedule,Payment capped at billed charges.,11.39,,,,,,,fee schedule,Payment capped at billed charges.,16.17,,,,,,,fee schedule,Payment capped at billed charges.,19.41,,,,,,,fee schedule,Payment capped at billed charges.,15.29,,,,,,,fee schedule,Payment capped at billed charges.,13.15,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,31.45,,,,,,,percent of total billed charges,,24.05,,,,,,,percent of total billed charges,,15.19,,,,,,,fee schedule,Payment capped at 80% of billed charges.,26.38,,,,,,,fee schedule,Payment capped at billed charges.,31.73,,,,,,,fee schedule,Payment capped at billed charges.,10.1,,,,,,,fee schedule,,35.65,,,,,,,fee schedule,Payment capped at billed charges.,15.71,,,,,,,fee schedule,,15.65,,,,,,,fee schedule,Payment capped at billed charges.
OT THER EX EA 15 MIN,93500627,CDM,0430,RC,97110,CPT,11,Local,GO  ,outpatient,professional,,,80,80,27.16,90,,32.78,,,,,,,fee schedule,Payment capped at billed charges.,77.07,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,31.82,,,,,,,fee schedule,Payment capped at billed charges.,42.31,,,,,,,fee schedule,Payment capped at billed charges.,32.78,,,,,,,fee schedule,Payment capped at billed charges.,69.34,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,,33.96,,,,,,,fee schedule,Payment capped at billed charges.,42.04,,,,,,,fee schedule,Payment capped at billed charges.,33.38,,,,,,,fee schedule,Payment capped at billed charges.,33.41,,,,,,,fee schedule,Payment capped at billed charges.,40.1,,,,,,,fee schedule,Payment capped at billed charges.,31.64,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,68,,,,,,,percent of total billed charges,,52,,,,,,,percent of total billed charges,,31.37,,,,,,,fee schedule,Payment capped at 80% of billed charges.,54.01,,,,,,,fee schedule,Payment capped at billed charges.,64.95,,,,,,,fee schedule,Payment capped at billed charges.,29.61,,,,,,,fee schedule,,72.98,,,,,,,fee schedule,Payment capped at billed charges.,32.46,,,,,,,fee schedule,,32.34,,,,,,,fee schedule,Payment capped at billed charges.
OT NEURO RE-ED BAL 15MIN,93500635,CDM,0430,RC,97112,CPT,11,Local,GO  ,outpatient,professional,,,90,90,27.11,90,,36.47,,,,,,,fee schedule,Payment capped at billed charges.,88.64,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,34.24,,,,,,,fee schedule,Payment capped at billed charges.,35.4,,,,,,,fee schedule,Payment capped at billed charges.,40.29,,,,,,,fee schedule,Payment capped at billed charges.,36.47,,,,,,,fee schedule,Payment capped at billed charges.,80.77,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,,37.78,,,,,,,fee schedule,Payment capped at billed charges.,46.77,,,,,,,fee schedule,Payment capped at billed charges.,30.57,,,,,,,fee schedule,Payment capped at billed charges.,37.17,,,,,,,fee schedule,Payment capped at billed charges.,44.62,,,,,,,fee schedule,Payment capped at billed charges.,35.19,,,,,,,fee schedule,Payment capped at billed charges.,30.22,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,76.5,,,,,,,percent of total billed charges,,58.5,,,,,,,percent of total billed charges,,34.9,,,,,,,fee schedule,Payment capped at 80% of billed charges.,62.1,,,,,,,fee schedule,Payment capped at billed charges.,74.69,,,,,,,fee schedule,Payment capped at billed charges.,27.11,,,,,,,fee schedule,,83.92,,,,,,,fee schedule,Payment capped at billed charges.,36.11,,,,,,,fee schedule,,35.98,,,,,,,fee schedule,Payment capped at billed charges.
OT COGNITIVE FUNC INTRV 1ST15M,93500643,CDM,0430,RC,97129,CPT,11,Local,GO  ,outpatient,professional,,,72,72,20.09,90,,23.96,,,,,,,fee schedule,Payment capped at billed charges.,56.75,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.09,,,,,,,fee schedule,Payment capped at billed charges.,23.26,,,,,,,fee schedule,Payment capped at billed charges.,41.21,,,,,,,fee schedule,Payment capped at billed charges.,23.96,,,,,,,fee schedule,Payment capped at billed charges.,51.47,,,,,,,fee schedule,Payment capped at billed charges.,36,,,,,,,fee schedule,,24.82,,,,,,,fee schedule,Payment capped at billed charges.,30.73,,,,,,,fee schedule,Payment capped at billed charges.,23.58,,,,,,,fee schedule,Payment capped at billed charges.,24.42,,,,,,,fee schedule,Payment capped at billed charges.,29.31,,,,,,,fee schedule,Payment capped at billed charges.,23.81,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,61.2,,,,,,,percent of total billed charges,,46.8,,,,,,,percent of total billed charges,,22.93,,,,,,,fee schedule,Payment capped at 80% of billed charges.,39.95,,,,,,,fee schedule,Payment capped at billed charges.,48.05,,,,,,,fee schedule,Payment capped at billed charges.,20.71,,,,,,,fee schedule,,53.99,,,,,,,fee schedule,Payment capped at billed charges.,23.73,,,,,,,fee schedule,,23.64,,,,,,,fee schedule,Payment capped at billed charges.
OT COGNITIVE FUNC INTRV ADD15M,93500650,CDM,0430,RC,97130,CPT,11,Local,GO  ,outpatient,professional,,,72,72,19.18,90,,22.88,,,,,,,fee schedule,Payment capped at billed charges.,54.18,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,22.21,,,,,,,fee schedule,Payment capped at billed charges.,39.37,,,,,,,fee schedule,Payment capped at billed charges.,22.88,,,,,,,fee schedule,Payment capped at billed charges.,50,,,,,,,fee schedule,Payment capped at billed charges.,36,,,,,,,fee schedule,,23.7,,,,,,,fee schedule,Payment capped at billed charges.,29.34,,,,,,,fee schedule,Payment capped at billed charges.,22.53,,,,,,,fee schedule,Payment capped at billed charges.,23.32,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,22.75,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,61.2,,,,,,,percent of total billed charges,,46.8,,,,,,,percent of total billed charges,,21.89,,,,,,,fee schedule,Payment capped at 80% of billed charges.,38.15,,,,,,,fee schedule,Payment capped at billed charges.,45.88,,,,,,,fee schedule,Payment capped at billed charges.,19.79,,,,,,,fee schedule,,51.55,,,,,,,fee schedule,Payment capped at billed charges.,22.65,,,,,,,fee schedule,,22.57,,,,,,,fee schedule,Payment capped at billed charges.
OT UNLISTED PM R,93500668,CDM,0430,RC,97139,CPT,11,Local,GO  ,outpatient,professional,,,65,65,6.23,90,,14.1,,,,,,,fee schedule,Payment capped at billed charges.,33.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.85,,,,,,,fee schedule,Payment capped at billed charges.,32.5,,,,,,,fee schedule,,,,,,,,,,,42.25,,,,,,,fee schedule,Payment capped at billed charges.,15.39,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,6.23,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,55.25,,,,,,,percent of total billed charges,,42.25,,,,,,,percent of total billed charges,,52,,,,,,,fee schedule,Payment capped at 80% of billed charges.,42.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,13.51,,,,,,,fee schedule,,,,,,,,,,,22.75,,,,,,,fee schedule,,65,,,,,,,fee schedule,Payment capped at billed charges.
OT MANUAL THER EA 15 MIN,93500676,CDM,0430,RC,97140,CPT,11,Local,GO  ,outpatient,professional,,,74,74,23.92,90,,30.91,,,,,,,fee schedule,Payment capped at billed charges.,70.75,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.38,,,,,,,fee schedule,Payment capped at billed charges.,30.01,,,,,,,fee schedule,Payment capped at billed charges.,39.31,,,,,,,fee schedule,Payment capped at billed charges.,30.91,,,,,,,fee schedule,Payment capped at billed charges.,63.56,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,,32.02,,,,,,,fee schedule,Payment capped at billed charges.,39.65,,,,,,,fee schedule,Payment capped at billed charges.,26.97,,,,,,,fee schedule,Payment capped at billed charges.,31.51,,,,,,,fee schedule,Payment capped at billed charges.,37.82,,,,,,,fee schedule,Payment capped at billed charges.,29.86,,,,,,,fee schedule,Payment capped at billed charges.,25.62,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,62.9,,,,,,,percent of total billed charges,,48.1,,,,,,,percent of total billed charges,,29.59,,,,,,,fee schedule,Payment capped at 80% of billed charges.,49.59,,,,,,,fee schedule,Payment capped at billed charges.,59.64,,,,,,,fee schedule,Payment capped at billed charges.,23.92,,,,,,,fee schedule,,67.01,,,,,,,fee schedule,Payment capped at billed charges.,30.61,,,,,,,fee schedule,,30.5,,,,,,,fee schedule,Payment capped at billed charges.
OT THERAPEUTIC PROCEDURES GRP,93500684,CDM,0433,RC,97150,CPT,11,Local,GO  ,outpatient,professional,,,46,46,16.42,90,,19.81,,,,,,,fee schedule,Payment capped at billed charges.,46.2,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,21.54,,,,,,,fee schedule,Payment capped at billed charges.,19.24,,,,,,,fee schedule,Payment capped at billed charges.,23.94,,,,,,,fee schedule,Payment capped at billed charges.,19.81,,,,,,,fee schedule,Payment capped at billed charges.,41.18,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,,20.53,,,,,,,fee schedule,Payment capped at billed charges.,25.42,,,,,,,fee schedule,Payment capped at billed charges.,20.99,,,,,,,fee schedule,Payment capped at billed charges.,20.2,,,,,,,fee schedule,Payment capped at billed charges.,24.24,,,,,,,fee schedule,Payment capped at billed charges.,17.27,,,,,,,fee schedule,Payment capped at billed charges.,16.42,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,39.1,,,,,,,percent of total billed charges,,29.9,,,,,,,percent of total billed charges,,18.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,33.04,,,,,,,fee schedule,Payment capped at billed charges.,39.74,,,,,,,fee schedule,Payment capped at billed charges.,18.62,,,,,,,fee schedule,,44.65,,,,,,,fee schedule,Payment capped at billed charges.,19.62,,,,,,,fee schedule,,19.55,,,,,,,fee schedule,Payment capped at billed charges.
OT EVAL LOW COMPLEX,93500692,CDM,0434,RC,97165,CPT,11,Local,GO  ,outpatient,professional,,,262,262,60,262.63,,114.69,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,135.05,,,,,,,fee schedule,Payment capped at billed charges.,111.35,,,,,,,fee schedule,Payment capped at billed charges.,150.06,,,,,,,fee schedule,Payment capped at billed charges.,114.69,,,,,,,fee schedule,Payment capped at billed charges.,237.54,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,,118.82,,,,,,,fee schedule,Payment capped at billed charges.,147.11,,,,,,,fee schedule,Payment capped at billed charges.,77.06,,,,,,,fee schedule,Payment capped at billed charges.,116.92,,,,,,,fee schedule,Payment capped at billed charges.,140.32,,,,,,,fee schedule,Payment capped at billed charges.,110.55,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,109.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,186.65,,,,,,,fee schedule,Payment capped at billed charges.,224.48,,,,,,,fee schedule,Payment capped at billed charges.,68.35,,,,,,,fee schedule,,252.23,,,,,,,fee schedule,Payment capped at billed charges.,113.58,,,,,,,fee schedule,,113.16,,,,,,,fee schedule,Payment capped at billed charges.
OT EVAL MOD COMPLEX,93500700,CDM,0434,RC,97166,CPT,11,Local,GO  ,outpatient,professional,,,262,262,60,262.63,,114.69,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,132.1,,,,,,,fee schedule,Payment capped at billed charges.,111.35,,,,,,,fee schedule,Payment capped at billed charges.,146.77,,,,,,,fee schedule,Payment capped at billed charges.,114.69,,,,,,,fee schedule,Payment capped at billed charges.,237.54,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,,118.82,,,,,,,fee schedule,Payment capped at billed charges.,147.11,,,,,,,fee schedule,Payment capped at billed charges.,77.06,,,,,,,fee schedule,Payment capped at billed charges.,116.92,,,,,,,fee schedule,Payment capped at billed charges.,140.32,,,,,,,fee schedule,Payment capped at billed charges.,110.55,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,109.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,186.65,,,,,,,fee schedule,Payment capped at billed charges.,224.48,,,,,,,fee schedule,Payment capped at billed charges.,68.35,,,,,,,fee schedule,,252.23,,,,,,,fee schedule,Payment capped at billed charges.,113.58,,,,,,,fee schedule,,113.16,,,,,,,fee schedule,Payment capped at billed charges.
OT EVAL HIGH COMPLEX,93500718,CDM,0434,RC,97167,CPT,11,Local,GO  ,outpatient,professional,,,262,262,60,262.63,,114.69,,,,,,,fee schedule,Payment capped at billed charges.,262.63,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,138.15,,,,,,,fee schedule,Payment capped at billed charges.,111.35,,,,,,,fee schedule,Payment capped at billed charges.,153.49,,,,,,,fee schedule,Payment capped at billed charges.,114.69,,,,,,,fee schedule,Payment capped at billed charges.,237.54,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,,118.82,,,,,,,fee schedule,Payment capped at billed charges.,147.11,,,,,,,fee schedule,Payment capped at billed charges.,77.06,,,,,,,fee schedule,Payment capped at billed charges.,116.92,,,,,,,fee schedule,Payment capped at billed charges.,140.32,,,,,,,fee schedule,Payment capped at billed charges.,110.55,,,,,,,fee schedule,Payment capped at billed charges.,95.06,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,222.7,,,,,,,percent of total billed charges,,170.3,,,,,,,percent of total billed charges,,109.77,,,,,,,fee schedule,Payment capped at 80% of billed charges.,186.65,,,,,,,fee schedule,Payment capped at billed charges.,224.48,,,,,,,fee schedule,Payment capped at billed charges.,68.35,,,,,,,fee schedule,,252.23,,,,,,,fee schedule,Payment capped at billed charges.,113.58,,,,,,,fee schedule,,113.16,,,,,,,fee schedule,Payment capped at billed charges.
OT RE-EVAL EST PLAN CARE,93500726,CDM,0434,RC,97168,CPT,11,Local,GO  ,outpatient,professional,,,183,183,45.23,182.49,,79.74,,,,,,,fee schedule,Payment capped at billed charges.,182.49,,,,,,,fee schedule,Payment capped at billed charges.,66.09,,,,,,,fee schedule,Payment capped at billed charges.,66.09,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,91.56,,,,,,,fee schedule,Payment capped at billed charges.,77.42,,,,,,,fee schedule,Payment capped at billed charges.,101.72,,,,,,,fee schedule,Payment capped at billed charges.,79.74,,,,,,,fee schedule,Payment capped at billed charges.,164.63,,,,,,,fee schedule,Payment capped at billed charges.,66.09,,,,,,,fee schedule,,82.61,,,,,,,fee schedule,Payment capped at billed charges.,102.28,,,,,,,fee schedule,Payment capped at billed charges.,50.99,,,,,,,fee schedule,Payment capped at billed charges.,81.29,,,,,,,fee schedule,Payment capped at billed charges.,97.56,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,66.09,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,155.55,,,,,,,percent of total billed charges,,118.95,,,,,,,percent of total billed charges,,76.32,,,,,,,fee schedule,Payment capped at 80% of billed charges.,129.7,,,,,,,fee schedule,Payment capped at billed charges.,155.99,,,,,,,fee schedule,Payment capped at billed charges.,45.23,,,,,,,fee schedule,,175.27,,,,,,,fee schedule,Payment capped at billed charges.,78.97,,,,,,,fee schedule,,78.68,,,,,,,fee schedule,Payment capped at billed charges.
