hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|GA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Evans Memorial Hospital,2024-07-01,2.0.0,Evans Memorial Hospital,"200 North River St Claxton, GA 30417",582257925,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
SERVICE DESCRIPTION,CATEGORY,BILLING MSDRG | CPT | HCPCS,ITEM/SERVICE DESCRIPTION,BILLING REVENUE CODE,GROSS CHARGES,AETNA PLAN,AETNA REIMBURSEMENT METHOD,AETNA MEDICARE HMO PLAN,AETNA MEDICARE HMO REIMBURSEMENT METHOD,AETNA MEDICARE POS PLAN,AETNA MEDICARE POS REIMBURSEMENT METHOD,AETNA MEDICARE PPO PLAN,AETNA MEDICARE PPO REIMBURSEMENT METHOD,AMBETTER PLAN,AMBETTER REIMBURSEMENT METHOD,AMERIGROUP PLAN,AMERIGROUP REIMBURSEMENT METHOD,BCBS HMO PLAN,BCBS HMO REIMBURSEMENT METHOD,BCBS OPEN ACCESS PLAN,BCBS OPEN ACCESS REIMBURSEMENT METHOD,BCBS PATHWAY PLAN,BCBS PATHWAY REIMBURSEMENT METHOD,BCBS PPO PLAN,BCBS PPO REIMBURSEMENT METHOD,CARE IMPROVEMENT PLUS PLAN,CARE IMPROVEMENT PLUS REIMBURSEMENT METHOD,CARE NETWORK PLAN,CARE NETWORK REIMBURSEMENT METHOD,CARESOURCE PLAN,CARESOURCE REIMBURSEMENT METHOD,CIGNA PLAN,CIGNA REIMBURSEMENT METHOD,HUMANA CHOICECARE PLAN,HUMANA CHOICECARE REIMBURSEMENT METHOD,HUMANA CHOICECARE MEDICARE PLAN,HUMANA CHOICECARE MEDICARE REIMBURSEMENT METHOD,HUMANA TRICARE PLAN,HUMANA TRICARE REIMBURSEMENT METHOD,IBG PLAN,IBG REIMBURSEMENT METHOD,MEDICAID PLAN,MEDICAID REIMBURSEMENT METHOD,MEDICARE PLAN,MEDICARE REIMBURSEMENT METHOD,PEACHSTATE PLAN,PEACHSTATE REIMBURSEMENT METHOD,UHC PLAN,UHC REIMBURSEMENT METHOD,VA CCN PLAN,VA CCN REIMBURSEMENT METHOD,De-Identified Minimum Negotiated Rate,De-Identified Maximum Negotiated Rate,DISCOUNTED CASH PRICE
Outpatient Medical Services,LAB,81002,Manual urinalysis test with examination without using microscope,307,$60.00 ,$51.00 ,85% of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.48 ,Pays 100% Medicare OPPS,$3.48 ,Pays 100% Medicare OPPS,$4.52 ,Pays 130% Medicare OPPS,$3.86 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$3.54 ,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$4.02 ,125.18% of custom fee schedule,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.13 ,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$3.86 ,120.37% of custom fee schedule,$3.48 ,Pays 100% Medicare OPPS,$4.52 ,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.13 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,82670,Blood test to measure a type of estrogen in the blood,301,$450.00 ,$382.50 ,85% of total billed charges,$27.94 ,Pays 100% Medicare OPPS,$27.94 ,Pays 100% Medicare OPPS,$27.94 ,Pays 100% Medicare OPPS,$36.32 ,Pays 130% Medicare OPPS,$42.30 ,20.37% based on GA Medicaid OP CCR Rate,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$28.49 ,Pays 102% Medicare OPPS,$405.00 ,90% of total billed charges,$43.99 ,125.18% of custom fee schedule,$309.15 ,68.7% of total billed charges,$360.00 ,80 percent of total billed charges,$27.94 ,Pays 100% Medicare OPPS,$25.14 ,Pays 90% Medicare OPPS,$261.00 ,58% of total billed charges,$42.30 ,120.37% of custom fee schedule,$27.94 ,Pays 100% Medicare OPPS,$36.32 ,Pays 130% Medicare OPPS,$382.50 ,85% of total billed charges,$27.94 ,Pays 100% Medicare OPPS,$25.14 ,$405.00 ,$360.00 
Outpatient Medical Services,LAB,87635,COVID-19 SWAB,300,$250.00 ,$212.50 ,85% of total billed charges,$51.31 ,Pays 100% Medicare OPPS,$51.31 ,Pays 100% Medicare OPPS,$51.31 ,Pays 100% Medicare OPPS,$66.70 ,Pays 130% Medicare OPPS,$61.76 ,20.37% based on GA Medicaid OP CCR Rate,$141.25 ,56.5 percent of total billed charges,$141.25 ,56.5 percent of total billed charges,$141.25 ,56.5 percent of total billed charges,$141.25 ,56.5 percent of total billed charges,$52.33 ,Pays 102% Medicare OPPS,$225.00 ,90% of total billed charges,$64.23 ,125.18% of custom fee schedule,$171.75 ,68.7% of total billed charges,$200.00 ,80 percent of total billed charges,$51.31 ,Pays 100% Medicare OPPS,$46.17 ,Pays 90% Medicare OPPS,$145.00 ,58% of total billed charges,$61.76 ,120.37% of custom fee schedule,$51.31 ,Pays 100% Medicare OPPS,$66.70 ,Pays 130% Medicare OPPS,$212.50 ,85% of total billed charges,$51.31 ,Pays 100% Medicare OPPS,$46.17 ,$225.00 ,$200.00 
Outpatient Medical Services,LAB,82088,"ALDOSTERONE, SERUM",301,$345.00 ,$293.25 ,85% of total billed charges,$40.75 ,Pays 100% Medicare OPPS,$40.75 ,Pays 100% Medicare OPPS,$40.75 ,Pays 100% Medicare OPPS,$52.97 ,Pays 130% Medicare OPPS,$61.69 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$41.56 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$64.15 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$40.75 ,Pays 100% Medicare OPPS,$36.67 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$61.69 ,120.37% of custom fee schedule,$40.75 ,Pays 100% Medicare OPPS,$52.97 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$40.75 ,Pays 100% Medicare OPPS,$36.67 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,82088,"ALDOSTERONE, URINE",301,$525.00 ,$446.25 ,85% of total billed charges,$40.75 ,Pays 100% Medicare OPPS,$40.75 ,Pays 100% Medicare OPPS,$40.75 ,Pays 100% Medicare OPPS,$52.97 ,Pays 130% Medicare OPPS,$61.69 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$41.56 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$64.15 ,125.18% of custom fee schedule,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$40.75 ,Pays 100% Medicare OPPS,$36.67 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$61.69 ,120.37% of custom fee schedule,$40.75 ,Pays 100% Medicare OPPS,$52.97 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$40.75 ,Pays 100% Medicare OPPS,$36.67 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,82105,ALPHA FETOPROTEIN TUMOR M,301,$320.00 ,$272.00 ,85% of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$16.77 ,Pays 100% Medicare OPPS,$16.77 ,Pays 100% Medicare OPPS,$21.80 ,Pays 130% Medicare OPPS,$25.40 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$17.10 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$26.41 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$15.09 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$25.40 ,120.37% of custom fee schedule,$16.77 ,Pays 100% Medicare OPPS,$21.80 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$15.09 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,82105,"ALPHA FETOPROTEIN, MATERN",301,$320.00 ,$272.00 ,85% of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$16.77 ,Pays 100% Medicare OPPS,$16.77 ,Pays 100% Medicare OPPS,$21.80 ,Pays 130% Medicare OPPS,$25.40 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$17.10 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$26.41 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$15.09 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$25.40 ,120.37% of custom fee schedule,$16.77 ,Pays 100% Medicare OPPS,$21.80 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$15.09 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,82150,"AMYLASE, FLUID",301,$300.00 ,$255.00 ,85% of total billed charges,$6.48 ,Pays 100% Medicare OPPS,$6.48 ,Pays 100% Medicare OPPS,$6.48 ,Pays 100% Medicare OPPS,$8.42 ,Pays 130% Medicare OPPS,$9.81 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$6.60 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$10.20 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$6.48 ,Pays 100% Medicare OPPS,$5.83 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$9.81 ,120.37% of custom fee schedule,$6.48 ,Pays 100% Medicare OPPS,$8.42 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$6.48 ,Pays 100% Medicare OPPS,$5.83 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,82150,"AMYLASE, SERUM",301,$300.00 ,$255.00 ,85% of total billed charges,$6.48 ,Pays 100% Medicare OPPS,$6.48 ,Pays 100% Medicare OPPS,$6.48 ,Pays 100% Medicare OPPS,$8.42 ,Pays 130% Medicare OPPS,$9.81 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$6.60 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$10.20 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$6.48 ,Pays 100% Medicare OPPS,$5.83 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$9.81 ,120.37% of custom fee schedule,$6.48 ,Pays 100% Medicare OPPS,$8.42 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$6.48 ,Pays 100% Medicare OPPS,$5.83 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,86790,HERPES AB TY II IgM,302,$195.00 ,$165.75 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,86039,Blood test to determine autoimmune disorders,302,$110.00 ,$93.50 ,85% of total billed charges,$11.16 ,Pays 100% Medicare OPPS,$11.16 ,Pays 100% Medicare OPPS,$11.16 ,Pays 100% Medicare OPPS,$14.50 ,Pays 130% Medicare OPPS,$16.90 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$11.38 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$17.58 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$11.16 ,Pays 100% Medicare OPPS,$10.04 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$16.90 ,120.37% of custom fee schedule,$11.16 ,Pays 100% Medicare OPPS,$14.50 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$11.16 ,Pays 100% Medicare OPPS,$10.04 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,302,$320.00 ,$272.00 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,83520,ANTI HU AUTO,301,$370.00 ,$314.50 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$333.00 ,$296.00 
Outpatient Medical Services,LAB,86235,ANTI La,302,$165.00 ,$140.25 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,83520,ANTI MAG,301,$760.00 ,$646.00 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$684.00 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$522.12 ,68.7% of total billed charges,$608.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$440.80 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$646.00 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$684.00 ,$608.00 
Outpatient Medical Services,LAB,86235,ANTI RO,302,$165.00 ,$140.25 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,301,$660.00 ,$561.00 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$594.00 ,$528.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,301,$660.00 ,$561.00 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$594.00 ,$528.00 