OT THER ACT EA 15 MIN,93500734,CDM,0430,RC,97530,CPT,11,Local,GO  ,outpatient,professional,,,102,102,31.17,98.75,,39.86,,,,,,,fee schedule,Payment capped at billed charges.,98.75,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,38.7,,,,,,,fee schedule,Payment capped at billed charges.,42.5,,,,,,,fee schedule,Payment capped at billed charges.,39.86,,,,,,,fee schedule,Payment capped at billed charges.,89.29,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,,41.3,,,,,,,fee schedule,Payment capped at billed charges.,51.13,,,,,,,fee schedule,Payment capped at billed charges.,35.14,,,,,,,fee schedule,Payment capped at billed charges.,40.64,,,,,,,fee schedule,Payment capped at billed charges.,48.77,,,,,,,fee schedule,Payment capped at billed charges.,38.04,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,86.7,,,,,,,percent of total billed charges,,66.3,,,,,,,percent of total billed charges,,38.15,,,,,,,fee schedule,Payment capped at 80% of billed charges.,68.41,,,,,,,fee schedule,Payment capped at billed charges.,82.27,,,,,,,fee schedule,Payment capped at billed charges.,31.17,,,,,,,fee schedule,,92.44,,,,,,,fee schedule,Payment capped at billed charges.,39.47,,,,,,,fee schedule,,39.33,,,,,,,fee schedule,Payment capped at billed charges.
OT SENSORY INTEGRATION EA15MIN,93500742,CDM,0430,RC,97533,CPT,11,Local,GO  ,outpatient,professional,,,172,172,23.32,172.37,,70.95,,,,,,,fee schedule,Payment capped at billed charges.,172.37,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,49.69,,,,,,,fee schedule,Payment capped at billed charges.,68.88,,,,,,,fee schedule,Payment capped at billed charges.,55.21,,,,,,,fee schedule,Payment capped at billed charges.,70.95,,,,,,,fee schedule,Payment capped at billed charges.,158.57,,,,,,,fee schedule,Payment capped at billed charges.,86,,,,,,,fee schedule,,73.5,,,,,,,fee schedule,Payment capped at billed charges.,91,,,,,,,fee schedule,Payment capped at billed charges.,26.29,,,,,,,fee schedule,Payment capped at billed charges.,72.32,,,,,,,fee schedule,Payment capped at billed charges.,86.8,,,,,,,fee schedule,Payment capped at billed charges.,66.46,,,,,,,fee schedule,Payment capped at billed charges.,59.5,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,146.2,,,,,,,percent of total billed charges,,111.8,,,,,,,percent of total billed charges,,67.9,,,,,,,fee schedule,Payment capped at 80% of billed charges.,118.27,,,,,,,fee schedule,Payment capped at billed charges.,142.25,,,,,,,fee schedule,Payment capped at billed charges.,23.32,,,,,,,fee schedule,,159.83,,,,,,,fee schedule,Payment capped at billed charges.,70.26,,,,,,,fee schedule,,70,,,,,,,fee schedule,Payment capped at billed charges.
OT ADL SELF CARE/HOME MGT 15M,93500759,CDM,0430,RC,97535,CPT,11,Local,GO  ,outpatient,professional,,,86,86,27.98,90,,36.69,,,,,,,fee schedule,Payment capped at billed charges.,86.43,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,35.62,,,,,,,fee schedule,Payment capped at billed charges.,39.26,,,,,,,fee schedule,Payment capped at billed charges.,36.69,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,Payment capped at billed charges.,30.41,,,,,,,fee schedule,,38.01,,,,,,,fee schedule,Payment capped at billed charges.,47.06,,,,,,,fee schedule,Payment capped at billed charges.,31.54,,,,,,,fee schedule,Payment capped at billed charges.,37.4,,,,,,,fee schedule,Payment capped at billed charges.,44.89,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,30.41,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,73.1,,,,,,,percent of total billed charges,,55.9,,,,,,,percent of total billed charges,,35.11,,,,,,,fee schedule,Payment capped at 80% of billed charges.,60.51,,,,,,,fee schedule,Payment capped at billed charges.,72.78,,,,,,,fee schedule,Payment capped at billed charges.,27.98,,,,,,,fee schedule,,81.77,,,,,,,fee schedule,Payment capped at billed charges.,36.33,,,,,,,fee schedule,,36.2,,,,,,,fee schedule,Payment capped at billed charges.
OT COM/WORK REINTEG 15M,93500767,CDM,0430,RC,97537,CPT,11,Local,GO  ,outpatient,professional,,,84,84,24.2,90,,36.16,,,,,,,fee schedule,Payment capped at billed charges.,83.26,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,35.11,,,,,,,fee schedule,Payment capped at billed charges.,39.26,,,,,,,fee schedule,Payment capped at billed charges.,36.16,,,,,,,fee schedule,Payment capped at billed charges.,74.98,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,,37.46,,,,,,,fee schedule,Payment capped at billed charges.,46.38,,,,,,,fee schedule,Payment capped at billed charges.,27.29,,,,,,,fee schedule,Payment capped at billed charges.,36.86,,,,,,,fee schedule,Payment capped at billed charges.,44.24,,,,,,,fee schedule,Payment capped at billed charges.,33.39,,,,,,,fee schedule,Payment capped at billed charges.,29.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,71.4,,,,,,,percent of total billed charges,,54.6,,,,,,,percent of total billed charges,,67.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,58.34,,,,,,,fee schedule,Payment capped at billed charges.,70.17,,,,,,,fee schedule,Payment capped at billed charges.,24.2,,,,,,,fee schedule,,78.84,,,,,,,fee schedule,Payment capped at billed charges.,35.81,,,,,,,fee schedule,,35.68,,,,,,,fee schedule,Payment capped at billed charges.
OT WHEELCHAIR MGMT EA 15MIN,93500775,CDM,0430,RC,97542,CPT,11,Local,GO  ,outpatient,professional,,,83,83,27.74,90,,35,,,,,,,fee schedule,Payment capped at billed charges.,83.26,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,29.68,,,,,,,fee schedule,Payment capped at billed charges.,33.98,,,,,,,fee schedule,Payment capped at billed charges.,32.56,,,,,,,fee schedule,Payment capped at billed charges.,35,,,,,,,fee schedule,Payment capped at billed charges.,74.98,,,,,,,fee schedule,Payment capped at billed charges.,29,,,,,,,fee schedule,,36.26,,,,,,,fee schedule,Payment capped at billed charges.,44.89,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,35.68,,,,,,,fee schedule,Payment capped at billed charges.,42.82,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,70.55,,,,,,,percent of total billed charges,,53.95,,,,,,,percent of total billed charges,,33.49,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,27.74,,,,,,,fee schedule,,,,,,,,,,service not payable,34.66,,,,,,,fee schedule,,34.53,,,,,,,fee schedule,Payment capped at billed charges.
OT WORK HARDENING,93500783,CDM,0430,RC,97545,CPT,11,Local,GO  ,outpatient,professional,,,413,413,10.61,413,,136.09,,,,,,,fee schedule,Payment capped at billed charges.,326.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,326.53,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,362.8,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,412.96,,,,,,,fee schedule,Payment capped at billed charges.,206.5,,,,,,,fee schedule,,,,,,,,,,,268.45,,,,,,,fee schedule,Payment capped at billed charges.,12.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,351.05,,,,,,,percent of total billed charges,,268.45,,,,,,,percent of total billed charges,,330.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,313.44,,,,,,,fee schedule,Payment capped at billed charges.,376.98,,,,,,,fee schedule,Payment capped at billed charges.,10.61,,,,,,,fee schedule,,413,,,,,,,fee schedule,Payment capped at billed charges.,144.55,,,,,,,fee schedule,,263.01,,,,,,,fee schedule,Payment capped at billed charges.
OT WORK HARDENING ADD ON,93500791,CDM,0430,RC,97546,CPT,11,Local,GO  ,outpatient,professional,,,184,184,54.22,181.41,,54.22,,,,,,,fee schedule,Payment capped at billed charges.,130,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,163.27,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,181.41,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,163.16,,,,,,,fee schedule,Payment capped at billed charges.,92,,,,,,,fee schedule,,,,,,,,,,,119.6,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,156.4,,,,,,,percent of total billed charges,,119.6,,,,,,,percent of total billed charges,,147.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,124.99,,,,,,,fee schedule,Payment capped at billed charges.,150.33,,,,,,,fee schedule,Payment capped at billed charges.,62.56,,,,,,,fee schedule,,168.91,,,,,,,fee schedule,Payment capped at billed charges.,64.4,,,,,,,fee schedule,,77.76,,,,,,,fee schedule,Payment capped at billed charges.
OT SELECT DEBRID 1ST20SQCMLESS,93500809,CDM,0430,RC,97597,CPT,11,Local,GO  ,outpatient,professional,,,273,273,60,273,,113.39,,,,,,,fee schedule,Payment capped at billed charges.,273,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,94.83,,,,,,,fee schedule,Payment capped at billed charges.,110.09,,,,,,,fee schedule,Payment capped at billed charges.,105.38,,,,,,,fee schedule,Payment capped at billed charges.,113.39,,,,,,,fee schedule,Payment capped at billed charges.,251.6,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,,117.47,,,,,,,fee schedule,Payment capped at billed charges.,145.44,,,,,,,fee schedule,Payment capped at billed charges.,68.79,,,,,,,fee schedule,Payment capped at billed charges.,115.59,,,,,,,fee schedule,Payment capped at billed charges.,138.73,,,,,,,fee schedule,Payment capped at billed charges.,106.27,,,,,,,fee schedule,Payment capped at billed charges.,93.98,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,232.05,,,,,,,percent of total billed charges,,177.45,,,,,,,percent of total billed charges,,108.53,,,,,,,fee schedule,Payment capped at 80% of billed charges.,191.65,,,,,,,fee schedule,Payment capped at billed charges.,230.5,,,,,,,fee schedule,Payment capped at billed charges.,60.42,,,,,,,fee schedule,,258.99,,,,,,,fee schedule,Payment capped at billed charges.,112.29,,,,,,,fee schedule,,111.88,,,,,,,fee schedule,Payment capped at billed charges.
OT SELECT DEBRIDE EA ADD20SQCM,93500817,CDM,0430,RC,97598,CPT,11,Local,GO  ,outpatient,professional,,,138,138,25.94,133.51,,50.11,,,,,,,fee schedule,Payment capped at billed charges.,119.66,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,120.17,,,,,,,fee schedule,Payment capped at billed charges.,48.65,,,,,,,fee schedule,Payment capped at billed charges.,133.51,,,,,,,fee schedule,Payment capped at billed charges.,50.11,,,,,,,fee schedule,Payment capped at billed charges.,110.28,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,,51.91,,,,,,,fee schedule,Payment capped at billed charges.,64.27,,,,,,,fee schedule,Payment capped at billed charges.,29.53,,,,,,,fee schedule,Payment capped at billed charges.,51.08,,,,,,,fee schedule,Payment capped at billed charges.,61.31,,,,,,,fee schedule,Payment capped at billed charges.,47.63,,,,,,,fee schedule,Payment capped at billed charges.,41.53,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,117.3,,,,,,,percent of total billed charges,,89.7,,,,,,,percent of total billed charges,,47.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,84.19,,,,,,,fee schedule,Payment capped at billed charges.,101.26,,,,,,,fee schedule,Payment capped at billed charges.,25.94,,,,,,,fee schedule,,113.77,,,,,,,fee schedule,Payment capped at billed charges.,49.62,,,,,,,fee schedule,,49.44,,,,,,,fee schedule,Payment capped at billed charges.
OT PHYSICAL PERF TEST EA 15MIN,93500825,CDM,0430,RC,97750,CPT,11,Local,GO  ,outpatient,professional,,,90,90,26.23,90,,38.25,,,,,,,fee schedule,Payment capped at billed charges.,89.26,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,54.58,,,,,,,fee schedule,Payment capped at billed charges.,37.14,,,,,,,fee schedule,Payment capped at billed charges.,60.32,,,,,,,fee schedule,Payment capped at billed charges.,38.25,,,,,,,fee schedule,Payment capped at billed charges.,79.68,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,,39.63,,,,,,,fee schedule,Payment capped at billed charges.,49.06,,,,,,,fee schedule,Payment capped at billed charges.,29.58,,,,,,,fee schedule,Payment capped at billed charges.,38.99,,,,,,,fee schedule,Payment capped at billed charges.,46.8,,,,,,,fee schedule,Payment capped at billed charges.,36.61,,,,,,,fee schedule,Payment capped at billed charges.,31.7,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,76.5,,,,,,,percent of total billed charges,,58.5,,,,,,,percent of total billed charges,,36.61,,,,,,,fee schedule,Payment capped at 80% of billed charges.,63.12,,,,,,,fee schedule,Payment capped at billed charges.,75.92,,,,,,,fee schedule,Payment capped at billed charges.,26.23,,,,,,,fee schedule,,85.3,,,,,,,fee schedule,Payment capped at billed charges.,37.88,,,,,,,fee schedule,,37.74,,,,,,,fee schedule,Payment capped at billed charges.
OT EVAL ENVIR ASSES,93500833,CDM,0430,RC,97755,CPT,11,Local,GO  ,outpatient,professional,,,100,100,28.23,100.32,,42.57,,,,,,,fee schedule,Payment capped at billed charges.,100.32,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,64.84,,,,,,,fee schedule,Payment capped at billed charges.,41.33,,,,,,,fee schedule,Payment capped at billed charges.,72.04,,,,,,,fee schedule,Payment capped at billed charges.,42.57,,,,,,,fee schedule,Payment capped at billed charges.,88.72,,,,,,,fee schedule,Payment capped at billed charges.,35.28,,,,,,,fee schedule,,44.1,,,,,,,fee schedule,Payment capped at billed charges.,54.6,,,,,,,fee schedule,Payment capped at billed charges.,31.83,,,,,,,fee schedule,Payment capped at billed charges.,43.39,,,,,,,fee schedule,Payment capped at billed charges.,52.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,35.28,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,85,,,,,,,percent of total billed charges,,65,,,,,,,percent of total billed charges,,40.74,,,,,,,fee schedule,Payment capped at 80% of billed charges.,70.33,,,,,,,fee schedule,Payment capped at billed charges.,84.59,,,,,,,fee schedule,Payment capped at billed charges.,28.23,,,,,,,fee schedule,,95.04,,,,,,,fee schedule,Payment capped at billed charges.,42.15,,,,,,,fee schedule,,42,,,,,,,fee schedule,Payment capped at billed charges.
OT ORTH FIT/TRAIN INIT EA15MIN,93500841,CDM,0430,RC,97760,CPT,11,Local,GO  ,outpatient,professional,,,130,130,42.87,129.92,,53.27,,,,,,,fee schedule,Payment capped at billed charges.,129.92,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,48.3,,,,,,,fee schedule,Payment capped at billed charges.,51.72,,,,,,,fee schedule,Payment capped at billed charges.,53.68,,,,,,,fee schedule,Payment capped at billed charges.,53.27,,,,,,,fee schedule,Payment capped at billed charges.,117.81,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,,55.19,,,,,,,fee schedule,Payment capped at billed charges.,68.33,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,54.3,,,,,,,fee schedule,Payment capped at billed charges.,65.17,,,,,,,fee schedule,Payment capped at billed charges.,50.48,,,,,,,fee schedule,Payment capped at billed charges.,44.15,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,110.5,,,,,,,percent of total billed charges,,84.5,,,,,,,percent of total billed charges,,50.98,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,42.87,,,,,,,fee schedule,,,,,,,,,,service not payable,52.75,,,,,,,fee schedule,,52.56,,,,,,,fee schedule,Payment capped at billed charges.
OT PROSTH TRAIN INIT EA 15MIN,93500858,CDM,0430,RC,97761,CPT,11,Local,GO  ,outpatient,professional,,,111,111,36.5,111.16,,46.63,,,,,,,fee schedule,Payment capped at billed charges.,111.16,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,48.01,,,,,,,fee schedule,Payment capped at billed charges.,45.27,,,,,,,fee schedule,Payment capped at billed charges.,53.33,,,,,,,fee schedule,Payment capped at billed charges.,46.63,,,,,,,fee schedule,Payment capped at billed charges.,99.72,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,,48.31,,,,,,,fee schedule,Payment capped at billed charges.,59.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,47.54,,,,,,,fee schedule,Payment capped at billed charges.,57.05,,,,,,,fee schedule,Payment capped at billed charges.,44.42,,,,,,,fee schedule,Payment capped at billed charges.,38.65,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,94.35,,,,,,,percent of total billed charges,,72.15,,,,,,,percent of total billed charges,,44.62,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,36.5,,,,,,,fee schedule,,,,,,,,,,service not payable,46.18,,,,,,,fee schedule,,46.01,,,,,,,fee schedule,Payment capped at billed charges.