Outpatient Medical Services,LAB,86255,ANTI-PARIETAL CELL,302,$265.00 ,$225.25 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,86255,3RD ANTIMITOCHONDRIAL ANTIBOD,302,$260.00 ,$221.00 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,302,$275.00 ,$233.75 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,86063,.ASO W/(ARTHRITIS PROFILE),302,$100.00 ,$85.00 ,85% of total billed charges,$5.77 ,Pays 100% Medicare OPPS,$5.77 ,Pays 100% Medicare OPPS,$5.77 ,Pays 100% Medicare OPPS,$7.50 ,Pays 130% Medicare OPPS,$8.74 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$5.88 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$9.09 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$5.77 ,Pays 100% Medicare OPPS,$5.19 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$8.74 ,120.37% of custom fee schedule,$5.77 ,Pays 100% Medicare OPPS,$7.50 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$5.77 ,Pays 100% Medicare OPPS,$5.19 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,86753,.BABESIOSIS IgG ANTIBODIES,300,$240.00 ,$204.00 ,85% of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$12.39 ,Pays 100% Medicare OPPS,$12.39 ,Pays 100% Medicare OPPS,$16.10 ,Pays 130% Medicare OPPS,$18.77 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$12.63 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$19.52 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$11.15 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$18.77 ,120.37% of custom fee schedule,$12.39 ,Pays 100% Medicare OPPS,$16.10 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$11.15 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,86753,.BABESIOSIS IgM ANTIBODIES,300,$240.00 ,$204.00 ,85% of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$12.39 ,Pays 100% Medicare OPPS,$12.39 ,Pays 100% Medicare OPPS,$16.10 ,Pays 130% Medicare OPPS,$18.77 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$12.63 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$19.52 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$11.15 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$18.77 ,120.37% of custom fee schedule,$12.39 ,Pays 100% Medicare OPPS,$16.10 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$11.15 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,80346,"BENZODIAZEPINE, UA",301,$260.00 ,$221.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$28.00 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$29.12 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$28.00 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$28.00 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,84182,BOTULINUM TOXIN A AB,300,"$1,145.00 ",$973.25 ,85% of total billed charges,$29.21 ,Pays 100% Medicare OPPS,$29.21 ,Pays 100% Medicare OPPS,$29.21 ,Pays 100% Medicare OPPS,$37.97 ,Pays 130% Medicare OPPS,$27.25 ,20.37% based on GA Medicaid OP CCR Rate,$646.93 ,56.5 percent of total billed charges,$646.93 ,56.5 percent of total billed charges,$646.93 ,56.5 percent of total billed charges,$646.93 ,56.5 percent of total billed charges,$29.79 ,Pays 102% Medicare OPPS,"$1,030.50 ",90% of total billed charges,$28.34 ,125.18% of custom fee schedule,$786.62 ,68.7% of total billed charges,$916.00 ,80 percent of total billed charges,$29.21 ,Pays 100% Medicare OPPS,$26.28 ,Pays 90% Medicare OPPS,$664.10 ,58% of total billed charges,$27.25 ,120.37% of custom fee schedule,$29.21 ,Pays 100% Medicare OPPS,$37.97 ,Pays 130% Medicare OPPS,$973.25 ,85% of total billed charges,$29.21 ,Pays 100% Medicare OPPS,$26.28 ,"$1,030.50 ",$916.00 
Outpatient Medical Services,LAB,80345,FIORINAL LEVEL,301,$545.00 ,$463.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$17.35 ,20.37% based on GA Medicaid OP CCR Rate,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$490.50 ,90% of total billed charges,$18.04 ,125.18% of custom fee schedule,$374.42 ,68.7% of total billed charges,$436.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$316.10 ,58% of total billed charges,$17.35 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$463.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$17.35 ,$490.50 ,$436.00 
Outpatient Medical Services,LAB,86160,C4 COMPLEMENT,302,$320.00 ,$272.00 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$18.18 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$12.24 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$18.90 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$18.18 ,120.37% of custom fee schedule,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,86300,Blood test to monitor breast cancer,302,$375.00 ,$318.75 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$31.49 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$21.22 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$32.75 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$31.49 ,120.37% of custom fee schedule,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,82310,CALCIUM URINE SPOT,301,$150.00 ,$127.50 ,85% of total billed charges,$5.16 ,Pays 100% Medicare OPPS,$5.16 ,Pays 100% Medicare OPPS,$5.16 ,Pays 100% Medicare OPPS,$6.70 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.26 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.16 ,Pays 100% Medicare OPPS,$4.64 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$5.16 ,Pays 100% Medicare OPPS,$6.70 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.16 ,Pays 100% Medicare OPPS,$4.64 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,80156,CARBAMAZEPINE (TEGRETOL) LEVEL,301,$320.00 ,$272.00 ,85% of total billed charges,$14.57 ,Pays 100% Medicare OPPS,$14.57 ,Pays 100% Medicare OPPS,$14.57 ,Pays 100% Medicare OPPS,$18.94 ,Pays 130% Medicare OPPS,$22.04 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$14.86 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$22.92 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$14.57 ,Pays 100% Medicare OPPS,$13.11 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$22.04 ,120.37% of custom fee schedule,$14.57 ,Pays 100% Medicare OPPS,$18.94 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$14.57 ,Pays 100% Medicare OPPS,$13.11 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,82384,CATECHOLAMINES PLASMA,301,$415.00 ,$352.75 ,85% of total billed charges,$25.25 ,Pays 100% Medicare OPPS,$25.25 ,Pays 100% Medicare OPPS,$25.25 ,Pays 100% Medicare OPPS,$32.82 ,Pays 130% Medicare OPPS,$38.22 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$25.75 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$39.74 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$25.25 ,Pays 100% Medicare OPPS,$22.72 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$38.22 ,120.37% of custom fee schedule,$25.25 ,Pays 100% Medicare OPPS,$32.82 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$25.25 ,Pays 100% Medicare OPPS,$22.72 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,86360,CD-4/CD-8 COUNT ABSOLUTE,302,$485.00 ,$412.25 ,85% of total billed charges,$46.98 ,Pays 100% Medicare OPPS,$46.98 ,Pays 100% Medicare OPPS,$46.98 ,Pays 100% Medicare OPPS,$61.07 ,Pays 130% Medicare OPPS,$71.13 ,20.37% based on GA Medicaid OP CCR Rate,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$47.91 ,Pays 102% Medicare OPPS,$436.50 ,90% of total billed charges,$73.97 ,125.18% of custom fee schedule,$333.20 ,68.7% of total billed charges,$388.00 ,80 percent of total billed charges,$46.98 ,Pays 100% Medicare OPPS,$42.28 ,Pays 90% Medicare OPPS,$281.30 ,58% of total billed charges,$71.13 ,120.37% of custom fee schedule,$46.98 ,Pays 100% Medicare OPPS,$61.07 ,Pays 130% Medicare OPPS,$412.25 ,85% of total billed charges,$46.98 ,Pays 100% Medicare OPPS,$42.28 ,$436.50 ,$388.00 
Outpatient Medical Services,LAB,89050,CELL CO BODY FLUID WO DIF,309,$135.00 ,$114.75 ,85% of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,$7.16 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.81 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$7.45 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.16 ,120.37% of custom fee schedule,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,89050,CELL COUNT CSF,300,$135.00 ,$114.75 ,85% of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,$7.16 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.81 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$7.45 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.16 ,120.37% of custom fee schedule,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,89050,CELL COUNT PERITINEAL,309,$135.00 ,$114.75 ,85% of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,$7.16 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.81 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$7.45 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.16 ,120.37% of custom fee schedule,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86235,CENTROMERE ANTIB,302,$165.00 ,$140.25 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,86631,CHLAMYDIA TRACHOMATIS IGG ABS,302,$150.00 ,$127.50 ,85% of total billed charges,$11.82 ,Pays 100% Medicare OPPS,$11.82 ,Pays 100% Medicare OPPS,$11.82 ,Pays 100% Medicare OPPS,$15.36 ,Pays 130% Medicare OPPS,$17.90 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$12.05 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$18.61 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$11.82 ,Pays 100% Medicare OPPS,$10.63 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$17.90 ,120.37% of custom fee schedule,$11.82 ,Pays 100% Medicare OPPS,$15.36 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$11.82 ,Pays 100% Medicare OPPS,$10.63 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,86632,CHLAMYDIA TRACHOMATIS IGM ABS,302,$150.00 ,$127.50 ,85% of total billed charges,$12.68 ,Pays 100% Medicare OPPS,$12.68 ,Pays 100% Medicare OPPS,$12.68 ,Pays 100% Medicare OPPS,$16.48 ,Pays 130% Medicare OPPS,$19.22 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$12.93 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$19.99 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$12.68 ,Pays 100% Medicare OPPS,$11.41 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$19.22 ,120.37% of custom fee schedule,$12.68 ,Pays 100% Medicare OPPS,$16.48 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$12.68 ,Pays 100% Medicare OPPS,$11.41 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,82480,"CHOLINESTERASE, SERUM",301,$320.00 ,$272.00 ,85% of total billed charges,$7.87 ,Pays 100% Medicare OPPS,$7.87 ,Pays 100% Medicare OPPS,$7.87 ,Pays 100% Medicare OPPS,$10.23 ,Pays 130% Medicare OPPS,$11.93 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$8.02 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$12.41 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$7.87 ,Pays 100% Medicare OPPS,$7.08 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$11.93 ,120.37% of custom fee schedule,$7.87 ,Pays 100% Medicare OPPS,$10.23 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$7.87 ,Pays 100% Medicare OPPS,$7.08 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,88262,.CHROM ANAL15-20(CHROM7&11,311,"$1,045.00 ",$888.25 ,85% of total billed charges,$125.49 ,Pays 100% Medicare OPPS,$125.49 ,Pays 100% Medicare OPPS,$125.49 ,Pays 100% Medicare OPPS,$163.13 ,Pays 130% Medicare OPPS,$188.66 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$127.99 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$196.19 ,125.18% of custom fee schedule,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$125.49 ,Pays 100% Medicare OPPS,$112.94 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$188.66 ,120.37% of custom fee schedule,$125.49 ,Pays 100% Medicare OPPS,$163.13 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$125.49 ,Pays 100% Medicare OPPS,$112.94 ,$940.50 ,$836.00 