OT ORTH/PROS SUBS ENC EA15MIN,93500866,CDM,0430,RC,97763,CPT,11,Local,GO  ,outpatient,professional,,,144,144,47.77,143.3,,58.44,,,,,,,fee schedule,Payment capped at billed charges.,143.3,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,67.68,,,,,,,fee schedule,Payment capped at billed charges.,56.74,,,,,,,fee schedule,Payment capped at billed charges.,75.2,,,,,,,fee schedule,Payment capped at billed charges.,58.44,,,,,,,fee schedule,Payment capped at billed charges.,131.86,,,,,,,fee schedule,Payment capped at billed charges.,72,,,,,,,fee schedule,,60.54,,,,,,,fee schedule,Payment capped at billed charges.,74.96,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,59.57,,,,,,,fee schedule,Payment capped at billed charges.,71.5,,,,,,,fee schedule,Payment capped at billed charges.,55.1,,,,,,,fee schedule,Payment capped at billed charges.,49.01,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,122.4,,,,,,,percent of total billed charges,,93.6,,,,,,,percent of total billed charges,,55.93,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,47.77,,,,,,,fee schedule,,,,,,,,,,service not payable,57.87,,,,,,,fee schedule,,57.66,,,,,,,fee schedule,Payment capped at billed charges.
OT DRIVING EVAL,93500874,CDM,0430,RC,97799,CPT,11,Local,GO  ,outpatient,professional,,,350,350,20.2,350,,,,,,,,,,service not payable,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,227.5,,,,,,,fee schedule,Payment capped at billed charges.,175,,,,,,,fee schedule,,,,,,,,,,,227.5,,,,,,,fee schedule,Payment capped at billed charges.,23,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,297.5,,,,,,,percent of total billed charges,,227.5,,,,,,,percent of total billed charges,,280,,,,,,,fee schedule,Payment capped at 80% of billed charges.,227.5,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,20.2,,,,,,,fee schedule,,,,,,,,,,,122.5,,,,,,,fee schedule,,350,,,,,,,fee schedule,Payment capped at billed charges.
SP BIOFEEDBACK TRAINING,93500882,CDM,0440,RC,90901,CPT,11,Local,GN  ,outpatient,professional,,,141,141,28.82,120.85,,45.84,,,,,,,fee schedule,Payment capped at billed charges.,109.44,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,38.45,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,72,,,,,,,fee schedule,Payment capped at billed charges.,44.51,,,,,,,fee schedule,Payment capped at billed charges.,80.01,,,,,,,fee schedule,Payment capped at billed charges.,45.84,,,,,,,fee schedule,Payment capped at billed charges.,120.5,,,,,,,fee schedule,Payment capped at billed charges.,70.5,,,,,,,fee schedule,,47.49,,,,,,,fee schedule,Payment capped at billed charges.,45.23,,,,,,,fee schedule,Payment capped at billed charges.,32.81,,,,,,,fee schedule,Payment capped at billed charges.,46.73,,,,,,,fee schedule,Payment capped at billed charges.,56.09,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,38.45,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,119.85,,,,,,,percent of total billed charges,,91.65,,,,,,,percent of total billed charges,,43.87,,,,,,,fee schedule,Payment capped at 80% of billed charges.,89.43,,,,,,,fee schedule,Payment capped at billed charges.,107.56,,,,,,,fee schedule,Payment capped at billed charges.,28.82,,,,,,,fee schedule,,120.85,,,,,,,fee schedule,Payment capped at billed charges.,45.4,,,,,,,fee schedule,,45.23,,,,,,,fee schedule,Payment capped at billed charges.
SP COMM/COG/LANG TX,93500890,CDM,0440,RC,92507,CPT,11,Local,GN  ,outpatient,professional,,,275,275,60,233.75,,84.88,,,,,,,fee schedule,Payment capped at billed charges.,198.04,,,,,,,fee schedule,Payment capped at billed charges.,70.35,,,,,,,fee schedule,Payment capped at billed charges.,70.35,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,66.47,,,,,,,fee schedule,Payment capped at billed charges.,82.41,,,,,,,fee schedule,Payment capped at billed charges.,73.86,,,,,,,fee schedule,Payment capped at billed charges.,84.88,,,,,,,fee schedule,Payment capped at billed charges.,218.78,,,,,,,fee schedule,Payment capped at billed charges.,70.35,,,,,,,fee schedule,,87.94,,,,,,,fee schedule,Payment capped at billed charges.,83.75,,,,,,,fee schedule,Payment capped at billed charges.,73.59,,,,,,,fee schedule,Payment capped at billed charges.,86.53,,,,,,,fee schedule,Payment capped at billed charges.,103.85,,,,,,,fee schedule,Payment capped at billed charges.,82.46,,,,,,,fee schedule,Payment capped at billed charges.,70.35,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,233.75,,,,,,,percent of total billed charges,,178.75,,,,,,,percent of total billed charges,,81.24,,,,,,,fee schedule,Payment capped at 80% of billed charges.,161.91,,,,,,,fee schedule,Payment capped at billed charges.,194.73,,,,,,,fee schedule,Payment capped at billed charges.,65.27,,,,,,,fee schedule,,218.8,,,,,,,fee schedule,Payment capped at billed charges.,84.06,,,,,,,fee schedule,,83.75,,,,,,,fee schedule,Payment capped at billed charges.
SP LANGUAGE TX GROUP,93500908,CDM,0443,RC,92508,CPT,11,Local,GN  ,outpatient,professional,,,68,68,22.43,90,,27.06,,,,,,,fee schedule,Payment capped at billed charges.,62.59,,,,,,,fee schedule,Payment capped at billed charges.,22.43,,,,,,,fee schedule,Payment capped at billed charges.,22.43,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.35,,,,,,,fee schedule,Payment capped at billed charges.,26.27,,,,,,,fee schedule,Payment capped at billed charges.,43.74,,,,,,,fee schedule,Payment capped at billed charges.,27.06,,,,,,,fee schedule,Payment capped at billed charges.,68,,,,,,,fee schedule,Payment capped at billed charges.,22.43,,,,,,,fee schedule,,28.04,,,,,,,fee schedule,Payment capped at billed charges.,26.7,,,,,,,fee schedule,Payment capped at billed charges.,29.49,,,,,,,fee schedule,Payment capped at billed charges.,27.59,,,,,,,fee schedule,Payment capped at billed charges.,33.11,,,,,,,fee schedule,Payment capped at billed charges.,25.95,,,,,,,fee schedule,Payment capped at billed charges.,22.43,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,57.8,,,,,,,percent of total billed charges,,44.2,,,,,,,percent of total billed charges,,25.89,,,,,,,fee schedule,Payment capped at 80% of billed charges.,52.33,,,,,,,fee schedule,Payment capped at billed charges.,62.93,,,,,,,fee schedule,Payment capped at billed charges.,26.19,,,,,,,fee schedule,,68,,,,,,,fee schedule,Payment capped at billed charges.,26.8,,,,,,,fee schedule,,26.7,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL OF SPEECH FLUENCY,93500916,CDM,0444,RC,92521,CPT,11,Local,GN  ,outpatient,professional,,,378,378,60,378,,147.92,,,,,,,fee schedule,Payment capped at billed charges.,344.17,,,,,,,fee schedule,Payment capped at billed charges.,122.6,,,,,,,fee schedule,Payment capped at billed charges.,122.6,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,158.98,,,,,,,fee schedule,Payment capped at billed charges.,143.61,,,,,,,fee schedule,Payment capped at billed charges.,176.64,,,,,,,fee schedule,Payment capped at billed charges.,147.92,,,,,,,fee schedule,Payment capped at billed charges.,378,,,,,,,fee schedule,Payment capped at billed charges.,122.6,,,,,,,fee schedule,,153.25,,,,,,,fee schedule,Payment capped at billed charges.,145.95,,,,,,,fee schedule,Payment capped at billed charges.,105.05,,,,,,,fee schedule,Payment capped at billed charges.,150.8,,,,,,,fee schedule,Payment capped at billed charges.,180.98,,,,,,,fee schedule,Payment capped at billed charges.,143.6,,,,,,,fee schedule,Payment capped at billed charges.,122.6,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,321.3,,,,,,,percent of total billed charges,,245.7,,,,,,,percent of total billed charges,,141.57,,,,,,,fee schedule,Payment capped at 80% of billed charges.,282.3,,,,,,,fee schedule,Payment capped at billed charges.,339.52,,,,,,,fee schedule,Payment capped at billed charges.,93.18,,,,,,,fee schedule,,378,,,,,,,fee schedule,Payment capped at billed charges.,146.49,,,,,,,fee schedule,,145.95,,,,,,,fee schedule,Payment capped at billed charges.
SP EVALUATE SPEECH PRODUCTION,93500924,CDM,0444,RC,92522,CPT,11,Local,GN  ,outpatient,professional,,,316,316,60,316,,122.76,,,,,,,fee schedule,Payment capped at billed charges.,287.12,,,,,,,fee schedule,Payment capped at billed charges.,101.75,,,,,,,fee schedule,Payment capped at billed charges.,101.75,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,133.21,,,,,,,fee schedule,Payment capped at billed charges.,119.18,,,,,,,fee schedule,Payment capped at billed charges.,148.01,,,,,,,fee schedule,Payment capped at billed charges.,122.76,,,,,,,fee schedule,Payment capped at billed charges.,316,,,,,,,fee schedule,Payment capped at billed charges.,101.75,,,,,,,fee schedule,,127.18,,,,,,,fee schedule,Payment capped at billed charges.,121.12,,,,,,,fee schedule,Payment capped at billed charges.,85.1,,,,,,,fee schedule,Payment capped at billed charges.,125.14,,,,,,,fee schedule,Payment capped at billed charges.,150.19,,,,,,,fee schedule,Payment capped at billed charges.,119.43,,,,,,,fee schedule,Payment capped at billed charges.,101.75,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,268.6,,,,,,,percent of total billed charges,,205.4,,,,,,,percent of total billed charges,,117.49,,,,,,,fee schedule,Payment capped at 80% of billed charges.,235.9,,,,,,,fee schedule,Payment capped at billed charges.,283.71,,,,,,,fee schedule,Payment capped at billed charges.,75.48,,,,,,,fee schedule,,316,,,,,,,fee schedule,Payment capped at billed charges.,121.57,,,,,,,fee schedule,,121.12,,,,,,,fee schedule,Payment capped at billed charges.
SP SOUND LANG COMPREHEN,93500932,CDM,0444,RC,92523,CPT,11,Local,GN  ,outpatient,professional,,,644,644,60,644,,252.95,,,,,,,fee schedule,Payment capped at billed charges.,590.13,,,,,,,fee schedule,Payment capped at billed charges.,209.64,,,,,,,fee schedule,Payment capped at billed charges.,209.64,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,271.14,,,,,,,fee schedule,Payment capped at billed charges.,245.59,,,,,,,fee schedule,Payment capped at billed charges.,301.29,,,,,,,fee schedule,Payment capped at billed charges.,252.95,,,,,,,fee schedule,Payment capped at billed charges.,644,,,,,,,fee schedule,Payment capped at billed charges.,209.64,,,,,,,fee schedule,,262.06,,,,,,,fee schedule,Payment capped at billed charges.,249.58,,,,,,,fee schedule,Payment capped at billed charges.,177.07,,,,,,,fee schedule,Payment capped at billed charges.,257.87,,,,,,,fee schedule,Payment capped at billed charges.,309.48,,,,,,,fee schedule,Payment capped at billed charges.,245.61,,,,,,,fee schedule,Payment capped at billed charges.,209.64,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,547.4,,,,,,,percent of total billed charges,,418.6,,,,,,,percent of total billed charges,,242.09,,,,,,,fee schedule,Payment capped at 80% of billed charges.,483.96,,,,,,,fee schedule,Payment capped at billed charges.,582.06,,,,,,,fee schedule,Payment capped at billed charges.,157.05,,,,,,,fee schedule,,644,,,,,,,fee schedule,Payment capped at billed charges.,250.5,,,,,,,fee schedule,,249.58,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL OF VOICE/RESONANCE,93500940,CDM,0444,RC,92524,CPT,11,Local,GN  ,outpatient,professional,,,311,311,60,311,,120.43,,,,,,,fee schedule,Payment capped at billed charges.,283.38,,,,,,,fee schedule,Payment capped at billed charges.,99.81,,,,,,,fee schedule,Payment capped at billed charges.,99.81,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,130.99,,,,,,,fee schedule,Payment capped at billed charges.,116.92,,,,,,,fee schedule,Payment capped at billed charges.,145.54,,,,,,,fee schedule,Payment capped at billed charges.,120.43,,,,,,,fee schedule,Payment capped at billed charges.,311,,,,,,,fee schedule,Payment capped at billed charges.,99.81,,,,,,,fee schedule,,124.76,,,,,,,fee schedule,Payment capped at billed charges.,118.82,,,,,,,fee schedule,Payment capped at billed charges.,89.01,,,,,,,fee schedule,Payment capped at billed charges.,122.76,,,,,,,fee schedule,Payment capped at billed charges.,147.34,,,,,,,fee schedule,Payment capped at billed charges.,117.3,,,,,,,fee schedule,Payment capped at billed charges.,99.81,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,264.35,,,,,,,percent of total billed charges,,202.15,,,,,,,percent of total billed charges,,115.25,,,,,,,fee schedule,Payment capped at 80% of billed charges.,232.12,,,,,,,fee schedule,Payment capped at billed charges.,279.18,,,,,,,fee schedule,Payment capped at billed charges.,78.95,,,,,,,fee schedule,,311,,,,,,,fee schedule,Payment capped at billed charges.,119.26,,,,,,,fee schedule,,118.82,,,,,,,fee schedule,Payment capped at billed charges.
SP SWALLOW TX,93500957,CDM,0440,RC,92526,CPT,11,Local,GN  ,outpatient,professional,,,245,245,60,244.56,,94.09,,,,,,,fee schedule,Payment capped at billed charges.,221,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,138.21,,,,,,,fee schedule,Payment capped at billed charges.,91.34,,,,,,,fee schedule,Payment capped at billed charges.,153.56,,,,,,,fee schedule,Payment capped at billed charges.,94.09,,,,,,,fee schedule,Payment capped at billed charges.,244.56,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,,97.47,,,,,,,fee schedule,Payment capped at billed charges.,92.83,,,,,,,fee schedule,Payment capped at billed charges.,92.98,,,,,,,fee schedule,Payment capped at billed charges.,95.91,,,,,,,fee schedule,Payment capped at billed charges.,115.11,,,,,,,fee schedule,Payment capped at billed charges.,91,,,,,,,fee schedule,Payment capped at billed charges.,77.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,208.25,,,,,,,percent of total billed charges,,159.25,,,,,,,percent of total billed charges,,90.05,,,,,,,fee schedule,Payment capped at 80% of billed charges.,180.46,,,,,,,fee schedule,Payment capped at billed charges.,217.04,,,,,,,fee schedule,Payment capped at billed charges.,82.47,,,,,,,fee schedule,,243.87,,,,,,,fee schedule,Payment capped at billed charges.,93.17,,,,,,,fee schedule,,92.83,,,,,,,fee schedule,Payment capped at billed charges.
SP VOICE PROSTHESIS EVAL,93500965,CDM,0444,RC,92597,CPT,11,Local,GN  ,outpatient,professional,,,444,444,60,377.4,,80.36,,,,,,,fee schedule,Payment capped at billed charges.,185.39,,,,,,,fee schedule,Payment capped at billed charges.,66.6,,,,,,,fee schedule,Payment capped at billed charges.,66.6,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,158.93,,,,,,,fee schedule,Payment capped at billed charges.,78.02,,,,,,,fee schedule,Payment capped at billed charges.,176.58,,,,,,,fee schedule,Payment capped at billed charges.,80.36,,,,,,,fee schedule,Payment capped at billed charges.,205.76,,,,,,,fee schedule,Payment capped at billed charges.,66.6,,,,,,,fee schedule,,83.25,,,,,,,fee schedule,Payment capped at billed charges.,79.29,,,,,,,fee schedule,Payment capped at billed charges.,80.41,,,,,,,fee schedule,Payment capped at billed charges.,81.92,,,,,,,fee schedule,Payment capped at billed charges.,98.32,,,,,,,fee schedule,Payment capped at billed charges.,83.74,,,,,,,fee schedule,Payment capped at billed charges.,66.6,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,377.4,,,,,,,percent of total billed charges,,288.6,,,,,,,percent of total billed charges,,76.91,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,71.32,,,,,,,fee schedule,,,,,,,,,,service not payable,79.58,,,,,,,fee schedule,,79.29,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL-SP GEN DEV1ST HR,93500973,CDM,0444,RC,92607,CPT,11,Local,GN  ,outpatient,professional,,,527,527,60,447.95,,137.93,,,,,,,fee schedule,Payment capped at billed charges.,323.58,,,,,,,fee schedule,Payment capped at billed charges.,115.68,,,,,,,fee schedule,Payment capped at billed charges.,115.68,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,194.53,,,,,,,fee schedule,Payment capped at billed charges.,133.91,,,,,,,fee schedule,Payment capped at billed charges.,216.15,,,,,,,fee schedule,Payment capped at billed charges.,137.93,,,,,,,fee schedule,Payment capped at billed charges.,358.27,,,,,,,fee schedule,Payment capped at billed charges.,263.5,,,,,,,fee schedule,,142.89,,,,,,,fee schedule,Payment capped at billed charges.,136.09,,,,,,,fee schedule,Payment capped at billed charges.,140,,,,,,,fee schedule,Payment capped at billed charges.,140.61,,,,,,,fee schedule,Payment capped at billed charges.,168.75,,,,,,,fee schedule,Payment capped at billed charges.,132.94,,,,,,,fee schedule,Payment capped at billed charges.,115.68,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,447.95,,,,,,,percent of total billed charges,,342.55,,,,,,,percent of total billed charges,,132.02,,,,,,,fee schedule,Payment capped at 80% of billed charges.,265.25,,,,,,,fee schedule,Payment capped at billed charges.,319.01,,,,,,,fee schedule,Payment capped at billed charges.,124.17,,,,,,,fee schedule,,358.44,,,,,,,fee schedule,Payment capped at billed charges.,136.59,,,,,,,fee schedule,,136.09,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL-SP GEN DEVADDL 30 MIN,93500981,CDM,0444,RC,92608,CPT,11,Local,GN  ,outpatient,professional,,,275,275,38.19,233.75,,54.33,,,,,,,fee schedule,Payment capped at billed charges.,127.5,,,,,,,fee schedule,Payment capped at billed charges.,45.57,,,,,,,fee schedule,Payment capped at billed charges.,45.57,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,38.19,,,,,,,fee schedule,Payment capped at billed charges.,52.75,,,,,,,fee schedule,Payment capped at billed charges.,42.42,,,,,,,fee schedule,Payment capped at billed charges.,54.33,,,,,,,fee schedule,Payment capped at billed charges.,142.48,,,,,,,fee schedule,Payment capped at billed charges.,137.5,,,,,,,fee schedule,,56.29,,,,,,,fee schedule,Payment capped at billed charges.,53.61,,,,,,,fee schedule,Payment capped at billed charges.,47.76,,,,,,,fee schedule,Payment capped at billed charges.,55.39,,,,,,,fee schedule,Payment capped at billed charges.,66.48,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,45.57,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,233.75,,,,,,,percent of total billed charges,,178.75,,,,,,,percent of total billed charges,,52,,,,,,,fee schedule,Payment capped at 80% of billed charges.,104.33,,,,,,,fee schedule,Payment capped at billed charges.,125.47,,,,,,,fee schedule,Payment capped at billed charges.,41.95,,,,,,,fee schedule,,140.98,,,,,,,fee schedule,Payment capped at billed charges.,53.81,,,,,,,fee schedule,,53.61,,,,,,,fee schedule,Payment capped at billed charges.
SP TRAINING/FITTING SLP GEN DV,93500999,CDM,0440,RC,92609,CPT,11,Local,GN  ,outpatient,professional,,,306,306,60,301.34,,115.26,,,,,,,fee schedule,Payment capped at billed charges.,270.63,,,,,,,fee schedule,Payment capped at billed charges.,96.66,,,,,,,fee schedule,Payment capped at billed charges.,96.66,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,105.33,,,,,,,fee schedule,Payment capped at billed charges.,111.9,,,,,,,fee schedule,Payment capped at billed charges.,117.03,,,,,,,fee schedule,Payment capped at billed charges.,115.26,,,,,,,fee schedule,Payment capped at billed charges.,301.34,,,,,,,fee schedule,Payment capped at billed charges.,153,,,,,,,fee schedule,,119.41,,,,,,,fee schedule,Payment capped at billed charges.,113.72,,,,,,,fee schedule,Payment capped at billed charges.,99.2,,,,,,,fee schedule,Payment capped at billed charges.,117.5,,,,,,,fee schedule,Payment capped at billed charges.,141.01,,,,,,,fee schedule,Payment capped at billed charges.,110.9,,,,,,,fee schedule,Payment capped at billed charges.,96.66,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,260.1,,,,,,,percent of total billed charges,,198.9,,,,,,,percent of total billed charges,,110.31,,,,,,,fee schedule,Payment capped at 80% of billed charges.,,,,,,,,,service not payable,,,,,,,,,service not payable,87.99,,,,,,,fee schedule,,,,,,,,,,service not payable,114.14,,,,,,,fee schedule,,113.72,,,,,,,fee schedule,Payment capped at billed charges.
SP CLINICAL SWALLOW EVAL,93501005,CDM,0444,RC,92610,CPT,11,Local,GN  ,outpatient,professional,,,273,273,60,269.82,,95.04,,,,,,,fee schedule,Payment capped at billed charges.,221.48,,,,,,,fee schedule,Payment capped at billed charges.,79.7,,,,,,,fee schedule,Payment capped at billed charges.,79.7,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,242.84,,,,,,,fee schedule,Payment capped at billed charges.,92.27,,,,,,,fee schedule,Payment capped at billed charges.,269.82,,,,,,,fee schedule,Payment capped at billed charges.,95.04,,,,,,,fee schedule,Payment capped at billed charges.,246.34,,,,,,,fee schedule,Payment capped at billed charges.,136.5,,,,,,,fee schedule,,98.46,,,,,,,fee schedule,Payment capped at billed charges.,93.77,,,,,,,fee schedule,Payment capped at billed charges.,93.64,,,,,,,fee schedule,Payment capped at billed charges.,96.88,,,,,,,fee schedule,Payment capped at billed charges.,116.27,,,,,,,fee schedule,Payment capped at billed charges.,91.7,,,,,,,fee schedule,Payment capped at billed charges.,79.7,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,232.05,,,,,,,percent of total billed charges,,177.45,,,,,,,percent of total billed charges,,90.95,,,,,,,fee schedule,Payment capped at 80% of billed charges.,182.29,,,,,,,fee schedule,Payment capped at billed charges.,219.24,,,,,,,fee schedule,Payment capped at billed charges.,82.24,,,,,,,fee schedule,,246.34,,,,,,,fee schedule,Payment capped at billed charges.,94.12,,,,,,,fee schedule,,93.77,,,,,,,fee schedule,Payment capped at billed charges.
SP MOD BARIUM SWALLOWING STUDY,93501013,CDM,0440,RC,92611,CPT,11,Local,GN  ,outpatient,professional,,,264,264,60,264,,101.49,,,,,,,fee schedule,Payment capped at billed charges.,239.81,,,,,,,fee schedule,Payment capped at billed charges.,85.12,,,,,,,fee schedule,Payment capped at billed charges.,85.12,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,86.23,,,,,,,fee schedule,Payment capped at billed charges.,98.54,,,,,,,fee schedule,Payment capped at billed charges.,95.83,,,,,,,fee schedule,Payment capped at billed charges.,101.49,,,,,,,fee schedule,Payment capped at billed charges.,264,,,,,,,fee schedule,Payment capped at billed charges.,132,,,,,,,fee schedule,,105.15,,,,,,,fee schedule,Payment capped at billed charges.,100.14,,,,,,,fee schedule,Payment capped at billed charges.,101.87,,,,,,,fee schedule,Payment capped at billed charges.,103.46,,,,,,,fee schedule,Payment capped at billed charges.,124.17,,,,,,,fee schedule,Payment capped at billed charges.,97.75,,,,,,,fee schedule,Payment capped at billed charges.,85.12,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,224.4,,,,,,,percent of total billed charges,,171.6,,,,,,,percent of total billed charges,,97.14,,,,,,,fee schedule,Payment capped at 80% of billed charges.,197.04,,,,,,,fee schedule,Payment capped at billed charges.,236.98,,,,,,,fee schedule,Payment capped at billed charges.,89.47,,,,,,,fee schedule,,264,,,,,,,fee schedule,Payment capped at billed charges.,100.51,,,,,,,fee schedule,,100.14,,,,,,,fee schedule,Payment capped at billed charges.
SP FEES W/CINE OR VIDEO RECORD,93501021,CDM,0444,RC,92612,CPT,11,Local,GN  ,outpatient,professional,,,586,586,60,586,,228.03,,,,,,,fee schedule,Payment capped at billed charges.,536.1,,,,,,,fee schedule,Payment capped at billed charges.,191.24,,,,,,,fee schedule,Payment capped at billed charges.,191.24,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,336.96,,,,,,,fee schedule,Payment capped at billed charges.,221.39,,,,,,,fee schedule,Payment capped at billed charges.,374.4,,,,,,,fee schedule,Payment capped at billed charges.,228.03,,,,,,,fee schedule,Payment capped at billed charges.,586,,,,,,,fee schedule,Payment capped at billed charges.,293,,,,,,,fee schedule,,236.24,,,,,,,fee schedule,Payment capped at billed charges.,224.99,,,,,,,fee schedule,Payment capped at billed charges.,172.49,,,,,,,fee schedule,Payment capped at billed charges.,232.46,,,,,,,fee schedule,Payment capped at billed charges.,278.99,,,,,,,fee schedule,Payment capped at billed charges.,212.56,,,,,,,fee schedule,Payment capped at billed charges.,191.24,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,498.1,,,,,,,percent of total billed charges,,380.9,,,,,,,percent of total billed charges,,218.23,,,,,,,fee schedule,Payment capped at 80% of billed charges.,439.5,,,,,,,fee schedule,Payment capped at billed charges.,528.59,,,,,,,fee schedule,Payment capped at billed charges.,151.49,,,,,,,fee schedule,,586,,,,,,,fee schedule,Payment capped at billed charges.,225.82,,,,,,,fee schedule,,224.99,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL AUD REHAB STATUS 1STHR,93501039,CDM,0440,RC,92626,CPT,11,Local,GN  ,outpatient,professional,,,444,444,60,377.4,,94.59,,,,,,,fee schedule,Payment capped at billed charges.,225.9,,,,,,,fee schedule,Payment capped at billed charges.,78.39,,,,,,,fee schedule,Payment capped at billed charges.,78.39,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,183.25,,,,,,,fee schedule,Payment capped at billed charges.,91.84,,,,,,,fee schedule,Payment capped at billed charges.,203.6,,,,,,,fee schedule,Payment capped at billed charges.,94.59,,,,,,,fee schedule,Payment capped at billed charges.,253.13,,,,,,,fee schedule,Payment capped at billed charges.,78.39,,,,,,,fee schedule,,98,,,,,,,fee schedule,Payment capped at billed charges.,93.33,,,,,,,fee schedule,Payment capped at billed charges.,80.74,,,,,,,fee schedule,Payment capped at billed charges.,96.43,,,,,,,fee schedule,Payment capped at billed charges.,115.73,,,,,,,fee schedule,Payment capped at billed charges.,91.7,,,,,,,fee schedule,Payment capped at billed charges.,78.39,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,377.4,,,,,,,percent of total billed charges,,288.6,,,,,,,percent of total billed charges,,90.53,,,,,,,fee schedule,Payment capped at 80% of billed charges.,182.96,,,,,,,fee schedule,Payment capped at billed charges.,220.04,,,,,,,fee schedule,Payment capped at billed charges.,70.91,,,,,,,fee schedule,,247.24,,,,,,,fee schedule,Payment capped at billed charges.,93.67,,,,,,,fee schedule,,93.33,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL AUD REHAB STAT ADD 15M,93501047,CDM,0440,RC,92627,CPT,11,Local,GN  ,outpatient,professional,,,110,110,17.54,93.5,,22.37,,,,,,,fee schedule,Payment capped at billed charges.,53.19,,,,,,,fee schedule,Payment capped at billed charges.,18.54,,,,,,,fee schedule,Payment capped at billed charges.,18.54,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,46.32,,,,,,,fee schedule,Payment capped at billed charges.,21.72,,,,,,,fee schedule,Payment capped at billed charges.,51.48,,,,,,,fee schedule,Payment capped at billed charges.,22.37,,,,,,,fee schedule,Payment capped at billed charges.,59.35,,,,,,,fee schedule,Payment capped at billed charges.,18.54,,,,,,,fee schedule,,23.17,,,,,,,fee schedule,Payment capped at billed charges.,22.07,,,,,,,fee schedule,Payment capped at billed charges.,19.98,,,,,,,fee schedule,Payment capped at billed charges.,22.8,,,,,,,fee schedule,Payment capped at billed charges.,27.37,,,,,,,fee schedule,Payment capped at billed charges.,21.69,,,,,,,fee schedule,Payment capped at billed charges.,18.54,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,93.5,,,,,,,percent of total billed charges,,71.5,,,,,,,percent of total billed charges,,21.41,,,,,,,fee schedule,Payment capped at 80% of billed charges.,43.26,,,,,,,fee schedule,Payment capped at billed charges.,52.03,,,,,,,fee schedule,Payment capped at billed charges.,17.54,,,,,,,fee schedule,,58.46,,,,,,,fee schedule,Payment capped at billed charges.,22.15,,,,,,,fee schedule,,22.07,,,,,,,fee schedule,Payment capped at billed charges.
SP EVAL APHASIA 60 MIN,93501054,CDM,0444,RC,96105,CPT,11,Local,GN  ,outpatient,professional,,,281,281,60,278.57,,105.54,,,,,,,fee schedule,Payment capped at billed charges.,250.78,,,,,,,fee schedule,Payment capped at billed charges.,87.47,,,,,,,fee schedule,Payment capped at billed charges.,87.47,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,195.07,,,,,,,fee schedule,Payment capped at billed charges.,102.46,,,,,,,fee schedule,Payment capped at billed charges.,201.7,,,,,,,fee schedule,Payment capped at billed charges.,105.54,,,,,,,fee schedule,Payment capped at billed charges.,278.57,,,,,,,fee schedule,Payment capped at billed charges.,87.47,,,,,,,fee schedule,,109.34,,,,,,,fee schedule,Payment capped at billed charges.,104.13,,,,,,,fee schedule,Payment capped at billed charges.,96.12,,,,,,,fee schedule,Payment capped at billed charges.,107.59,,,,,,,fee schedule,Payment capped at billed charges.,129.12,,,,,,,fee schedule,Payment capped at billed charges.,103.07,,,,,,,fee schedule,Payment capped at billed charges.,87.47,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,238.85,,,,,,,percent of total billed charges,,182.65,,,,,,,percent of total billed charges,,101,,,,,,,fee schedule,Payment capped at 80% of billed charges.,202.58,,,,,,,fee schedule,Payment capped at billed charges.,243.65,,,,,,,fee schedule,Payment capped at billed charges.,84.42,,,,,,,fee schedule,,273.76,,,,,,,fee schedule,Payment capped at billed charges.,104.51,,,,,,,fee schedule,,104.13,,,,,,,fee schedule,Payment capped at billed charges.
SP DEVEL TEST ADMIN 1ST HR,93501062,CDM,0440,RC,96112,CPT,11,Local,GN  ,outpatient,professional,,,378,378,60,354.81,,142.13,,,,,,,fee schedule,Payment capped at billed charges.,319.72,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,235.55,,,,,,,fee schedule,Payment capped at billed charges.,137.99,,,,,,,fee schedule,Payment capped at billed charges.,261.71,,,,,,,fee schedule,Payment capped at billed charges.,142.13,,,,,,,fee schedule,Payment capped at billed charges.,354.81,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,,147.24,,,,,,,fee schedule,Payment capped at billed charges.,140.23,,,,,,,fee schedule,Payment capped at billed charges.,133.03,,,,,,,fee schedule,Payment capped at billed charges.,144.89,,,,,,,fee schedule,Payment capped at billed charges.,173.89,,,,,,,fee schedule,Payment capped at billed charges.,173.96,,,,,,,fee schedule,Payment capped at billed charges.,117.79,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,321.3,,,,,,,percent of total billed charges,,245.7,,,,,,,percent of total billed charges,,136.01,,,,,,,fee schedule,Payment capped at 80% of billed charges.,259.02,,,,,,,fee schedule,Payment capped at billed charges.,311.53,,,,,,,fee schedule,Payment capped at billed charges.,116.84,,,,,,,fee schedule,,350.03,,,,,,,fee schedule,Payment capped at billed charges.,140.75,,,,,,,fee schedule,,140.23,,,,,,,fee schedule,Payment capped at billed charges.