Outpatient Medical Services,LAB,80367,CLONAZEPAM LEVEL,301,$320.00 ,$272.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$65.18 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$112.00 ,35% based on GA Medicaid OP CCR Rate,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$65.18 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$65.18 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80299,CLOZAPINE,301,$365.00 ,$310.25 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,82374,CO2 URINE 24 HOUR,300,$365.00 ,$310.25 ,85% of total billed charges,$4.88 ,Pays 100% Medicare OPPS,$4.88 ,Pays 100% Medicare OPPS,$4.88 ,Pays 100% Medicare OPPS,$6.34 ,Pays 130% Medicare OPPS,$7.40 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$4.97 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$7.70 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$4.88 ,Pays 100% Medicare OPPS,$4.39 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$7.40 ,120.37% of custom fee schedule,$4.88 ,Pays 100% Medicare OPPS,$6.34 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$4.88 ,Pays 100% Medicare OPPS,$4.39 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,82570,Test to measure creatinine in the urine,301,$150.00 ,$127.50 ,85% of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$5.18 ,Pays 100% Medicare OPPS,$5.18 ,Pays 100% Medicare OPPS,$6.73 ,Pays 130% Medicare OPPS,$7.84 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.28 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$8.15 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$4.66 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.84 ,120.37% of custom fee schedule,$5.18 ,Pays 100% Medicare OPPS,$6.73 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$4.66 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,87449,CRYPTOCOCCUS ANTIGEN(CSF),302,$300.00 ,$255.00 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$12.21 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,89060,CRYSTALS KNEE FLUID,309,$175.00 ,$148.75 ,85% of total billed charges,$7.33 ,Pays 100% Medicare OPPS,$7.33 ,Pays 100% Medicare OPPS,$7.33 ,Pays 100% Medicare OPPS,$9.52 ,Pays 130% Medicare OPPS,$10.82 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$7.47 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$11.25 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$7.33 ,Pays 100% Medicare OPPS,$6.59 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$10.82 ,120.37% of custom fee schedule,$7.33 ,Pays 100% Medicare OPPS,$9.52 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$7.33 ,Pays 100% Medicare OPPS,$6.59 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,87252,CULTURE HERPES,306,$345.00 ,$293.25 ,85% of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$26.07 ,Pays 100% Medicare OPPS,$26.07 ,Pays 100% Medicare OPPS,$33.89 ,Pays 130% Medicare OPPS,$33.46 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$26.59 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$34.80 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$23.46 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$33.46 ,120.37% of custom fee schedule,$26.07 ,Pays 100% Medicare OPPS,$33.89 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$23.46 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,306,$275.00 ,$233.75 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,306,$310.00 ,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,306,$310.00 ,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,87046,Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,306,$135.00 ,$114.75 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$3.57 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$9.62 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$3.72 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$8.49 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$3.57 ,120.37% of custom fee schedule,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$3.57 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,306,$310.00 ,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,87046,Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,306,$410.00 ,$348.50 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$3.57 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$9.62 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$3.72 ,125.18% of custom fee schedule,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$8.49 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$3.57 ,120.37% of custom fee schedule,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$3.57 ,$369.00 ,$328.00 
Outpatient Medical Services,LAB,87252,3RD CULTURE VIRAL,306,$345.00 ,$293.25 ,85% of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$26.07 ,Pays 100% Medicare OPPS,$26.07 ,Pays 100% Medicare OPPS,$33.89 ,Pays 130% Medicare OPPS,$33.46 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$26.59 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$34.80 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$23.46 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$33.46 ,120.37% of custom fee schedule,$26.07 ,Pays 100% Medicare OPPS,$33.89 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$23.46 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,87015,.CYCLOSPORA CONCENTRATION,300,$150.00 ,$127.50 ,85% of total billed charges,$6.68 ,Pays 100% Medicare OPPS,$6.68 ,Pays 100% Medicare OPPS,$6.68 ,Pays 100% Medicare OPPS,$8.68 ,Pays 130% Medicare OPPS,$10.11 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$6.81 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$10.52 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$6.68 ,Pays 100% Medicare OPPS,$6.01 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$10.11 ,120.37% of custom fee schedule,$6.68 ,Pays 100% Medicare OPPS,$8.68 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$6.68 ,Pays 100% Medicare OPPS,$6.01 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,87046,Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,306,$135.00 ,$114.75 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$3.57 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$9.62 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$3.72 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$8.49 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$3.57 ,120.37% of custom fee schedule,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$3.57 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86645,3RD CYTOMEGALOVIRUS IgM Ab,302,$320.00 ,$272.00 ,85% of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$16.85 ,Pays 100% Medicare OPPS,$16.85 ,Pays 100% Medicare OPPS,$21.90 ,Pays 130% Medicare OPPS,$25.51 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$17.18 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$26.53 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$15.16 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$25.51 ,120.37% of custom fee schedule,$16.85 ,Pays 100% Medicare OPPS,$21.90 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$15.16 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80367,DARVON LEVEL,301,$365.00 ,$310.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$74.35 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$127.75 ,35% based on GA Medicaid OP CCR Rate,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$74.35 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$74.35 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86790,DENGUE VIRUS IgM ANTIBODY,300,$450.00 ,$382.50 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$405.00 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$309.15 ,68.7% of total billed charges,$360.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$261.00 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$382.50 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$405.00 ,$360.00 
Outpatient Medical Services,LAB,80338,DESYREL  LEVEL,301,$410.00 ,$348.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$143.50 ,35% based on GA Medicaid OP CCR Rate,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$83.52 ,$369.00 ,$328.00 