SP DEVEL TEST ADMIN EA ADD 30M,93501070,CDM,0440,RC,96113,CPT,11,Local,GN  ,outpatient,professional,,,169,169,49.16,169,,59.31,,,,,,,fee schedule,Payment capped at billed charges.,151.94,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,110.86,,,,,,,fee schedule,Payment capped at billed charges.,57.58,,,,,,,fee schedule,Payment capped at billed charges.,123.18,,,,,,,fee schedule,Payment capped at billed charges.,59.31,,,,,,,fee schedule,Payment capped at billed charges.,168.24,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,,61.45,,,,,,,fee schedule,Payment capped at billed charges.,58.52,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,60.46,,,,,,,fee schedule,Payment capped at billed charges.,72.56,,,,,,,fee schedule,Payment capped at billed charges.,73.04,,,,,,,fee schedule,Payment capped at billed charges.,49.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,143.65,,,,,,,percent of total billed charges,,109.85,,,,,,,percent of total billed charges,,56.76,,,,,,,fee schedule,Payment capped at 80% of billed charges.,126.01,,,,,,,fee schedule,Payment capped at billed charges.,151.55,,,,,,,fee schedule,Payment capped at billed charges.,55.66,,,,,,,fee schedule,,169,,,,,,,fee schedule,Payment capped at billed charges.,58.74,,,,,,,fee schedule,,58.52,,,,,,,fee schedule,Payment capped at billed charges.
SP COGNITIVE PERF TEST PER HR,93501088,CDM,0444,RC,96125,CPT,11,Local,GN  ,outpatient,professional,,,305,305,60,297.27,,112.79,,,,,,,fee schedule,Payment capped at billed charges.,265.41,,,,,,,fee schedule,Payment capped at billed charges.,94.6,,,,,,,fee schedule,Payment capped at billed charges.,94.6,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,226.03,,,,,,,fee schedule,Payment capped at billed charges.,109.51,,,,,,,fee schedule,Payment capped at billed charges.,251.15,,,,,,,fee schedule,Payment capped at billed charges.,112.79,,,,,,,fee schedule,Payment capped at billed charges.,297.27,,,,,,,fee schedule,Payment capped at billed charges.,152.5,,,,,,,fee schedule,,116.85,,,,,,,fee schedule,Payment capped at billed charges.,111.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,114.98,,,,,,,fee schedule,Payment capped at billed charges.,138,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,94.6,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,259.25,,,,,,,percent of total billed charges,,198.25,,,,,,,percent of total billed charges,,107.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,217.4,,,,,,,fee schedule,Payment capped at billed charges.,261.46,,,,,,,fee schedule,Payment capped at billed charges.,90.19,,,,,,,fee schedule,,293.78,,,,,,,fee schedule,Payment capped at billed charges.,111.7,,,,,,,fee schedule,,111.29,,,,,,,fee schedule,Payment capped at billed charges.
SP THERAPUTIC EXERCISE 15MIN,93501096,CDM,0440,RC,97110,CPT,11,Local,GN  ,outpatient,professional,,,80,80,27.16,90,,32.78,,,,,,,fee schedule,Payment capped at billed charges.,77.07,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,31.82,,,,,,,fee schedule,Payment capped at billed charges.,42.31,,,,,,,fee schedule,Payment capped at billed charges.,32.78,,,,,,,fee schedule,Payment capped at billed charges.,69.34,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,,33.96,,,,,,,fee schedule,Payment capped at billed charges.,32.34,,,,,,,fee schedule,Payment capped at billed charges.,33.38,,,,,,,fee schedule,Payment capped at billed charges.,33.41,,,,,,,fee schedule,Payment capped at billed charges.,40.1,,,,,,,fee schedule,Payment capped at billed charges.,31.64,,,,,,,fee schedule,Payment capped at billed charges.,27.16,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,68,,,,,,,percent of total billed charges,,52,,,,,,,percent of total billed charges,,31.37,,,,,,,fee schedule,Payment capped at 80% of billed charges.,54.01,,,,,,,fee schedule,Payment capped at billed charges.,64.95,,,,,,,fee schedule,Payment capped at billed charges.,29.61,,,,,,,fee schedule,,72.98,,,,,,,fee schedule,Payment capped at billed charges.,32.46,,,,,,,fee schedule,,32.34,,,,,,,fee schedule,Payment capped at billed charges.
SP COGNITIVE FUNC INTRV 1ST15M,93501104,CDM,0440,RC,97129,CPT,11,Local,GN  ,outpatient,professional,,,72,72,20.09,90,,23.96,,,,,,,fee schedule,Payment capped at billed charges.,56.75,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.09,,,,,,,fee schedule,Payment capped at billed charges.,23.26,,,,,,,fee schedule,Payment capped at billed charges.,41.21,,,,,,,fee schedule,Payment capped at billed charges.,23.96,,,,,,,fee schedule,Payment capped at billed charges.,51.47,,,,,,,fee schedule,Payment capped at billed charges.,36,,,,,,,fee schedule,,24.82,,,,,,,fee schedule,Payment capped at billed charges.,23.64,,,,,,,fee schedule,Payment capped at billed charges.,23.58,,,,,,,fee schedule,Payment capped at billed charges.,24.42,,,,,,,fee schedule,Payment capped at billed charges.,29.31,,,,,,,fee schedule,Payment capped at billed charges.,23.81,,,,,,,fee schedule,Payment capped at billed charges.,20.09,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,61.2,,,,,,,percent of total billed charges,,46.8,,,,,,,percent of total billed charges,,22.93,,,,,,,fee schedule,Payment capped at 80% of billed charges.,39.95,,,,,,,fee schedule,Payment capped at billed charges.,48.05,,,,,,,fee schedule,Payment capped at billed charges.,20.71,,,,,,,fee schedule,,53.99,,,,,,,fee schedule,Payment capped at billed charges.,23.73,,,,,,,fee schedule,,23.64,,,,,,,fee schedule,Payment capped at billed charges.
SP COGNITIVE FUNC INTRV ADD15M,93501112,CDM,0440,RC,97130,CPT,11,Local,GN  ,outpatient,professional,,,72,72,19.18,90,,22.88,,,,,,,fee schedule,Payment capped at billed charges.,54.18,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,35.43,,,,,,,fee schedule,Payment capped at billed charges.,22.21,,,,,,,fee schedule,Payment capped at billed charges.,39.37,,,,,,,fee schedule,Payment capped at billed charges.,22.88,,,,,,,fee schedule,Payment capped at billed charges.,50,,,,,,,fee schedule,Payment capped at billed charges.,36,,,,,,,fee schedule,,23.7,,,,,,,fee schedule,Payment capped at billed charges.,22.57,,,,,,,fee schedule,Payment capped at billed charges.,22.53,,,,,,,fee schedule,Payment capped at billed charges.,23.32,,,,,,,fee schedule,Payment capped at billed charges.,27.99,,,,,,,fee schedule,Payment capped at billed charges.,22.75,,,,,,,fee schedule,Payment capped at billed charges.,19.18,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,61.2,,,,,,,percent of total billed charges,,46.8,,,,,,,percent of total billed charges,,21.89,,,,,,,fee schedule,Payment capped at 80% of billed charges.,38.15,,,,,,,fee schedule,Payment capped at billed charges.,45.88,,,,,,,fee schedule,Payment capped at billed charges.,19.79,,,,,,,fee schedule,,51.55,,,,,,,fee schedule,Payment capped at billed charges.,22.65,,,,,,,fee schedule,,22.57,,,,,,,fee schedule,Payment capped at billed charges.
SP OTHER THERA PROC 1 -15MIN,93501120,CDM,0440,RC,97139,CPT,11,Local,GN  ,outpatient,professional,,,65,65,6.23,90,,14.1,,,,,,,fee schedule,Payment capped at billed charges.,33.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.85,,,,,,,fee schedule,Payment capped at billed charges.,32.5,,,,,,,fee schedule,,,,,,,,,,,42.25,,,,,,,fee schedule,Payment capped at billed charges.,15.39,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,6.23,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,55.25,,,,,,,percent of total billed charges,,42.25,,,,,,,percent of total billed charges,,52,,,,,,,fee schedule,Payment capped at 80% of billed charges.,42.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,13.51,,,,,,,fee schedule,,,,,,,,,,,22.75,,,,,,,fee schedule,,65,,,,,,,fee schedule,Payment capped at billed charges.
SP THER ACT EA 15 MIN,93501138,CDM,0440,RC,97530,CPT,11,Local,GN  ,outpatient,professional,,,102,102,31.17,98.75,,39.86,,,,,,,fee schedule,Payment capped at billed charges.,98.75,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,37.27,,,,,,,fee schedule,Payment capped at billed charges.,38.7,,,,,,,fee schedule,Payment capped at billed charges.,42.5,,,,,,,fee schedule,Payment capped at billed charges.,39.86,,,,,,,fee schedule,Payment capped at billed charges.,89.29,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,,41.3,,,,,,,fee schedule,Payment capped at billed charges.,39.33,,,,,,,fee schedule,Payment capped at billed charges.,35.14,,,,,,,fee schedule,Payment capped at billed charges.,40.64,,,,,,,fee schedule,Payment capped at billed charges.,48.77,,,,,,,fee schedule,Payment capped at billed charges.,38.04,,,,,,,fee schedule,Payment capped at billed charges.,33.03,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,86.7,,,,,,,percent of total billed charges,,66.3,,,,,,,percent of total billed charges,,38.15,,,,,,,fee schedule,Payment capped at 80% of billed charges.,68.41,,,,,,,fee schedule,Payment capped at billed charges.,82.27,,,,,,,fee schedule,Payment capped at billed charges.,31.17,,,,,,,fee schedule,,92.44,,,,,,,fee schedule,Payment capped at billed charges.,39.47,,,,,,,fee schedule,,39.33,,,,,,,fee schedule,Payment capped at billed charges.
AFO MOLDED TP PATIENT PLASTI,93501153,CDM,0274,RC,L1940,HCPCS,11,Local,NU  ,outpatient,professional,,,571,571,60,571,,230.17,,,,,,,fee schedule,Payment capped at billed charges.,551.83,,,,,,,fee schedule,Payment capped at billed charges.,468.01,,,,,,,fee schedule,Payment capped at billed charges.,468.01,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,299,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,299,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,371.15,,,,,,,fee schedule,Payment capped at billed charges.,468.01,,,,,,,fee schedule,,,,,,,,,,,371.15,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,571,,,,,,,fee schedule,Payment capped at billed charges.,468.01,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,485.35,,,,,,,percent of total billed charges,,371.15,,,,,,,percent of total billed charges,,456.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,432.66,,,,,,,fee schedule,Payment capped at billed charges.,520.36,,,,,,,fee schedule,Payment capped at billed charges.,194.14,,,,,,,fee schedule,,571,,,,,,,fee schedule,Payment capped at billed charges.,199.85,,,,,,,fee schedule,,571,,,,,,,fee schedule,Payment capped at billed charges.
AFO TIB FX CAST MOLDED TO PT,93501161,CDM,0274,RC,L2108,HCPCS,11,Local,NU  ,outpatient,professional,,,1234,1234,60,1321.01,,551,,,,,,,fee schedule,Payment capped at billed charges.,1321.01,,,,,,,fee schedule,Payment capped at billed charges.,1120.33,,,,,,,fee schedule,Payment capped at billed charges.,1120.33,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,715,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,715,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,802.1,,,,,,,fee schedule,Payment capped at billed charges.,1120.33,,,,,,,fee schedule,,,,,,,,,,,802.1,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1234,,,,,,,fee schedule,Payment capped at billed charges.,1120.33,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,1048.9,,,,,,,percent of total billed charges,,802.1,,,,,,,percent of total billed charges,,987.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1035.69,,,,,,,fee schedule,Payment capped at billed charges.,1234,,,,,,,fee schedule,Payment capped at billed charges.,419.56,,,,,,,fee schedule,,1234,,,,,,,fee schedule,Payment capped at billed charges.,431.9,,,,,,,fee schedule,,1234,,,,,,,fee schedule,Payment capped at billed charges.
KAFO FEM FX CAST MOLDED TO PT,93501179,CDM,0274,RC,L2128,HCPCS,11,Local,NU  ,outpatient,professional,,,1981,1981,60,2077.11,,866.38,,,,,,,fee schedule,Payment capped at billed charges.,2077.11,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,1124,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,1124,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,1287.65,,,,,,,fee schedule,Payment capped at billed charges.,990.5,,,,,,,fee schedule,,,,,,,,,,,1287.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1981,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1683.85,,,,,,,percent of total billed charges,,1287.65,,,,,,,percent of total billed charges,,1584.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1628.5,,,,,,,fee schedule,Payment capped at billed charges.,1958.6,,,,,,,fee schedule,Payment capped at billed charges.,673.54,,,,,,,fee schedule,,1981,,,,,,,fee schedule,Payment capped at billed charges.,693.35,,,,,,,fee schedule,,1981,,,,,,,fee schedule,Payment capped at billed charges.
FOOT LONGITUDE METATARSAL SUP,93501187,CDM,0274,RC,L3020,HCPCS,11,Local,NU  ,outpatient,professional,,,239,239,60,239,,96.39,,,,,,,fee schedule,Payment capped at billed charges.,231.09,,,,,,,fee schedule,Payment capped at billed charges.,195.97,,,,,,,fee schedule,Payment capped at billed charges.,195.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,130.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,130.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,155.35,,,,,,,fee schedule,Payment capped at billed charges.,195.97,,,,,,,fee schedule,,,,,,,,,,,155.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,239,,,,,,,fee schedule,Payment capped at billed charges.,195.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,203.15,,,,,,,percent of total billed charges,,155.35,,,,,,,percent of total billed charges,,191.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,181.17,,,,,,,fee schedule,Payment capped at billed charges.,217.89,,,,,,,fee schedule,Payment capped at billed charges.,81.26,,,,,,,fee schedule,,239,,,,,,,fee schedule,Payment capped at billed charges.,83.65,,,,,,,fee schedule,,239,,,,,,,fee schedule,Payment capped at billed charges.
SO CAP DESIGN W/O JNTS CF,93501195,CDM,0274,RC,L3671,HCPCS,11,Local,NU  ,outpatient,professional,,,905,905,60,955.2,,398.42,,,,,,,fee schedule,Payment capped at billed charges.,955.2,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,586.7,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,586.7,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,588.25,,,,,,,fee schedule,Payment capped at billed charges.,452.5,,,,,,,fee schedule,,,,,,,,,,,588.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,905,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,769.25,,,,,,,percent of total billed charges,,588.25,,,,,,,percent of total billed charges,,724,,,,,,,fee schedule,Payment capped at 80% of billed charges.,748.89,,,,,,,fee schedule,Payment capped at billed charges.,900.69,,,,,,,fee schedule,Payment capped at billed charges.,307.7,,,,,,,fee schedule,,905,,,,,,,fee schedule,Payment capped at billed charges.,316.75,,,,,,,fee schedule,,905,,,,,,,fee schedule,Payment capped at billed charges.
SO AIRPLANE W/WO JOINT CF,93501203,CDM,0274,RC,L3674,HCPCS,11,Local,NU  ,outpatient,professional,,,1187,1187,60,1253,,522.64,,,,,,,fee schedule,Payment capped at billed charges.,1253,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,797.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,797.81,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,771.55,,,,,,,fee schedule,Payment capped at billed charges.,593.5,,,,,,,fee schedule,,,,,,,,,,,771.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1187,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1008.95,,,,,,,percent of total billed charges,,771.55,,,,,,,percent of total billed charges,,949.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,982.37,,,,,,,fee schedule,Payment capped at billed charges.,1181.5,,,,,,,fee schedule,Payment capped at billed charges.,403.58,,,,,,,fee schedule,,1187,,,,,,,fee schedule,Payment capped at billed charges.,415.45,,,,,,,fee schedule,,1187,,,,,,,fee schedule,Payment capped at billed charges.
EO ELBOW STATIC CUST FIT ADJ,93501211,CDM,0274,RC,L3702,HCPCS,11,Local,NU  ,outpatient,professional,,,328,328,60,328,,127.67,,,,,,,fee schedule,Payment capped at billed charges.,306.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,188,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,188,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,213.2,,,,,,,fee schedule,Payment capped at billed charges.,164,,,,,,,fee schedule,,,,,,,,,,,213.2,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,328,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,278.8,,,,,,,percent of total billed charges,,213.2,,,,,,,percent of total billed charges,,262.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,239.97,,,,,,,fee schedule,Payment capped at billed charges.,288.62,,,,,,,fee schedule,Payment capped at billed charges.,111.52,,,,,,,fee schedule,,324.29,,,,,,,fee schedule,Payment capped at billed charges.,114.8,,,,,,,fee schedule,,328,,,,,,,fee schedule,Payment capped at billed charges.
EO ELB STAT PROG DBL HING CUST,93501229,CDM,0274,RC,L3730,HCPCS,11,Local,NU  ,outpatient,professional,,,1019,1019,60,1019,,410.55,,,,,,,fee schedule,Payment capped at billed charges.,984.29,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,533,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,533,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,662.35,,,,,,,fee schedule,Payment capped at billed charges.,509.5,,,,,,,fee schedule,,,,,,,,,,,662.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1019,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,866.15,,,,,,,percent of total billed charges,,662.35,,,,,,,percent of total billed charges,,815.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,771.71,,,,,,,fee schedule,Payment capped at billed charges.,928.14,,,,,,,fee schedule,Payment capped at billed charges.,346.46,,,,,,,fee schedule,,1019,,,,,,,fee schedule,Payment capped at billed charges.,356.65,,,,,,,fee schedule,,1019,,,,,,,fee schedule,Payment capped at billed charges.
EO STAT CUSTOM F A,93501237,CDM,0274,RC,L3740,HCPCS,11,Local,NU  ,outpatient,professional,,,1208,1208,60,1208,,486.75,,,,,,,fee schedule,Payment capped at billed charges.,1166.97,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,632,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,632,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,785.2,,,,,,,fee schedule,Payment capped at billed charges.,604,,,,,,,fee schedule,,,,,,,,,,,785.2,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1208,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1026.8,,,,,,,percent of total billed charges,,785.2,,,,,,,percent of total billed charges,,966.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,914.93,,,,,,,fee schedule,Payment capped at billed charges.,1100.39,,,,,,,fee schedule,Payment capped at billed charges.,410.72,,,,,,,fee schedule,,1208,,,,,,,fee schedule,Payment capped at billed charges.,422.8,,,,,,,fee schedule,,1208,,,,,,,fee schedule,Payment capped at billed charges.
EWHO ELB WRIST HD STAT CUSTFIT,93501245,CDM,0274,RC,L3763,HCPCS,11,Local,NU  ,outpatient,professional,,,739,739,60,744.08,,310.36,,,,,,,fee schedule,Payment capped at billed charges.,744.08,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,457.04,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,457.04,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,480.35,,,,,,,fee schedule,Payment capped at billed charges.,369.5,,,,,,,fee schedule,,,,,,,,,,,480.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,739,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,628.15,,,,,,,percent of total billed charges,,480.35,,,,,,,percent of total billed charges,,591.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,583.37,,,,,,,fee schedule,Payment capped at billed charges.,701.62,,,,,,,fee schedule,Payment capped at billed charges.,251.26,,,,,,,fee schedule,,739,,,,,,,fee schedule,Payment capped at billed charges.,258.65,,,,,,,fee schedule,,739,,,,,,,fee schedule,Payment capped at billed charges.
EWHO W/JOINT(S) CF,93501252,CDM,0274,RC,L3764,HCPCS,11,Local,NU  ,outpatient,professional,,,841,841,60,971.19,,405.09,,,,,,,fee schedule,Payment capped at billed charges.,971.19,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,596.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,596.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,546.65,,,,,,,fee schedule,Payment capped at billed charges.,420.5,,,,,,,fee schedule,,,,,,,,,,,546.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,841,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,714.85,,,,,,,percent of total billed charges,,546.65,,,,,,,percent of total billed charges,,672.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,761.45,,,,,,,fee schedule,Payment capped at billed charges.,841,,,,,,,fee schedule,Payment capped at billed charges.,285.94,,,,,,,fee schedule,,841,,,,,,,fee schedule,Payment capped at billed charges.,294.35,,,,,,,fee schedule,,841,,,,,,,fee schedule,Payment capped at billed charges.
EWHFO STATIC CUSTOM FIT   ADJ,93501260,CDM,0274,RC,L3765,HCPCS,11,Local,NU  ,outpatient,professional,,,1288,1288,60,1359.22,,566.94,,,,,,,fee schedule,Payment capped at billed charges.,1359.22,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,876.61,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,876.61,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,837.2,,,,,,,fee schedule,Payment capped at billed charges.,644,,,,,,,fee schedule,,,,,,,,,,,837.2,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1288,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1094.8,,,,,,,percent of total billed charges,,837.2,,,,,,,percent of total billed charges,,1030.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1065.65,,,,,,,fee schedule,Payment capped at billed charges.,1281.66,,,,,,,fee schedule,Payment capped at billed charges.,437.92,,,,,,,fee schedule,,1288,,,,,,,fee schedule,Payment capped at billed charges.,450.8,,,,,,,fee schedule,,1288,,,,,,,fee schedule,Payment capped at billed charges.
EWHFO W/JOINT(S) CF,93501278,CDM,0274,RC,L3766,HCPCS,11,Local,NU  ,outpatient,professional,,,1363,1363,60,1439.32,,600.35,,,,,,,fee schedule,Payment capped at billed charges.,1439.32,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,928.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,928.26,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,885.95,,,,,,,fee schedule,Payment capped at billed charges.,681.5,,,,,,,fee schedule,,,,,,,,,,,885.95,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1363,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1158.55,,,,,,,percent of total billed charges,,885.95,,,,,,,percent of total billed charges,,1090.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1128.45,,,,,,,fee schedule,Payment capped at billed charges.,1357.19,,,,,,,fee schedule,Payment capped at billed charges.,463.42,,,,,,,fee schedule,,1363,,,,,,,fee schedule,Payment capped at billed charges.,477.05,,,,,,,fee schedule,,1363,,,,,,,fee schedule,Payment capped at billed charges.
WHFO STAT PROG DYN CUSTOM FIT,93501286,CDM,0274,RC,L3806,HCPCS,11,Local,NU  ,outpatient,professional,,,518,518,60,518,,200.85,,,,,,,fee schedule,Payment capped at billed charges.,481.53,,,,,,,fee schedule,Payment capped at billed charges.,408.39,,,,,,,fee schedule,Payment capped at billed charges.,408.39,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,310.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,310.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,336.7,,,,,,,fee schedule,Payment capped at billed charges.,408.39,,,,,,,fee schedule,,,,,,,,,,,336.7,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,518,,,,,,,fee schedule,Payment capped at billed charges.,408.39,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,440.3,,,,,,,percent of total billed charges,,336.7,,,,,,,percent of total billed charges,,414.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,377.53,,,,,,,fee schedule,Payment capped at billed charges.,454.06,,,,,,,fee schedule,Payment capped at billed charges.,176.12,,,,,,,fee schedule,,510.18,,,,,,,fee schedule,Payment capped at billed charges.,181.3,,,,,,,fee schedule,,518,,,,,,,fee schedule,Payment capped at billed charges.
WHFO STATIC CUSTOM FIT   ADJ,93501294,CDM,0274,RC,L3808,HCPCS,11,Local,NU  ,outpatient,professional,,,374,374,60,396.4,,165.34,,,,,,,fee schedule,Payment capped at billed charges.,396.4,,,,,,,fee schedule,Payment capped at billed charges.,336.19,,,,,,,fee schedule,Payment capped at billed charges.,336.19,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,243.47,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,243.47,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,243.1,,,,,,,fee schedule,Payment capped at billed charges.,336.19,,,,,,,fee schedule,,,,,,,,,,,243.1,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,374,,,,,,,fee schedule,Payment capped at billed charges.,336.19,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,317.9,,,,,,,percent of total billed charges,,243.1,,,,,,,percent of total billed charges,,299.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,310.79,,,,,,,fee schedule,Payment capped at billed charges.,373.78,,,,,,,fee schedule,Payment capped at billed charges.,127.16,,,,,,,fee schedule,,374,,,,,,,fee schedule,Payment capped at billed charges.,130.9,,,,,,,fee schedule,,374,,,,,,,fee schedule,Payment capped at billed charges.
TENODESIS SPLINT CUST FIT ADJ,93501302,CDM,0274,RC,L3900,HCPCS,11,Local,NU  ,outpatient,professional,,,1463,1463,60,1545.65,,644.7,,,,,,,fee schedule,Payment capped at billed charges.,1545.65,,,,,,,fee schedule,Payment capped at billed charges.,1310.85,,,,,,,fee schedule,Payment capped at billed charges.,1310.85,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,837,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,837,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,950.95,,,,,,,fee schedule,Payment capped at billed charges.,1310.85,,,,,,,fee schedule,,,,,,,,,,,950.95,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1463,,,,,,,fee schedule,Payment capped at billed charges.,1310.85,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,1243.55,,,,,,,percent of total billed charges,,950.95,,,,,,,percent of total billed charges,,1170.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1211.82,,,,,,,fee schedule,Payment capped at billed charges.,1457.46,,,,,,,fee schedule,Payment capped at billed charges.,497.42,,,,,,,fee schedule,,1463,,,,,,,fee schedule,Payment capped at billed charges.,512.05,,,,,,,fee schedule,,1463,,,,,,,fee schedule,Payment capped at billed charges.
WHO STATIC PROG DYN CUSTOM FIT,93501310,CDM,0274,RC,L3905,HCPCS,11,Local,NU  ,outpatient,professional,,,996,996,60,1051.25,,438.48,,,,,,,fee schedule,Payment capped at billed charges.,1051.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,645.71,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,645.71,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,647.4,,,,,,,fee schedule,Payment capped at billed charges.,498,,,,,,,fee schedule,,,,,,,,,,,647.4,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,996,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,846.6,,,,,,,percent of total billed charges,,647.4,,,,,,,percent of total billed charges,,796.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,824.2,,,,,,,fee schedule,Payment capped at billed charges.,991.27,,,,,,,fee schedule,Payment capped at billed charges.,338.64,,,,,,,fee schedule,,996,,,,,,,fee schedule,Payment capped at billed charges.,348.6,,,,,,,fee schedule,,996,,,,,,,fee schedule,Payment capped at billed charges.
WHO STATIC CUSTOM FIT   ADJ,93501328,CDM,0274,RC,L3906,HCPCS,11,Local,NU  ,outpatient,professional,,,447,447,60,466.75,,194.68,,,,,,,fee schedule,Payment capped at billed charges.,466.75,,,,,,,fee schedule,Payment capped at billed charges.,395.84,,,,,,,fee schedule,Payment capped at billed charges.,395.84,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,253,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,253,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,290.55,,,,,,,fee schedule,Payment capped at billed charges.,395.84,,,,,,,fee schedule,,,,,,,,,,,290.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,447,,,,,,,fee schedule,Payment capped at billed charges.,395.84,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,379.95,,,,,,,percent of total billed charges,,290.55,,,,,,,percent of total billed charges,,357.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,365.94,,,,,,,fee schedule,Payment capped at billed charges.,440.11,,,,,,,fee schedule,Payment capped at billed charges.,151.98,,,,,,,fee schedule,,447,,,,,,,fee schedule,Payment capped at billed charges.,156.45,,,,,,,fee schedule,,447,,,,,,,fee schedule,Payment capped at billed charges.
HFO STATIC CUSTOM FIT   ADJ,93501336,CDM,0274,RC,L3913,HCPCS,11,Local,NU  ,outpatient,professional,,,285,285,60,287.11,,119.76,,,,,,,fee schedule,Payment capped at billed charges.,287.11,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,176.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,176.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,185.25,,,,,,,fee schedule,Payment capped at billed charges.,142.5,,,,,,,fee schedule,,,,,,,,,,,185.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,285,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,242.25,,,,,,,percent of total billed charges,,185.25,,,,,,,percent of total billed charges,,228,,,,,,,fee schedule,Payment capped at 80% of billed charges.,225.09,,,,,,,fee schedule,Payment capped at billed charges.,270.72,,,,,,,fee schedule,Payment capped at billed charges.,96.9,,,,,,,fee schedule,,285,,,,,,,fee schedule,Payment capped at billed charges.,99.75,,,,,,,fee schedule,,285,,,,,,,fee schedule,Payment capped at billed charges.
HO HAND ORTHO STAT CUST FIT,93501344,CDM,0274,RC,L3919,HCPCS,11,Local,NU  ,outpatient,professional,,,272,272,60,287.11,,119.76,,,,,,,fee schedule,Payment capped at billed charges.,287.11,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,176.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,176.35,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,176.8,,,,,,,fee schedule,Payment capped at billed charges.,136,,,,,,,fee schedule,,,,,,,,,,,176.8,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,272,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,231.2,,,,,,,percent of total billed charges,,176.8,,,,,,,percent of total billed charges,,217.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,225.09,,,,,,,fee schedule,Payment capped at billed charges.,270.72,,,,,,,fee schedule,Payment capped at billed charges.,92.48,,,,,,,fee schedule,,272,,,,,,,fee schedule,Payment capped at billed charges.,95.2,,,,,,,fee schedule,,272,,,,,,,fee schedule,Payment capped at billed charges.
HFO STATIC PROG/DYN CUSTOM FIT,93501351,CDM,0274,RC,L3921,HCPCS,11,Local,NU  ,outpatient,professional,,,345,345,60,345,,142.02,,,,,,,fee schedule,Payment capped at billed charges.,340.49,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,209.15,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,209.15,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,224.25,,,,,,,fee schedule,Payment capped at billed charges.,172.5,,,,,,,fee schedule,,,,,,,,,,,224.25,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,345,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,293.25,,,,,,,percent of total billed charges,,224.25,,,,,,,percent of total billed charges,,276,,,,,,,fee schedule,Payment capped at 80% of billed charges.,266.96,,,,,,,fee schedule,Payment capped at billed charges.,321.07,,,,,,,fee schedule,Payment capped at billed charges.,117.3,,,,,,,fee schedule,,345,,,,,,,fee schedule,Payment capped at billed charges.,120.75,,,,,,,fee schedule,,345,,,,,,,fee schedule,Payment capped at billed charges.
FO FINGR STATIC CUST ORTHO FIT,93501369,CDM,0274,RC,L3933,HCPCS,11,Local,NU  ,outpatient,professional,,,214,214,60,226.15,,94.33,,,,,,,fee schedule,Payment capped at billed charges.,226.15,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,138.92,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,138.92,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,139.1,,,,,,,fee schedule,Payment capped at billed charges.,107,,,,,,,fee schedule,,,,,,,,,,,139.1,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,214,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,181.9,,,,,,,percent of total billed charges,,139.1,,,,,,,percent of total billed charges,,171.2,,,,,,,fee schedule,Payment capped at 80% of billed charges.,177.3,,,,,,,fee schedule,Payment capped at billed charges.,213.24,,,,,,,fee schedule,Payment capped at billed charges.,72.76,,,,,,,fee schedule,,214,,,,,,,fee schedule,Payment capped at billed charges.,74.9,,,,,,,fee schedule,,214,,,,,,,fee schedule,Payment capped at billed charges.
FO STAT PROG/DYN CUST ORTH FIT,93501377,CDM,0274,RC,L3935,HCPCS,11,Local,NU  ,outpatient,professional,,,222,222,60,234.16,,97.67,,,,,,,fee schedule,Payment capped at billed charges.,234.16,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,143.84,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,143.84,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,144.3,,,,,,,fee schedule,Payment capped at billed charges.,111,,,,,,,fee schedule,,,,,,,,,,,144.3,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,222,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,188.7,,,,,,,percent of total billed charges,,144.3,,,,,,,percent of total billed charges,,177.6,,,,,,,fee schedule,Payment capped at 80% of billed charges.,183.59,,,,,,,fee schedule,Payment capped at billed charges.,220.8,,,,,,,fee schedule,Payment capped at billed charges.,75.48,,,,,,,fee schedule,,222,,,,,,,fee schedule,Payment capped at billed charges.,77.7,,,,,,,fee schedule,,222,,,,,,,fee schedule,Payment capped at billed charges.