Outpatient Medical Services,LAB,80299,DISOPYRAMIDE LEVEL,301,$275.00 ,$233.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,86225,DNA ANTIBODIES (dsDNA),302,$275.00 ,$233.75 ,85% of total billed charges,$13.74 ,Pays 100% Medicare OPPS,$13.74 ,Pays 100% Medicare OPPS,$13.74 ,Pays 100% Medicare OPPS,$17.86 ,Pays 130% Medicare OPPS,$20.80 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$14.01 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$21.63 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$13.74 ,Pays 100% Medicare OPPS,$12.36 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$20.80 ,120.37% of custom fee schedule,$13.74 ,Pays 100% Medicare OPPS,$17.86 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$13.74 ,Pays 100% Medicare OPPS,$12.36 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,86225,DNA BY FARR ASSAY,302,$345.00 ,$293.25 ,85% of total billed charges,$13.74 ,Pays 100% Medicare OPPS,$13.74 ,Pays 100% Medicare OPPS,$13.74 ,Pays 100% Medicare OPPS,$17.86 ,Pays 130% Medicare OPPS,$20.80 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$14.01 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$21.63 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$13.74 ,Pays 100% Medicare OPPS,$12.36 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$20.80 ,120.37% of custom fee schedule,$13.74 ,Pays 100% Medicare OPPS,$17.86 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$13.74 ,Pays 100% Medicare OPPS,$12.36 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,80375,DRUG SCREEN CONFIRM Ua ea,301,$175.00 ,$148.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$21.97 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$22.85 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$21.97 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$21.97 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,80307,Testing for presence of drug,301,$335.00 ,$284.75 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$73.62 ,20.37% based on GA Medicaid OP CCR Rate,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$63.38 ,Pays 102% Medicare OPPS,$301.50 ,90% of total billed charges,$76.56 ,125.18% of custom fee schedule,$230.15 ,68.7% of total billed charges,$268.00 ,80 percent of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,Pays 90% Medicare OPPS,$194.30 ,58% of total billed charges,$73.62 ,120.37% of custom fee schedule,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$284.75 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,$301.50 ,$268.00 
Outpatient Medical Services,LAB,80377,"DRUG SCREEN, INDUS I,UA",301,$275.00 ,$233.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$56.02 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$96.25 ,35% based on GA Medicaid OP CCR Rate,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$56.02 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$56.02 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,80377,"DRUG SCREEN, NIDA",301,$335.00 ,$284.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$68.24 ,20.37% based on GA Medicaid OP CCR Rate,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$301.50 ,90% of total billed charges,$117.25 ,35% based on GA Medicaid OP CCR Rate,$230.15 ,68.7% of total billed charges,$268.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$194.30 ,58% of total billed charges,$68.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$284.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$68.24 ,$301.50 ,$268.00 
Outpatient Medical Services,LAB,80377,"DRUG SCREEN, REGULAR QUEST",301,$120.00 ,$102.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$24.44 ,20.37% based on GA Medicaid OP CCR Rate,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$108.00 ,90% of total billed charges,$42.00 ,35% based on GA Medicaid OP CCR Rate,$82.44 ,68.7% of total billed charges,$96.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$69.60 ,58% of total billed charges,$24.44 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$102.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$24.44 ,$108.00 ,$96.00 
Outpatient Medical Services,LAB,G0481,"DRUG SCREEN, UA (MEDICAL)",301,$215.00 ,$182.75 ,85% of total billed charges,$156.59 ,Pays 100% Medicare OPPS,$156.59 ,Pays 100% Medicare OPPS,$156.59 ,Pays 100% Medicare OPPS,$203.56 ,Pays 130% Medicare OPPS,$155.02 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$159.72 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$161.22 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$156.59 ,Pays 100% Medicare OPPS,$140.93 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$155.02 ,120.37% of custom fee schedule,$156.59 ,Pays 100% Medicare OPPS,$203.56 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$156.59 ,Pays 100% Medicare OPPS,$121.48 ,$203.56 ,$172.00 
Outpatient Medical Services,LAB,86666,.EHRLICH.TIT IgM(CHAFF/EQU,302,$300.00 ,$255.00 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$15.41 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$10.38 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$16.02 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$15.41 ,120.37% of custom fee schedule,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,86666,3RD EHRLICHIA ANTIBODIES,300,$160.00 ,$136.00 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$15.41 ,20.37% based on GA Medicaid OP CCR Rate,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$10.38 ,Pays 102% Medicare OPPS,$144.00 ,90% of total billed charges,$16.02 ,125.18% of custom fee schedule,$109.92 ,68.7% of total billed charges,$128.00 ,80 percent of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,Pays 90% Medicare OPPS,$92.80 ,58% of total billed charges,$15.41 ,120.37% of custom fee schedule,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$136.00 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,$144.00 ,$128.00 
Outpatient Medical Services,LAB,86651,"ENCEPH,CALIFORNIA IgM",302,$170.00 ,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$19.97 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$13.45 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$20.77 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$19.97 ,120.37% of custom fee schedule,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86652,"ENCEPH,E.EQUINE IgM",302,$170.00 ,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$19.97 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$13.45 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$20.77 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$19.97 ,120.37% of custom fee schedule,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86653,"ENCEPH,ST. LOUIS IgM",302,$170.00 ,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$19.97 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$13.45 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$20.77 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$19.97 ,120.37% of custom fee schedule,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86654,WESTERN EQUINE IgM,302,$170.00 ,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$19.97 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$13.45 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$20.77 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$19.97 ,120.37% of custom fee schedule,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,85999,EOSIN COUNT URINE,300,$150.00 ,$127.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$30.56 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$52.50 ,35% based on GA Medicaid OP CCR Rate,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$30.56 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$30.56 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,80055,Obstetric blood test panel,301,$420.00 ,$357.00 ,85% of total billed charges,$47.81 ,Pays 100% Medicare OPPS,$47.81 ,Pays 100% Medicare OPPS,$47.81 ,Pays 100% Medicare OPPS,$62.15 ,Pays 130% Medicare OPPS,$33.80 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$48.76 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$35.15 ,125.18% of custom fee schedule,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$47.81 ,Pays 100% Medicare OPPS,$43.02 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$33.80 ,120.37% of custom fee schedule,$47.81 ,Pays 100% Medicare OPPS,$62.15 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$47.81 ,Pays 100% Medicare OPPS,$33.80 ,$378.00 ,$336.00 
Outpatient Medical Services,LAB,88291,".CYTOGENETICS, INTERP/REPO",311,$145.00 ,$123.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$30.56 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$31.78 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$30.56 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$30.56 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82128,"3RD AMINO ACID PROFILE,URINE",301,"$1,090.00 ",$926.50 ,85% of total billed charges,$13.87 ,Pays 100% Medicare OPPS,$13.87 ,Pays 100% Medicare OPPS,$13.87 ,Pays 100% Medicare OPPS,$18.03 ,Pays 130% Medicare OPPS,$20.98 ,20.37% based on GA Medicaid OP CCR Rate,$615.85 ,56.5 percent of total billed charges,$615.85 ,56.5 percent of total billed charges,$615.85 ,56.5 percent of total billed charges,$615.85 ,56.5 percent of total billed charges,$14.14 ,Pays 102% Medicare OPPS,$981.00 ,90% of total billed charges,$21.82 ,125.18% of custom fee schedule,$748.83 ,68.7% of total billed charges,$872.00 ,80 percent of total billed charges,$13.87 ,Pays 100% Medicare OPPS,$12.48 ,Pays 90% Medicare OPPS,$632.20 ,58% of total billed charges,$20.98 ,120.37% of custom fee schedule,$13.87 ,Pays 100% Medicare OPPS,$18.03 ,Pays 130% Medicare OPPS,$926.50 ,85% of total billed charges,$13.87 ,Pays 100% Medicare OPPS,$12.48 ,$981.00 ,$872.00 
Outpatient Medical Services,LAB,81241,FACTOR V LEIDEN,300,$300.00 ,$255.00 ,85% of total billed charges,$73.37 ,Pays 100% Medicare OPPS,$73.37 ,Pays 100% Medicare OPPS,$73.37 ,Pays 100% Medicare OPPS,$95.38 ,Pays 130% Medicare OPPS,$48.15 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$74.83 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$50.07 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$73.37 ,Pays 100% Medicare OPPS,$66.03 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$48.15 ,120.37% of custom fee schedule,$73.37 ,Pays 100% Medicare OPPS,$95.38 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$73.37 ,Pays 100% Medicare OPPS,$48.15 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,80299,FLECAINIDE LEVEL,301,$260.00 ,$221.00 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,88182,".FLOW CYTOMETRY, EA MARKER",300,$150.00 ,$127.50 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$80.60 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$45.53 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$83.82 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$80.60 ,120.37% of custom fee schedule,$44.10 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,86256,.FLUORESCENT NONINF TITER,302,$175.00 ,$148.75 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,87206,.FUNGUS STAIN,306,$135.00 ,$114.75 ,85% of total billed charges,$5.39 ,Pays 100% Medicare OPPS,$5.39 ,Pays 100% Medicare OPPS,$5.39 ,Pays 100% Medicare OPPS,$7.00 ,Pays 130% Medicare OPPS,$8.12 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.49 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.45 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.39 ,Pays 100% Medicare OPPS,$4.85 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$8.12 ,120.37% of custom fee schedule,$5.39 ,Pays 100% Medicare OPPS,$7.00 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.39 ,Pays 100% Medicare OPPS,$4.85 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,80199,TIAGABINE,301,$465.00 ,$395.25 ,85% of total billed charges,$27.11 ,Pays 100% Medicare OPPS,$27.11 ,Pays 100% Medicare OPPS,$27.11 ,Pays 100% Medicare OPPS,$35.24 ,Pays 130% Medicare OPPS,$7.88 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$27.65 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$8.20 ,125.18% of custom fee schedule,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$27.11 ,Pays 100% Medicare OPPS,$24.39 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$7.88 ,120.37% of custom fee schedule,$27.11 ,Pays 100% Medicare OPPS,$35.24 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$27.11 ,Pays 100% Medicare OPPS,$7.88 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,80307,Testing for presence of drug,301,$720.00 ,$612.00 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$73.62 ,20.37% based on GA Medicaid OP CCR Rate,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$63.38 ,Pays 102% Medicare OPPS,$648.00 ,90% of total billed charges,$76.56 ,125.18% of custom fee schedule,$494.64 ,68.7% of total billed charges,$576.00 ,80 percent of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,Pays 90% Medicare OPPS,$417.60 ,58% of total billed charges,$73.62 ,120.37% of custom fee schedule,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$612.00 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,$648.00 ,$576.00 
Outpatient Medical Services,LAB,87590,.GC (DNA PROBE),306,$190.00 ,$161.50 ,85% of total billed charges,$26.88 ,Pays 100% Medicare OPPS,$26.88 ,Pays 100% Medicare OPPS,$26.88 ,Pays 100% Medicare OPPS,$34.94 ,Pays 130% Medicare OPPS,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$27.41 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$66.50 ,35% based on GA Medicaid OP CCR Rate,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$26.88 ,Pays 100% Medicare OPPS,$24.19 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$26.88 ,Pays 100% Medicare OPPS,$34.94 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$26.88 ,Pays 100% Medicare OPPS,$24.19 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,83520,GD1a IgM,301,$525.00 ,$446.25 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,83520,GD1a IgG,301,$375.00 ,$318.75 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,86674,"GIARDIA, IgG, IgM (SERUM)",302,$275.00 ,$233.75 ,85% of total billed charges,$14.72 ,Pays 100% Medicare OPPS,$14.72 ,Pays 100% Medicare OPPS,$14.72 ,Pays 100% Medicare OPPS,$19.13 ,Pays 130% Medicare OPPS,$22.27 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$15.01 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$23.16 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$14.72 ,Pays 100% Medicare OPPS,$13.24 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$22.27 ,120.37% of custom fee schedule,$14.72 ,Pays 100% Medicare OPPS,$19.13 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$14.72 ,Pays 100% Medicare OPPS,$13.24 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,301,$125.00 ,$106.25 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,82950,Test of glucose level in the blood,301,$145.00 ,$123.25 ,85% of total billed charges,$4.75 ,Pays 100% Medicare OPPS,$4.75 ,Pays 100% Medicare OPPS,$4.75 ,Pays 100% Medicare OPPS,$6.17 ,Pays 130% Medicare OPPS,$7.20 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.84 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$7.49 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.75 ,Pays 100% Medicare OPPS,$4.27 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$7.20 ,120.37% of custom fee schedule,$4.75 ,Pays 100% Medicare OPPS,$6.17 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.75 ,Pays 100% Medicare OPPS,$4.27 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82945,GLUCOSE CSF,301,$145.00 ,$123.25 ,85% of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.93 ,Pays 100% Medicare OPPS,$3.93 ,Pays 100% Medicare OPPS,$5.10 ,Pays 130% Medicare OPPS,$5.93 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.00 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$6.17 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.53 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$5.93 ,120.37% of custom fee schedule,$3.93 ,Pays 100% Medicare OPPS,$5.10 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.53 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,83519,3RD GLUTAMIC ACID DECARBOXYLA,301,$575.00 ,$488.75 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$20.45 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$18.76 ,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$21.27 ,125.18% of custom fee schedule,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$20.45 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$517.50 ,$460.00 
Outpatient Medical Services,LAB,82747,RBC FOLATE,301,$245.00 ,$208.25 ,85% of total billed charges,$17.64 ,Pays 100% Medicare OPPS,$17.64 ,Pays 100% Medicare OPPS,$17.64 ,Pays 100% Medicare OPPS,$22.94 ,Pays 130% Medicare OPPS,$26.22 ,20.37% based on GA Medicaid OP CCR Rate,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$18.00 ,Pays 102% Medicare OPPS,$220.50 ,90% of total billed charges,$27.26 ,125.18% of custom fee schedule,$168.32 ,68.7% of total billed charges,$196.00 ,80 percent of total billed charges,$17.64 ,Pays 100% Medicare OPPS,$15.88 ,Pays 90% Medicare OPPS,$142.10 ,58% of total billed charges,$26.22 ,120.37% of custom fee schedule,$17.64 ,Pays 100% Medicare OPPS,$22.94 ,Pays 130% Medicare OPPS,$208.25 ,85% of total billed charges,$17.64 ,Pays 100% Medicare OPPS,$15.88 ,$220.50 ,$196.00 
Outpatient Medical Services,LAB,87329,".....GIARDIA ANTIGEN, STOOL",302,$275.00 ,$233.75 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$12.21 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,82951,Test to predict likelihood of gestational diabetes,301,$175.00 ,$148.75 ,85% of total billed charges,$12.87 ,Pays 100% Medicare OPPS,$12.87 ,Pays 100% Medicare OPPS,$12.87 ,Pays 100% Medicare OPPS,$16.73 ,Pays 130% Medicare OPPS,$19.49 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$13.12 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$20.27 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$12.87 ,Pays 100% Medicare OPPS,$11.58 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$19.49 ,120.37% of custom fee schedule,$12.87 ,Pays 100% Medicare OPPS,$16.73 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$12.87 ,Pays 100% Medicare OPPS,$11.58 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,86677,Blood test to if peptic ulcers are caused by a certain bacterium,302,$260.00 ,$221.00 ,85% of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$16.85 ,Pays 100% Medicare OPPS,$16.85 ,Pays 100% Medicare OPPS,$21.90 ,Pays 130% Medicare OPPS,$21.97 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$17.18 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$22.85 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$15.16 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$21.97 ,120.37% of custom fee schedule,$16.85 ,Pays 100% Medicare OPPS,$21.90 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$15.16 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,87158,HAEMOPHILUS ID,306,$50.00 ,$42.50 ,85% of total billed charges,$7.74 ,Pays 100% Medicare OPPS,$7.74 ,Pays 100% Medicare OPPS,$7.74 ,Pays 100% Medicare OPPS,$10.06 ,Pays 130% Medicare OPPS,$7.92 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$7.89 ,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$8.24 ,125.18% of custom fee schedule,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,$7.74 ,Pays 100% Medicare OPPS,$6.96 ,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$7.92 ,120.37% of custom fee schedule,$7.74 ,Pays 100% Medicare OPPS,$10.06 ,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,$7.74 ,Pays 100% Medicare OPPS,$6.96 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,80173,HALDOL LEVEL,301,$370.00 ,$314.50 ,85% of total billed charges,$15.78 ,Pays 100% Medicare OPPS,$15.78 ,Pays 100% Medicare OPPS,$15.78 ,Pays 100% Medicare OPPS,$20.51 ,Pays 130% Medicare OPPS,$22.04 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$16.09 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$22.92 ,125.18% of custom fee schedule,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$15.78 ,Pays 100% Medicare OPPS,$14.20 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$22.04 ,120.37% of custom fee schedule,$15.78 ,Pays 100% Medicare OPPS,$20.51 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$15.78 ,Pays 100% Medicare OPPS,$14.20 ,$333.00 ,$296.00 
Outpatient Medical Services,LAB,83015,HEAVY METALS (URINE),301,$195.00 ,$165.75 ,85% of total billed charges,$20.94 ,Pays 100% Medicare OPPS,$20.94 ,Pays 100% Medicare OPPS,$20.94 ,Pays 100% Medicare OPPS,$27.22 ,Pays 130% Medicare OPPS,$28.50 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$21.35 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$29.64 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$20.94 ,Pays 100% Medicare OPPS,$18.84 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$28.50 ,120.37% of custom fee schedule,$20.94 ,Pays 100% Medicare OPPS,$27.22 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$20.94 ,Pays 100% Medicare OPPS,$18.84 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,81223,.HEPATITIS AMP OF PNA,301,$690.00 ,$586.50 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,"$1,155.55 ",20.37% based on GA Medicaid OP CCR Rate,$389.85 ,56.5 percent of total billed charges,$389.85 ,56.5 percent of total billed charges,$389.85 ,56.5 percent of total billed charges,$389.85 ,56.5 percent of total billed charges,$508.98 ,Pays 102% Medicare OPPS,$621.00 ,90% of total billed charges,"$1,201.73 ",125.18% of custom fee schedule,$474.03 ,68.7% of total billed charges,$552.00 ,80 percent of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$449.10 ,Pays 90% Medicare OPPS,$400.20 ,58% of total billed charges,"$1,155.55 ",120.37% of custom fee schedule,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,$586.50 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$389.85 ,"$1,201.73 ",$552.00 