SEWHO CAP DESIGN W/O JNTS CF,93501385,CDM,0274,RC,L3961,HCPCS,11,Local,NU  ,outpatient,professional,,,1688,1688,60,1780.97,,742.86,,,,,,,fee schedule,Payment capped at billed charges.,1780.97,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,1148.61,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,1148.61,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,1097.2,,,,,,,fee schedule,Payment capped at billed charges.,844,,,,,,,fee schedule,,,,,,,,,,,1097.2,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,,,,,,,,,,,,,,,,,,,1688,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,90,,,,,,,Per Diem,Payment capped at billed charges.,1434.8,,,,,,,percent of total billed charges,,1097.2,,,,,,,percent of total billed charges,,1350.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,1396.32,,,,,,,fee schedule,Payment capped at billed charges.,1679.36,,,,,,,fee schedule,Payment capped at billed charges.,573.92,,,,,,,fee schedule,,1688,,,,,,,fee schedule,Payment capped at billed charges.,590.8,,,,,,,fee schedule,,1688,,,,,,,fee schedule,Payment capped at billed charges.
SP LARYNGEAL FUNCTION STUDIES,93501393,CDM,0440,RC,92520,CPT,11,Local,GN  ,outpatient,professional,,,285,285,60,259.88,,102.56,,,,,,,fee schedule,Payment capped at billed charges.,229.14,,,,,,,fee schedule,Payment capped at billed charges.,85,,,,,,,fee schedule,Payment capped at billed charges.,85,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,108.47,,,,,,,fee schedule,Payment capped at billed charges.,99.57,,,,,,,fee schedule,Payment capped at billed charges.,120.51,,,,,,,fee schedule,Payment capped at billed charges.,102.56,,,,,,,fee schedule,Payment capped at billed charges.,245.25,,,,,,,fee schedule,Payment capped at billed charges.,85,,,,,,,fee schedule,,106.25,,,,,,,fee schedule,Payment capped at billed charges.,101.19,,,,,,,fee schedule,Payment capped at billed charges.,69.05,,,,,,,fee schedule,Payment capped at billed charges.,104.55,,,,,,,fee schedule,Payment capped at billed charges.,125.48,,,,,,,fee schedule,Payment capped at billed charges.,96.33,,,,,,,fee schedule,Payment capped at billed charges.,85,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,242.25,,,,,,,percent of total billed charges,,185.25,,,,,,,percent of total billed charges,,98.15,,,,,,,fee schedule,Payment capped at 80% of billed charges.,192.31,,,,,,,fee schedule,Payment capped at billed charges.,231.29,,,,,,,fee schedule,Payment capped at billed charges.,60.64,,,,,,,fee schedule,,259.88,,,,,,,fee schedule,Payment capped at billed charges.,101.56,,,,,,,fee schedule,,101.19,,,,,,,fee schedule,Payment capped at billed charges.
PT CAREGIVER TRAING 1ST 30 MIN,93501419,CDM,0420,RC,97550,CPT,11,Local,GP  ,outpatient,professional,,,155,155,48.46,152.56,,58.47,,,,,,,fee schedule,Payment capped at billed charges.,117.13,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,79.45,,,,,,,fee schedule,Payment capped at billed charges.,56.77,,,,,,,fee schedule,Payment capped at billed charges.,88.28,,,,,,,fee schedule,Payment capped at billed charges.,58.47,,,,,,,fee schedule,Payment capped at billed charges.,152.56,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,,60.57,,,,,,,fee schedule,Payment capped at billed charges.,57.69,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,59.61,,,,,,,fee schedule,Payment capped at billed charges.,71.54,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,131.75,,,,,,,percent of total billed charges,,100.75,,,,,,,percent of total billed charges,,55.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,111.57,,,,,,,fee schedule,Payment capped at billed charges.,134.19,,,,,,,fee schedule,Payment capped at billed charges.,54.49,,,,,,,fee schedule,,150.77,,,,,,,fee schedule,Payment capped at billed charges.,57.9,,,,,,,fee schedule,,57.69,,,,,,,fee schedule,Payment capped at billed charges.
PT CAREGIVER TRAING EA ADDL 15,93501427,CDM,0420,RC,97551,CPT,11,Local,GP  ,outpatient,professional,,,76,76,23.59,90,,28.47,,,,,,,fee schedule,Payment capped at billed charges.,57.81,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.22,,,,,,,fee schedule,Payment capped at billed charges.,27.64,,,,,,,fee schedule,Payment capped at billed charges.,43.57,,,,,,,fee schedule,Payment capped at billed charges.,28.47,,,,,,,fee schedule,Payment capped at billed charges.,75.11,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,29.49,,,,,,,fee schedule,Payment capped at billed charges.,28.09,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.02,,,,,,,fee schedule,Payment capped at billed charges.,34.83,,,,,,,fee schedule,Payment capped at billed charges.,28.08,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,64.6,,,,,,,percent of total billed charges,,49.4,,,,,,,percent of total billed charges,,27.25,,,,,,,fee schedule,Payment capped at 80% of billed charges.,55.07,,,,,,,fee schedule,Payment capped at billed charges.,66.23,,,,,,,fee schedule,Payment capped at billed charges.,26.61,,,,,,,fee schedule,,74.42,,,,,,,fee schedule,Payment capped at billed charges.,28.19,,,,,,,fee schedule,,28.09,,,,,,,fee schedule,Payment capped at billed charges.
PT GROUP CAREGIVER TRAINING,93501435,CDM,0420,RC,97552,CPT,11,Local,GP  ,outpatient,professional,,,68,68,21.18,90,,25.55,,,,,,,fee schedule,Payment capped at billed charges.,51.09,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,34.64,,,,,,,fee schedule,Payment capped at billed charges.,24.81,,,,,,,fee schedule,Payment capped at billed charges.,38.49,,,,,,,fee schedule,Payment capped at billed charges.,25.55,,,,,,,fee schedule,Payment capped at billed charges.,67.25,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,,26.47,,,,,,,fee schedule,Payment capped at billed charges.,25.21,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,26.05,,,,,,,fee schedule,Payment capped at billed charges.,31.26,,,,,,,fee schedule,Payment capped at billed charges.,24.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,57.8,,,,,,,percent of total billed charges,,44.2,,,,,,,percent of total billed charges,,24.45,,,,,,,fee schedule,Payment capped at 80% of billed charges.,48.65,,,,,,,fee schedule,Payment capped at billed charges.,58.51,,,,,,,fee schedule,Payment capped at billed charges.,23.35,,,,,,,fee schedule,,65.74,,,,,,,fee schedule,Payment capped at billed charges.,25.3,,,,,,,fee schedule,,25.21,,,,,,,fee schedule,Payment capped at billed charges.
OT CAREGIVER TRAING 1ST 30 MIN,93501443,CDM,0430,RC,97550,CPT,11,Local,GO  ,outpatient,professional,,,155,155,48.46,152.56,,58.47,,,,,,,fee schedule,Payment capped at billed charges.,117.13,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,79.45,,,,,,,fee schedule,Payment capped at billed charges.,56.77,,,,,,,fee schedule,Payment capped at billed charges.,88.28,,,,,,,fee schedule,Payment capped at billed charges.,58.47,,,,,,,fee schedule,Payment capped at billed charges.,152.56,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,,60.57,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,59.61,,,,,,,fee schedule,Payment capped at billed charges.,71.54,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,131.75,,,,,,,percent of total billed charges,,100.75,,,,,,,percent of total billed charges,,55.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,111.57,,,,,,,fee schedule,Payment capped at billed charges.,134.19,,,,,,,fee schedule,Payment capped at billed charges.,54.49,,,,,,,fee schedule,,150.77,,,,,,,fee schedule,Payment capped at billed charges.,57.9,,,,,,,fee schedule,,57.69,,,,,,,fee schedule,Payment capped at billed charges.
OT CAREGIVER TRAING EA ADDL 15,93501450,CDM,0430,RC,97551,CPT,11,Local,GO  ,outpatient,professional,,,76,76,23.59,90,,28.47,,,,,,,fee schedule,Payment capped at billed charges.,57.81,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.22,,,,,,,fee schedule,Payment capped at billed charges.,27.64,,,,,,,fee schedule,Payment capped at billed charges.,43.57,,,,,,,fee schedule,Payment capped at billed charges.,28.47,,,,,,,fee schedule,Payment capped at billed charges.,75.11,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,29.49,,,,,,,fee schedule,Payment capped at billed charges.,36.52,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.02,,,,,,,fee schedule,Payment capped at billed charges.,34.83,,,,,,,fee schedule,Payment capped at billed charges.,28.08,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,64.6,,,,,,,percent of total billed charges,,49.4,,,,,,,percent of total billed charges,,27.25,,,,,,,fee schedule,Payment capped at 80% of billed charges.,55.07,,,,,,,fee schedule,Payment capped at billed charges.,66.23,,,,,,,fee schedule,Payment capped at billed charges.,26.61,,,,,,,fee schedule,,74.42,,,,,,,fee schedule,Payment capped at billed charges.,28.19,,,,,,,fee schedule,,28.09,,,,,,,fee schedule,Payment capped at billed charges.
OT GROUP CAREGIVER TRAINING,93501468,CDM,0430,RC,97552,CPT,11,Local,GO  ,outpatient,professional,,,68,68,21.18,90,,25.55,,,,,,,fee schedule,Payment capped at billed charges.,51.09,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,34.64,,,,,,,fee schedule,Payment capped at billed charges.,24.81,,,,,,,fee schedule,Payment capped at billed charges.,38.49,,,,,,,fee schedule,Payment capped at billed charges.,25.55,,,,,,,fee schedule,Payment capped at billed charges.,67.25,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,,26.47,,,,,,,fee schedule,Payment capped at billed charges.,32.77,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,26.05,,,,,,,fee schedule,Payment capped at billed charges.,31.26,,,,,,,fee schedule,Payment capped at billed charges.,24.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,57.8,,,,,,,percent of total billed charges,,44.2,,,,,,,percent of total billed charges,,24.45,,,,,,,fee schedule,Payment capped at 80% of billed charges.,48.65,,,,,,,fee schedule,Payment capped at billed charges.,58.51,,,,,,,fee schedule,Payment capped at billed charges.,23.35,,,,,,,fee schedule,,65.74,,,,,,,fee schedule,Payment capped at billed charges.,25.3,,,,,,,fee schedule,,25.21,,,,,,,fee schedule,Payment capped at billed charges.
SP CAREGIVER TRAING 1ST 30 MIN,93501476,CDM,0440,RC,97550,CPT,11,Local,GN  ,outpatient,professional,,,155,155,48.46,152.56,,58.47,,,,,,,fee schedule,Payment capped at billed charges.,117.13,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,79.45,,,,,,,fee schedule,Payment capped at billed charges.,56.77,,,,,,,fee schedule,Payment capped at billed charges.,88.28,,,,,,,fee schedule,Payment capped at billed charges.,58.47,,,,,,,fee schedule,Payment capped at billed charges.,152.56,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,,60.57,,,,,,,fee schedule,Payment capped at billed charges.,57.69,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,59.61,,,,,,,fee schedule,Payment capped at billed charges.,71.54,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,Payment capped at billed charges.,48.46,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,131.75,,,,,,,percent of total billed charges,,100.75,,,,,,,percent of total billed charges,,55.96,,,,,,,fee schedule,Payment capped at 80% of billed charges.,111.57,,,,,,,fee schedule,Payment capped at billed charges.,134.19,,,,,,,fee schedule,Payment capped at billed charges.,54.49,,,,,,,fee schedule,,150.77,,,,,,,fee schedule,Payment capped at billed charges.,57.9,,,,,,,fee schedule,,57.69,,,,,,,fee schedule,Payment capped at billed charges.
SP CAREGIVER TRAING EA ADDL 15,93501484,CDM,0440,RC,97551,CPT,11,Local,GN  ,outpatient,professional,,,76,76,23.59,90,,28.47,,,,,,,fee schedule,Payment capped at billed charges.,57.81,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.22,,,,,,,fee schedule,Payment capped at billed charges.,27.64,,,,,,,fee schedule,Payment capped at billed charges.,43.57,,,,,,,fee schedule,Payment capped at billed charges.,28.47,,,,,,,fee schedule,Payment capped at billed charges.,75.11,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,29.49,,,,,,,fee schedule,Payment capped at billed charges.,28.09,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,29.02,,,,,,,fee schedule,Payment capped at billed charges.,34.83,,,,,,,fee schedule,Payment capped at billed charges.,28.08,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,64.6,,,,,,,percent of total billed charges,,49.4,,,,,,,percent of total billed charges,,27.25,,,,,,,fee schedule,Payment capped at 80% of billed charges.,55.07,,,,,,,fee schedule,Payment capped at billed charges.,66.23,,,,,,,fee schedule,Payment capped at billed charges.,26.61,,,,,,,fee schedule,,74.42,,,,,,,fee schedule,Payment capped at billed charges.,28.19,,,,,,,fee schedule,,28.09,,,,,,,fee schedule,Payment capped at billed charges.
SP GROUP CAREGIVER TRAINING,93501492,CDM,0440,RC,97552,CPT,11,Local,GN  ,outpatient,professional,,,68,68,21.18,90,,25.55,,,,,,,fee schedule,Payment capped at billed charges.,51.09,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,34.64,,,,,,,fee schedule,Payment capped at billed charges.,24.81,,,,,,,fee schedule,Payment capped at billed charges.,38.49,,,,,,,fee schedule,Payment capped at billed charges.,25.55,,,,,,,fee schedule,Payment capped at billed charges.,67.25,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,,26.47,,,,,,,fee schedule,Payment capped at billed charges.,25.21,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,26.05,,,,,,,fee schedule,Payment capped at billed charges.,31.26,,,,,,,fee schedule,Payment capped at billed charges.,24.18,,,,,,,fee schedule,Payment capped at billed charges.,21.18,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,57.8,,,,,,,percent of total billed charges,,44.2,,,,,,,percent of total billed charges,,24.45,,,,,,,fee schedule,Payment capped at 80% of billed charges.,48.65,,,,,,,fee schedule,Payment capped at billed charges.,58.51,,,,,,,fee schedule,Payment capped at billed charges.,23.35,,,,,,,fee schedule,,65.74,,,,,,,fee schedule,Payment capped at billed charges.,25.3,,,,,,,fee schedule,,25.21,,,,,,,fee schedule,Payment capped at billed charges.
PT RTM INITIAL SETUP,93501500,CDM,0940,RC,98975,CPT,11,Local,GP  ,outpatient,professional,,,258,258,19.97,219.3,,23.82,,,,,,,fee schedule,Payment capped at billed charges.,53.49,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.28,,,,,,,fee schedule,Payment capped at billed charges.,23.12,,,,,,,fee schedule,Payment capped at billed charges.,43.64,,,,,,,fee schedule,Payment capped at billed charges.,23.82,,,,,,,fee schedule,Payment capped at billed charges.,59.25,,,,,,,fee schedule,Payment capped at billed charges.,129,,,,,,,fee schedule,,24.68,,,,,,,fee schedule,Payment capped at billed charges.,23.5,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,24.28,,,,,,,fee schedule,Payment capped at billed charges.,29.14,,,,,,,fee schedule,Payment capped at billed charges.,21.69,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,219.3,,,,,,,percent of total billed charges,,167.7,,,,,,,percent of total billed charges,,206.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,45.43,,,,,,,fee schedule,Payment capped at billed charges.,21.42,,,,,,,fee schedule,,51.05,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,23.5,,,,,,,fee schedule,Payment capped at billed charges.
PT RTM DATA COLLECTION,93501518,CDM,0940,RC,98977,CPT,11,Local,GP  ,outpatient,professional,,,75,75,37.5,90,,51.96,,,,,,,fee schedule,Payment capped at billed charges.,77.03,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,75,,,,,,,fee schedule,Payment capped at billed charges.,50.45,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,51.96,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,37.5,,,,,,,fee schedule,,53.83,,,,,,,fee schedule,Payment capped at billed charges.,51.27,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,52.97,,,,,,,fee schedule,Payment capped at billed charges.,63.57,,,,,,,fee schedule,Payment capped at billed charges.,47.27,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,63.75,,,,,,,percent of total billed charges,,48.75,,,,,,,percent of total billed charges,,60,,,,,,,fee schedule,Payment capped at 80% of billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,46.45,,,,,,,fee schedule,,75,,,,,,,fee schedule,Payment capped at billed charges.,51.46,,,,,,,fee schedule,,51.27,,,,,,,fee schedule,Payment capped at billed charges.