Outpatient Medical Services,LAB,87902,3RD HEPATITIS C GENOTYPE,300,$910.00 ,$773.50 ,85% of total billed charges,$257.45 ,Pays 100% Medicare OPPS,$257.45 ,Pays 100% Medicare OPPS,$257.45 ,Pays 100% Medicare OPPS,$334.68 ,Pays 130% Medicare OPPS,$132.01 ,20.37% based on GA Medicaid OP CCR Rate,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,$262.59 ,Pays 102% Medicare OPPS,$819.00 ,90% of total billed charges,$137.28 ,125.18% of custom fee schedule,$625.17 ,68.7% of total billed charges,$728.00 ,80 percent of total billed charges,$257.45 ,Pays 100% Medicare OPPS,$231.70 ,Pays 90% Medicare OPPS,$527.80 ,58% of total billed charges,$132.01 ,120.37% of custom fee schedule,$257.45 ,Pays 100% Medicare OPPS,$334.68 ,Pays 130% Medicare OPPS,$773.50 ,85% of total billed charges,$257.45 ,Pays 100% Medicare OPPS,$132.01 ,$819.00 ,$728.00 
Outpatient Medical Services,LAB,86790,HERPES AB TYP I IgM,302,$195.00 ,$165.75 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,87530,HERPES SPINAL FLUID,300,$950.00 ,$807.50 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$193.52 ,20.37% based on GA Medicaid OP CCR Rate,$536.75 ,56.5 percent of total billed charges,$536.75 ,56.5 percent of total billed charges,$536.75 ,56.5 percent of total billed charges,$536.75 ,56.5 percent of total billed charges,$43.69 ,Pays 102% Medicare OPPS,$855.00 ,90% of total billed charges,$332.50 ,35% based on GA Medicaid OP CCR Rate,$652.65 ,68.7% of total billed charges,$760.00 ,80 percent of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,Pays 90% Medicare OPPS,$551.00 ,58% of total billed charges,$193.52 ,20.37% based on GA Medicaid OP CCR Rate,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$807.50 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,$855.00 ,$760.00 
Outpatient Medical Services,LAB,87901,3RD HIV GENOTYPE,300,"$1,360.00 ","$1,156.00 ",85% of total billed charges,$257.45 ,Pays 100% Medicare OPPS,$257.45 ,Pays 100% Medicare OPPS,$257.45 ,Pays 100% Medicare OPPS,$334.68 ,Pays 130% Medicare OPPS,$132.01 ,20.37% based on GA Medicaid OP CCR Rate,$768.40 ,56.5 percent of total billed charges,$768.40 ,56.5 percent of total billed charges,$768.40 ,56.5 percent of total billed charges,$768.40 ,56.5 percent of total billed charges,$262.59 ,Pays 102% Medicare OPPS,"$1,224.00 ",90% of total billed charges,$137.28 ,125.18% of custom fee schedule,$934.32 ,68.7% of total billed charges,"$1,088.00 ",80 percent of total billed charges,$257.45 ,Pays 100% Medicare OPPS,$231.70 ,Pays 90% Medicare OPPS,$788.80 ,58% of total billed charges,$132.01 ,120.37% of custom fee schedule,$257.45 ,Pays 100% Medicare OPPS,$334.68 ,Pays 130% Medicare OPPS,"$1,156.00 ",85% of total billed charges,$257.45 ,Pays 100% Medicare OPPS,$132.01 ,"$1,224.00 ","$1,088.00 "
Outpatient Medical Services,LAB,87389,Test for HIV,300,$100.00 ,$85.00 ,85% of total billed charges,$24.08 ,Pays 100% Medicare OPPS,$24.08 ,Pays 100% Medicare OPPS,$24.08 ,Pays 100% Medicare OPPS,$31.30 ,Pays 130% Medicare OPPS,$32.86 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$24.56 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$34.17 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$24.08 ,Pays 100% Medicare OPPS,$21.67 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$32.86 ,120.37% of custom fee schedule,$24.08 ,Pays 100% Medicare OPPS,$31.30 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$24.08 ,Pays 100% Medicare OPPS,$21.67 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,87536,3RD HIV VIRAL LOAD,306,$820.00 ,$697.00 ,85% of total billed charges,$85.10 ,Pays 100% Medicare OPPS,$85.10 ,Pays 100% Medicare OPPS,$85.10 ,Pays 100% Medicare OPPS,$110.63 ,Pays 130% Medicare OPPS,$68.01 ,20.37% based on GA Medicaid OP CCR Rate,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$86.80 ,Pays 102% Medicare OPPS,$738.00 ,90% of total billed charges,$70.73 ,125.18% of custom fee schedule,$563.34 ,68.7% of total billed charges,$656.00 ,80 percent of total billed charges,$85.10 ,Pays 100% Medicare OPPS,$76.58 ,Pays 90% Medicare OPPS,$475.60 ,58% of total billed charges,$68.01 ,120.37% of custom fee schedule,$85.10 ,Pays 100% Medicare OPPS,$110.63 ,Pays 130% Medicare OPPS,$697.00 ,85% of total billed charges,$85.10 ,Pays 100% Medicare OPPS,$68.01 ,$738.00 ,$656.00 
Outpatient Medical Services,LAB,86790,HTLV I/II,300,$320.00 ,$272.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80329,IBUPROFEN LEVEL,301,$325.00 ,$276.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$30.63 ,20.37% based on GA Medicaid OP CCR Rate,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$292.50 ,90% of total billed charges,$31.86 ,125.18% of custom fee schedule,$223.28 ,68.7% of total billed charges,$260.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$188.50 ,58% of total billed charges,$30.63 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$276.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$30.63 ,$292.50 ,$260.00 
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,301,$175.00 ,$148.75 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$14.07 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$9.48 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$14.63 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$14.07 ,120.37% of custom fee schedule,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,301,$190.00 ,$161.50 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$14.07 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$9.48 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$14.63 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$14.07 ,120.37% of custom fee schedule,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,301,$175.00 ,$148.75 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$14.07 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$9.48 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$14.63 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$14.07 ,120.37% of custom fee schedule,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,301,$320.00 ,$272.00 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$14.07 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$9.48 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$14.63 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$14.07 ,120.37% of custom fee schedule,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,83520,.IMMUNOASSAY NOT SPECIFIED,300,$75.00 ,$63.75 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$67.50 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$51.53 ,68.7% of total billed charges,$60.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$43.50 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$63.75 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$67.50 ,$60.00 
Outpatient Medical Services,LAB,83520,".IMMUNOASSAY QUANT,NOT SPE",301,$175.00 ,$148.75 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,83883,3RD KAPPA/LAMBDA CHAINS URINE,302,$375.00 ,$318.75 ,85% of total billed charges,$13.60 ,Pays 100% Medicare OPPS,$13.60 ,Pays 100% Medicare OPPS,$13.60 ,Pays 100% Medicare OPPS,$17.68 ,Pays 130% Medicare OPPS,$20.58 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$13.87 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$21.41 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$13.60 ,Pays 100% Medicare OPPS,$12.24 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$20.58 ,120.37% of custom fee schedule,$13.60 ,Pays 100% Medicare OPPS,$17.68 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$13.60 ,Pays 100% Medicare OPPS,$12.24 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,86334,.IMMUNOFIX ELEC (SPEP W IM,302,$215.00 ,$182.75 ,85% of total billed charges,$22.34 ,Pays 100% Medicare OPPS,$22.34 ,Pays 100% Medicare OPPS,$22.34 ,Pays 100% Medicare OPPS,$29.04 ,Pays 130% Medicare OPPS,$33.81 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$22.78 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$35.16 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$22.34 ,Pays 100% Medicare OPPS,$20.10 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$33.81 ,120.37% of custom fee schedule,$22.34 ,Pays 100% Medicare OPPS,$29.04 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$22.34 ,Pays 100% Medicare OPPS,$20.10 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,84166,IMMUNOFIXATION URINE+UPEP,302,$375.00 ,$318.75 ,85% of total billed charges,$17.82 ,Pays 100% Medicare OPPS,$17.82 ,Pays 100% Medicare OPPS,$17.82 ,Pays 100% Medicare OPPS,$23.17 ,Pays 130% Medicare OPPS,$27.00 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$18.18 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$28.08 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$17.82 ,Pays 100% Medicare OPPS,$16.04 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$27.00 ,120.37% of custom fee schedule,$17.82 ,Pays 100% Medicare OPPS,$23.17 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$17.82 ,Pays 100% Medicare OPPS,$16.04 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,87210,A lab test to screen for evidence of vaginal infection,306,$110.00 ,$93.50 ,85% of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.82 ,Pays 100% Medicare OPPS,$5.82 ,Pays 100% Medicare OPPS,$7.56 ,Pays 130% Medicare OPPS,$6.45 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$5.93 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$6.71 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.23 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$6.45 ,120.37% of custom fee schedule,$5.82 ,Pays 100% Medicare OPPS,$7.56 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.23 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,87798,.INFECTIOUS AGENT BY NA AP,306,$525.00 ,$446.25 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$29.70 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$30.88 ,125.18% of custom fee schedule,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$29.70 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$29.70 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,87400,.INFLUENZA B RAPID TEST,300,$135.00 ,$114.75 ,85% of total billed charges,$14.13 ,Pays 100% Medicare OPPS,$14.13 ,Pays 100% Medicare OPPS,$14.13 ,Pays 100% Medicare OPPS,$18.36 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$14.41 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$14.13 ,Pays 100% Medicare OPPS,$12.71 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$14.13 ,Pays 100% Medicare OPPS,$18.36 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$14.13 ,Pays 100% Medicare OPPS,$12.71 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86710,INFLUENZA B VIRUS AB,302,$345.00 ,$293.25 ,85% of total billed charges,$13.55 ,Pays 100% Medicare OPPS,$13.55 ,Pays 100% Medicare OPPS,$13.55 ,Pays 100% Medicare OPPS,$17.61 ,Pays 130% Medicare OPPS,$20.52 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$13.82 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$21.34 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$13.55 ,Pays 100% Medicare OPPS,$12.19 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$20.52 ,120.37% of custom fee schedule,$13.55 ,Pays 100% Medicare OPPS,$17.61 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$13.55 ,Pays 100% Medicare OPPS,$12.19 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,301,$95.00 ,$80.75 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$14.07 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$9.48 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$14.63 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$14.07 ,120.37% of custom fee schedule,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,86235,JO-1 ANTIBODY,302,$190.00 ,$161.50 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,80299,3RD LAMICTAL LEVEL,301,$375.00 ,$318.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,80299,3RD LAMOTRIGINE LEVEL,301,$370.00 ,$314.50 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$333.00 ,$296.00 
Outpatient Medical Services,LAB,86039,Blood test to determine autoimmune disorders,302,$260.00 ,$221.00 ,85% of total billed charges,$11.16 ,Pays 100% Medicare OPPS,$11.16 ,Pays 100% Medicare OPPS,$11.16 ,Pays 100% Medicare OPPS,$14.50 ,Pays 130% Medicare OPPS,$16.90 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$11.38 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$17.58 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$11.16 ,Pays 100% Medicare OPPS,$10.04 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$16.90 ,120.37% of custom fee schedule,$11.16 ,Pays 100% Medicare OPPS,$14.50 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$11.16 ,Pays 100% Medicare OPPS,$10.04 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,83655,Blood test to determine the concentration of lead in the blood,301,$240.00 ,$204.00 ,85% of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$12.11 ,Pays 100% Medicare OPPS,$12.11 ,Pays 100% Medicare OPPS,$15.74 ,Pays 130% Medicare OPPS,$12.04 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$12.35 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$12.52 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$10.89 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$12.04 ,120.37% of custom fee schedule,$12.11 ,Pays 100% Medicare OPPS,$15.74 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$10.89 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,80177,LEVETIRACETAM,301,$575.00 ,$488.75 ,85% of total billed charges,$13.25 ,Pays 100% Medicare OPPS,$13.25 ,Pays 100% Medicare OPPS,$13.25 ,Pays 100% Medicare OPPS,$17.22 ,Pays 130% Medicare OPPS,$17.42 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$13.51 ,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$18.11 ,125.18% of custom fee schedule,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,$13.25 ,Pays 100% Medicare OPPS,$11.92 ,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$17.42 ,120.37% of custom fee schedule,$13.25 ,Pays 100% Medicare OPPS,$17.22 ,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,$13.25 ,Pays 100% Medicare OPPS,$11.92 ,$517.50 ,$460.00 
Outpatient Medical Services,LAB,83704,LIPOMED (NMR),301,$415.00 ,$352.75 ,85% of total billed charges,$34.19 ,Pays 100% Medicare OPPS,$34.19 ,Pays 100% Medicare OPPS,$34.19 ,Pays 100% Medicare OPPS,$44.44 ,Pays 130% Medicare OPPS,$47.75 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$34.87 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$49.66 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$34.19 ,Pays 100% Medicare OPPS,$30.77 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$47.75 ,120.37% of custom fee schedule,$34.19 ,Pays 100% Medicare OPPS,$44.44 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$34.19 ,Pays 100% Medicare OPPS,$30.77 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,83735,MAGNESIUM URINE W/CREATININE,301,$165.00 ,$140.25 ,85% of total billed charges,$6.70 ,Pays 100% Medicare OPPS,$6.70 ,Pays 100% Medicare OPPS,$6.70 ,Pays 100% Medicare OPPS,$8.71 ,Pays 130% Medicare OPPS,$10.14 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$6.83 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$10.54 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$6.70 ,Pays 100% Medicare OPPS,$6.03 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$10.14 ,120.37% of custom fee schedule,$6.70 ,Pays 100% Medicare OPPS,$8.71 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$6.70 ,Pays 100% Medicare OPPS,$6.03 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,87207,3RD MALARIA SMEAR,306,$135.00 ,$114.75 ,85% of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.99 ,Pays 100% Medicare OPPS,$5.99 ,Pays 100% Medicare OPPS,$7.78 ,Pays 130% Medicare OPPS,$9.06 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$6.10 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$9.43 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.39 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$9.06 ,120.37% of custom fee schedule,$5.99 ,Pays 100% Medicare OPPS,$7.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.39 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,83825,MERCURY BLOOD,301,$190.00 ,$161.50 ,85% of total billed charges,$16.26 ,Pays 100% Medicare OPPS,$16.26 ,Pays 100% Medicare OPPS,$16.26 ,Pays 100% Medicare OPPS,$21.13 ,Pays 130% Medicare OPPS,$24.62 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$16.58 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$25.60 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$16.26 ,Pays 100% Medicare OPPS,$14.63 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$24.62 ,120.37% of custom fee schedule,$16.26 ,Pays 100% Medicare OPPS,$21.13 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$16.26 ,Pays 100% Medicare OPPS,$14.63 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,83835,"3RD METANEPHRINES,PLASMA",301,"$1,590.00 ","$1,351.50 ",85% of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$16.94 ,Pays 100% Medicare OPPS,$16.94 ,Pays 100% Medicare OPPS,$22.02 ,Pays 130% Medicare OPPS,$25.64 ,20.37% based on GA Medicaid OP CCR Rate,$898.35 ,56.5 percent of total billed charges,$898.35 ,56.5 percent of total billed charges,$898.35 ,56.5 percent of total billed charges,$898.35 ,56.5 percent of total billed charges,$17.27 ,Pays 102% Medicare OPPS,"$1,431.00 ",90% of total billed charges,$26.66 ,125.18% of custom fee schedule,"$1,092.33 ",68.7% of total billed charges,"$1,272.00 ",80 percent of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$15.24 ,Pays 90% Medicare OPPS,$922.20 ,58% of total billed charges,$25.64 ,120.37% of custom fee schedule,$16.94 ,Pays 100% Medicare OPPS,$22.02 ,Pays 130% Medicare OPPS,"$1,351.50 ",85% of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$15.24 ,"$1,431.00 ","$1,272.00 "
Outpatient Medical Services,LAB,80299,"METHOTREXATE, SERUM",301,$310.00 ,$263.50 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,80299,MEXILETINE  LEVEL,301,$365.00 ,$310.25 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86780,Blood test to determine existence of certain bacterium that causes syphilis,302,$320.00 ,$272.00 ,85% of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$13.24 ,Pays 100% Medicare OPPS,$13.24 ,Pays 100% Medicare OPPS,$17.21 ,Pays 130% Medicare OPPS,$65.18 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.50 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$112.00 ,35% based on GA Medicaid OP CCR Rate,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$11.91 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$65.18 ,20.37% based on GA Medicaid OP CCR Rate,$13.24 ,Pays 100% Medicare OPPS,$17.21 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$11.91 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,81223,MOLECULAR DGN AMP (C FG X,301,$305.00 ,$259.25 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,"$1,155.55 ",20.37% based on GA Medicaid OP CCR Rate,$172.33 ,56.5 percent of total billed charges,$172.33 ,56.5 percent of total billed charges,$172.33 ,56.5 percent of total billed charges,$172.33 ,56.5 percent of total billed charges,$508.98 ,Pays 102% Medicare OPPS,$274.50 ,90% of total billed charges,"$1,201.73 ",125.18% of custom fee schedule,$209.54 ,68.7% of total billed charges,$244.00 ,80 percent of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$449.10 ,Pays 90% Medicare OPPS,$176.90 ,58% of total billed charges,"$1,155.55 ",120.37% of custom fee schedule,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,$259.25 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$172.33 ,"$1,201.73 ",$244.00 