PT RTM INITIAL 20 MINS CONSULT,93501526,CDM,0940,RC,98980,CPT,11,Local,GP  ,outpatient,professional,,,106,106,48.47,108.86,,57.79,,,,,,,fee schedule,Payment capped at billed charges.,108.86,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,95.29,,,,,,,fee schedule,Payment capped at billed charges.,56.11,,,,,,,fee schedule,Payment capped at billed charges.,105.88,,,,,,,fee schedule,Payment capped at billed charges.,57.79,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53,,,,,,,fee schedule,,59.87,,,,,,,fee schedule,Payment capped at billed charges.,57.02,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,58.91,,,,,,,fee schedule,Payment capped at billed charges.,70.7,,,,,,,fee schedule,Payment capped at billed charges.,55.1,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,90.1,,,,,,,percent of total billed charges,,68.9,,,,,,,percent of total billed charges,,84.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,91.29,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53.18,,,,,,,fee schedule,,106,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,,57.02,,,,,,,fee schedule,Payment capped at billed charges.
PT RTM ADDL 20 MINS CONSULT,93501534,CDM,0940,RC,98981,CPT,11,Local,GP  ,outpatient,professional,,,83,83,37.37,90,,44.55,,,,,,,fee schedule,Payment capped at billed charges.,85.24,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,76.5,,,,,,,fee schedule,Payment capped at billed charges.,43.26,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,44.55,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.5,,,,,,,fee schedule,,46.16,,,,,,,fee schedule,Payment capped at billed charges.,43.96,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,45.42,,,,,,,fee schedule,Payment capped at billed charges.,54.51,,,,,,,fee schedule,Payment capped at billed charges.,43.01,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,70.55,,,,,,,percent of total billed charges,,53.95,,,,,,,percent of total billed charges,,66.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,71.2,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.35,,,,,,,fee schedule,,83,,,,,,,fee schedule,Payment capped at billed charges.,44.12,,,,,,,fee schedule,,43.96,,,,,,,fee schedule,Payment capped at billed charges.
OT RTM INITIAL SETUP,93501542,CDM,0940,RC,98975,CPT,11,Local,GO  ,outpatient,professional,,,258,258,19.97,219.3,,23.82,,,,,,,fee schedule,Payment capped at billed charges.,53.49,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.28,,,,,,,fee schedule,Payment capped at billed charges.,23.12,,,,,,,fee schedule,Payment capped at billed charges.,43.64,,,,,,,fee schedule,Payment capped at billed charges.,23.82,,,,,,,fee schedule,Payment capped at billed charges.,59.25,,,,,,,fee schedule,Payment capped at billed charges.,129,,,,,,,fee schedule,,24.68,,,,,,,fee schedule,Payment capped at billed charges.,30.55,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,24.28,,,,,,,fee schedule,Payment capped at billed charges.,29.14,,,,,,,fee schedule,Payment capped at billed charges.,21.69,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,219.3,,,,,,,percent of total billed charges,,167.7,,,,,,,percent of total billed charges,,206.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,45.43,,,,,,,fee schedule,Payment capped at billed charges.,21.42,,,,,,,fee schedule,,51.05,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,23.5,,,,,,,fee schedule,Payment capped at billed charges.
OT RTM DATA COLLECTION,93501559,CDM,0940,RC,98977,CPT,11,Local,GO  ,outpatient,professional,,,75,75,37.5,90,,51.96,,,,,,,fee schedule,Payment capped at billed charges.,77.03,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,75,,,,,,,fee schedule,Payment capped at billed charges.,50.45,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,51.96,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,37.5,,,,,,,fee schedule,,53.83,,,,,,,fee schedule,Payment capped at billed charges.,66.65,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,52.97,,,,,,,fee schedule,Payment capped at billed charges.,63.57,,,,,,,fee schedule,Payment capped at billed charges.,47.27,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,63.75,,,,,,,percent of total billed charges,,48.75,,,,,,,percent of total billed charges,,60,,,,,,,fee schedule,Payment capped at 80% of billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,46.45,,,,,,,fee schedule,,75,,,,,,,fee schedule,Payment capped at billed charges.,51.46,,,,,,,fee schedule,,51.27,,,,,,,fee schedule,Payment capped at billed charges.
OT RTM INITIAL 20 MINS CONSULT,93501567,CDM,0940,RC,98980,CPT,11,Local,GO  ,outpatient,professional,,,106,106,48.47,108.86,,57.79,,,,,,,fee schedule,Payment capped at billed charges.,108.86,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,95.29,,,,,,,fee schedule,Payment capped at billed charges.,56.11,,,,,,,fee schedule,Payment capped at billed charges.,105.88,,,,,,,fee schedule,Payment capped at billed charges.,57.79,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53,,,,,,,fee schedule,,59.87,,,,,,,fee schedule,Payment capped at billed charges.,74.13,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,58.91,,,,,,,fee schedule,Payment capped at billed charges.,70.7,,,,,,,fee schedule,Payment capped at billed charges.,55.1,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,90.1,,,,,,,percent of total billed charges,,68.9,,,,,,,percent of total billed charges,,84.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,91.29,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53.18,,,,,,,fee schedule,,106,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,,57.02,,,,,,,fee schedule,Payment capped at billed charges.
OT RTM ADDL 20 MINS CONSULT,93501575,CDM,0940,RC,98981,CPT,11,Local,GO  ,outpatient,professional,,,83,83,37.37,90,,44.55,,,,,,,fee schedule,Payment capped at billed charges.,85.24,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,76.5,,,,,,,fee schedule,Payment capped at billed charges.,43.26,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,44.55,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.5,,,,,,,fee schedule,,46.16,,,,,,,fee schedule,Payment capped at billed charges.,57.15,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,45.42,,,,,,,fee schedule,Payment capped at billed charges.,54.51,,,,,,,fee schedule,Payment capped at billed charges.,43.01,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,70.55,,,,,,,percent of total billed charges,,53.95,,,,,,,percent of total billed charges,,66.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,71.2,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.35,,,,,,,fee schedule,,83,,,,,,,fee schedule,Payment capped at billed charges.,44.12,,,,,,,fee schedule,,43.96,,,,,,,fee schedule,Payment capped at billed charges.
SP RTM INITIAL SETUP,93501583,CDM,0940,RC,98975,CPT,11,Local,GN  ,outpatient,professional,,,258,258,19.97,219.3,,23.82,,,,,,,fee schedule,Payment capped at billed charges.,53.49,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,39.28,,,,,,,fee schedule,Payment capped at billed charges.,23.12,,,,,,,fee schedule,Payment capped at billed charges.,43.64,,,,,,,fee schedule,Payment capped at billed charges.,23.82,,,,,,,fee schedule,Payment capped at billed charges.,59.25,,,,,,,fee schedule,Payment capped at billed charges.,129,,,,,,,fee schedule,,24.68,,,,,,,fee schedule,Payment capped at billed charges.,23.5,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,24.28,,,,,,,fee schedule,Payment capped at billed charges.,29.14,,,,,,,fee schedule,Payment capped at billed charges.,21.69,,,,,,,fee schedule,Payment capped at billed charges.,19.97,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,219.3,,,,,,,percent of total billed charges,,167.7,,,,,,,percent of total billed charges,,206.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,37.78,,,,,,,fee schedule,Payment capped at billed charges.,45.43,,,,,,,fee schedule,Payment capped at billed charges.,21.42,,,,,,,fee schedule,,51.05,,,,,,,fee schedule,Payment capped at billed charges.,23.59,,,,,,,fee schedule,,23.5,,,,,,,fee schedule,Payment capped at billed charges.
SP RTM DATA COLLECTION,93501591,CDM,0940,RC,98977,CPT,11,Local,GN  ,outpatient,professional,,,75,75,37.5,90,,51.96,,,,,,,fee schedule,Payment capped at billed charges.,77.03,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,75,,,,,,,fee schedule,Payment capped at billed charges.,50.45,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,51.96,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,37.5,,,,,,,fee schedule,,53.83,,,,,,,fee schedule,Payment capped at billed charges.,51.27,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,52.97,,,,,,,fee schedule,Payment capped at billed charges.,63.57,,,,,,,fee schedule,Payment capped at billed charges.,47.27,,,,,,,fee schedule,Payment capped at billed charges.,43.58,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,63.75,,,,,,,percent of total billed charges,,48.75,,,,,,,percent of total billed charges,,60,,,,,,,fee schedule,Payment capped at 80% of billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,75,,,,,,,fee schedule,Payment capped at billed charges.,46.45,,,,,,,fee schedule,,75,,,,,,,fee schedule,Payment capped at billed charges.,51.46,,,,,,,fee schedule,,51.27,,,,,,,fee schedule,Payment capped at billed charges.
SP RTM INITIAL 20 MINS CONSULT,93501609,CDM,0940,RC,98980,CPT,11,Local,GN  ,outpatient,professional,,,106,106,48.47,108.86,,57.79,,,,,,,fee schedule,Payment capped at billed charges.,108.86,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,95.29,,,,,,,fee schedule,Payment capped at billed charges.,56.11,,,,,,,fee schedule,Payment capped at billed charges.,105.88,,,,,,,fee schedule,Payment capped at billed charges.,57.79,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53,,,,,,,fee schedule,,59.87,,,,,,,fee schedule,Payment capped at billed charges.,57.02,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,58.91,,,,,,,fee schedule,Payment capped at billed charges.,70.7,,,,,,,fee schedule,Payment capped at billed charges.,55.1,,,,,,,fee schedule,Payment capped at billed charges.,48.47,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,90.1,,,,,,,percent of total billed charges,,68.9,,,,,,,percent of total billed charges,,84.8,,,,,,,fee schedule,Payment capped at 80% of billed charges.,91.29,,,,,,,fee schedule,Payment capped at billed charges.,106,,,,,,,fee schedule,Payment capped at billed charges.,53.18,,,,,,,fee schedule,,106,,,,,,,fee schedule,Payment capped at billed charges.,57.23,,,,,,,fee schedule,,57.02,,,,,,,fee schedule,Payment capped at billed charges.
SP RTM ADDL 20 MINS CONSULT,93501617,CDM,0940,RC,98981,CPT,11,Local,GN  ,outpatient,professional,,,83,83,37.37,90,,44.55,,,,,,,fee schedule,Payment capped at billed charges.,85.24,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,60,,,,,,,Per Diem,Payment capped at billed charges,60,,,,,,,Per Diem,Payment capped at billed charges,76.5,,,,,,,fee schedule,Payment capped at billed charges.,43.26,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,44.55,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.5,,,,,,,fee schedule,,46.16,,,,,,,fee schedule,Payment capped at billed charges.,43.96,,,,,,,fee schedule,Payment capped at billed charges.,,,,,,,,,,45.42,,,,,,,fee schedule,Payment capped at billed charges.,54.51,,,,,,,fee schedule,Payment capped at billed charges.,43.01,,,,,,,fee schedule,Payment capped at billed charges.,37.37,,,,,,,fee schedule,Payment capped at billed charges.,90,,,,,,,Per Diem,Payment capped at billed charges.,70.55,,,,,,,percent of total billed charges,,53.95,,,,,,,percent of total billed charges,,66.4,,,,,,,fee schedule,Payment capped at 80% of billed charges.,71.2,,,,,,,fee schedule,Payment capped at billed charges.,83,,,,,,,fee schedule,Payment capped at billed charges.,41.35,,,,,,,fee schedule,,83,,,,,,,fee schedule,Payment capped at billed charges.,44.12,,,,,,,fee schedule,,43.96,,,,,,,fee schedule,Payment capped at billed charges.
Bilateral Procedure,,,,,,,,,50,outpatient,facility,,,,,,,,,150,,,,,,,Reimburses at 150% of the contracted rate,,150,,,,,,,Reimburses at 150% of the contracted rate,,150,,,,,,,Reimburses at 150% of the contracted rate,,150,,,,,,,Reimburses at 150% of the contracted rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150,,,,,,,Reimburses at 150% of the contracted rate,,,,,,,,,,,150,,,,,,,Reimburses at 150% of the contracted rate,,,,,,,,,,,,,,,,,,,,150,,,,,,,Reimburses at 150% of the contracted rate,,150,,,,,,,Reimburses at 150% of the contracted rate,,,,,,,,,,,150,,,,,,,Reimburses at 150% of the contracted rate,,150,,,,,,,Reimburses at 150% of the contracted rate,,,,,,,,,,,150,,,,,,,Reimburses at 150% of the contracted rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150,,,,,,,Reimburses at 150% of the contracted rate,,,,,,,,,,,150,,,,,,,Reimburses at 150% of the contracted rate,,150,,,,,,,Reimburses at 150% of the contracted rate
Reduced Services,,,,,,,,,52,outpatient,facility,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction)
Surgical Procedure Only,,,,,,,,,54,outpatient,facility,,,,,,,,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,,,,,,,,,,,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.,,,,,,,,,Intra_OP and Pre_OP Columns percentages added together then multiplied by fee scheudule.
Follow-up Care Only,,,,,,,,,55,outpatient,facility,,,,,,,,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,,,,,,,,,,,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate,,,,,,,,,Fee Schedule rate * Post Op column percentage from MPFSRVU = base rate
Pre-Op Only,,,,,,,,,56,outpatient,facility,,,,,,,,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,,,,,,,,,,,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,,,,,,,,,,Fee Schedule rate * Pre-Op column percentage,,,,,,,,,Fee Schedule rate * Pre-Op column percentage
Two Surgeons,,,,,,,,,62,outpatient,facility,,,,,,,,,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,,,,,,,,,,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,,,,,,,,,,,,,,,,,,,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,,,,,,,,,,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,,,,,,,,,,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,,,,,,,,,,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction),,62.5,,,,,,,Reimburses at 62.50% of the contracted rate (37.50% reduction)
Surgical Team,,,,,,,,,66,outpatient,facility,,,,,,,,,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,,,,,,,,,,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,,,,,,,,,,,,,,,,,,,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,,,,,,,,,,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,,,,,,,,,,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,,,,,,,,,,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction),,33,,,,,,,Reimburses at 33% of the contracted rate (67% reduction)
Discontinued Procedure,,,,,,,,,73,outpatient,facility,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction)
Return To OR,,,,,,,,,78,outpatient,facility,,,,,,,,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,,,,,,,,,,,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,,,,,,,,,,Intro-Op column percentage * fee schedule rate,,,,,,,,,Intro-Op column percentage * fee schedule rate
Assistant Surgeon,,,,,,,,,80,outpatient,facility,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction)
Minimum Assistant Surgeon,,,,,,,,,81,outpatient,facility,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction)
Assistant Surgeon (when qualified resident surgeon not available),,,,,,,,,82,outpatient,facility,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction)
"Physician Assistant, Nurse Practitioner, Or Clinical nurse Specialist Services For Assistant At Surgery.",,,,,,,,,AS,outpatient,facility,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,,,,,,,,,,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction),,16,,,,,,,Reimburses at 16% of the contracted rate (84% reduction)
"Waiver of Liability Statement Issued, as Required by Payer Policy",,,,,,,,,GA,outpatient,facility,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility
"Item or service statutorily excluded, does not meet the definition of any Medicare benefit",,,,,,,,,GY,outpatient,facility,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,,,,,,,,,,Prices to 0 - patient responsibility,,,,,,,,,Prices to 0 - patient responsibility
Item or service expected to be denied as not reasonable and necessary,,,,,,,,,GZ,outpatient,facility,,,,,,,,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,,,,,,,,,,,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.,,,,,,,,,Prices to 0 - non-covered but not patient responsibility.
"Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals",,,,,,,,,QK,outpatient,facility,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction)
Medical Direction by Anesthesiologist,,,,,,,,,QX,outpatient,facility,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction
Medical Direction of CRNA,,,,,,,,,QY,outpatient,facility,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,,,,,,,,,,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction),,50,,,,,,,Reimburses at 50% of the contracted rate (50% reduction)
Therapy Modifiers for a PTA or an OTA,,,,,,,,,CO|GO,outpatient,facility,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction)
Therapy Modifiers for a PTA or an OTA,,,,,,,,,GP|CQ,outpatient,facility,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,,,,,,,,,,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction),,85,,,,,,,Reimburses at 85% of the contracted rate (15% reduction)