Outpatient Medical Services,LAB,83892,MOLECULAR DGN ENZ,301,$210.00 ,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$73.50 ,35% based on GA Medicaid OP CCR Rate,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$42.78 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,83892,MOLECULAR DGN ENZ (C FG X,301,$65.00 ,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$22.75 ,35% based on GA Medicaid OP CCR Rate,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$13.24 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,83986,PH  BODY FLUID LEVEL,301,$135.00 ,$114.75 ,85% of total billed charges,$3.58 ,Pays 100% Medicare OPPS,$3.58 ,Pays 100% Medicare OPPS,$3.58 ,Pays 100% Medicare OPPS,$4.65 ,Pays 130% Medicare OPPS,$5.42 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$3.65 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$5.63 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$3.58 ,Pays 100% Medicare OPPS,$3.22 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$5.42 ,120.37% of custom fee schedule,$3.58 ,Pays 100% Medicare OPPS,$4.65 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$3.58 ,Pays 100% Medicare OPPS,$3.22 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,83894,MOLECULAR DGN SEP (C FG X,301,$65.00 ,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$22.75 ,35% based on GA Medicaid OP CCR Rate,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$13.24 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,83890,MOLECULAR DIAG (C FRAG X),301,$65.00 ,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$22.75 ,35% based on GA Medicaid OP CCR Rate,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$13.24 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,81223,"MOLECULAR DIAG, AMP PNA,1",301,$80.00 ,$68.00 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,"$1,155.55 ",20.37% based on GA Medicaid OP CCR Rate,$45.20 ,56.5 percent of total billed charges,$45.20 ,56.5 percent of total billed charges,$45.20 ,56.5 percent of total billed charges,$45.20 ,56.5 percent of total billed charges,$508.98 ,Pays 102% Medicare OPPS,$72.00 ,90% of total billed charges,"$1,201.73 ",125.18% of custom fee schedule,$54.96 ,68.7% of total billed charges,$64.00 ,80 percent of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$449.10 ,Pays 90% Medicare OPPS,$46.40 ,58% of total billed charges,"$1,155.55 ",120.37% of custom fee schedule,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,$68.00 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$45.20 ,"$1,201.73 ",$64.00 
Outpatient Medical Services,LAB,81223,"MOLECULAR DIAG, AMP PNA,1",301,$210.00 ,$178.50 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,"$1,155.55 ",20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$508.98 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,"$1,201.73 ",125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$449.10 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,"$1,155.55 ",120.37% of custom fee schedule,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$118.65 ,"$1,201.73 ",$168.00 
Outpatient Medical Services,LAB,83912,"MOLECULAR DIAG, INTERPRET",301,$210.00 ,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$73.50 ,35% based on GA Medicaid OP CCR Rate,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$42.78 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,83912,"MOLECULAR DIAG, INTERPRET",301,$45.00 ,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$40.50 ,90% of total billed charges,$15.75 ,35% based on GA Medicaid OP CCR Rate,$30.92 ,68.7% of total billed charges,$36.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$26.10 ,58% of total billed charges,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$9.17 ,$40.50 ,$36.00 
Outpatient Medical Services,LAB,83890,"MOLECULAR DIAG, ISOLATION",301,$45.00 ,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$40.50 ,90% of total billed charges,$15.75 ,35% based on GA Medicaid OP CCR Rate,$30.92 ,68.7% of total billed charges,$36.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$26.10 ,58% of total billed charges,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$9.17 ,$40.50 ,$36.00 
Outpatient Medical Services,LAB,83896,"MOLECULAR DIAG, NAP",301,$45.00 ,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$40.50 ,90% of total billed charges,$15.75 ,35% based on GA Medicaid OP CCR Rate,$30.92 ,68.7% of total billed charges,$36.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$26.10 ,58% of total billed charges,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$9.17 ,$40.50 ,$36.00 
Outpatient Medical Services,LAB,83901,"MOLECULAR DIAG,AMP PNA",301,$140.00 ,$119.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$28.52 ,20.37% based on GA Medicaid OP CCR Rate,$79.10 ,56.5 percent of total billed charges,$79.10 ,56.5 percent of total billed charges,$79.10 ,56.5 percent of total billed charges,$79.10 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$126.00 ,90% of total billed charges,$49.00 ,35% based on GA Medicaid OP CCR Rate,$96.18 ,68.7% of total billed charges,$112.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$81.20 ,58% of total billed charges,$28.52 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$119.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$28.52 ,$126.00 ,$112.00 
Outpatient Medical Services,LAB,83893,"MOLECULAR DIAG,DOT/SLOT B",301,$65.00 ,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$22.75 ,35% based on GA Medicaid OP CCR Rate,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$13.24 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,83891,"MOLECULAR DIAG,ISO/EX PNA",301,$65.00 ,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$22.75 ,35% based on GA Medicaid OP CCR Rate,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$13.24 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,83864,MUCOPOLYSACCHARIDES URINE QUANT,301,$260.00 ,$221.00 ,85% of total billed charges,$28.50 ,Pays 100% Medicare OPPS,$28.50 ,Pays 100% Medicare OPPS,$28.50 ,Pays 100% Medicare OPPS,$37.05 ,Pays 130% Medicare OPPS,$16.26 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$29.07 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$16.91 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$28.50 ,Pays 100% Medicare OPPS,$25.65 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$16.26 ,120.37% of custom fee schedule,$28.50 ,Pays 100% Medicare OPPS,$37.05 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$28.50 ,Pays 100% Medicare OPPS,$16.26 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86735,MUMPS VIRUS IGM ANTIBODY,302,$365.00 ,$310.25 ,85% of total billed charges,$13.05 ,Pays 100% Medicare OPPS,$13.05 ,Pays 100% Medicare OPPS,$13.05 ,Pays 100% Medicare OPPS,$16.96 ,Pays 130% Medicare OPPS,$19.75 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$13.31 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$20.54 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$13.05 ,Pays 100% Medicare OPPS,$11.74 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$19.75 ,120.37% of custom fee schedule,$13.05 ,Pays 100% Medicare OPPS,$16.96 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$13.05 ,Pays 100% Medicare OPPS,$11.74 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,87206,.MYCOBACTERIA STAIN,306,$135.00 ,$114.75 ,85% of total billed charges,$5.39 ,Pays 100% Medicare OPPS,$5.39 ,Pays 100% Medicare OPPS,$5.39 ,Pays 100% Medicare OPPS,$7.00 ,Pays 130% Medicare OPPS,$8.12 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.49 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.45 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.39 ,Pays 100% Medicare OPPS,$4.85 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$8.12 ,120.37% of custom fee schedule,$5.39 ,Pays 100% Medicare OPPS,$7.00 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.39 ,Pays 100% Medicare OPPS,$4.85 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86738,MYCOPLASMA PNEUMONIAE/IgM,302,$240.00 ,$204.00 ,85% of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$13.24 ,Pays 100% Medicare OPPS,$13.24 ,Pays 100% Medicare OPPS,$17.21 ,Pays 130% Medicare OPPS,$20.05 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$13.50 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$20.85 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$11.91 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$20.05 ,120.37% of custom fee schedule,$13.24 ,Pays 100% Medicare OPPS,$17.21 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$11.91 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,83874,MYOGLOBIN URINE,301,$320.00 ,$272.00 ,85% of total billed charges,$12.92 ,Pays 100% Medicare OPPS,$12.92 ,Pays 100% Medicare OPPS,$12.92 ,Pays 100% Medicare OPPS,$16.79 ,Pays 130% Medicare OPPS,$19.55 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.17 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$20.33 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.92 ,Pays 100% Medicare OPPS,$11.62 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$19.55 ,120.37% of custom fee schedule,$12.92 ,Pays 100% Medicare OPPS,$16.79 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.92 ,Pays 100% Medicare OPPS,$11.62 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80171,3RD GABAPENTIN,301,$345.00 ,$293.25 ,85% of total billed charges,$21.67 ,Pays 100% Medicare OPPS,$21.67 ,Pays 100% Medicare OPPS,$21.67 ,Pays 100% Medicare OPPS,$28.17 ,Pays 130% Medicare OPPS,$17.42 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$22.10 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$18.11 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$21.67 ,Pays 100% Medicare OPPS,$19.50 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$17.42 ,120.37% of custom fee schedule,$21.67 ,Pays 100% Medicare OPPS,$28.17 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$21.67 ,Pays 100% Medicare OPPS,$17.42 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,84591,NIACIN LEVEL,301,$500.00 ,$425.00 ,85% of total billed charges,$17.05 ,Pays 100% Medicare OPPS,$17.05 ,Pays 100% Medicare OPPS,$17.05 ,Pays 100% Medicare OPPS,$22.17 ,Pays 130% Medicare OPPS,$17.55 ,20.37% based on GA Medicaid OP CCR Rate,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$17.40 ,Pays 102% Medicare OPPS,$450.00 ,90% of total billed charges,$18.25 ,125.18% of custom fee schedule,$343.50 ,68.7% of total billed charges,$400.00 ,80 percent of total billed charges,$17.05 ,Pays 100% Medicare OPPS,$15.35 ,Pays 90% Medicare OPPS,$290.00 ,58% of total billed charges,$17.55 ,120.37% of custom fee schedule,$17.05 ,Pays 100% Medicare OPPS,$22.17 ,Pays 130% Medicare OPPS,$425.00 ,85% of total billed charges,$17.05 ,Pays 100% Medicare OPPS,$15.35 ,$450.00 ,$400.00 
Outpatient Medical Services,LAB,80365,"OXYCONTIN, QUANTITATIVE LEVEL",301,$575.00 ,$488.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$201.25 ,35% based on GA Medicaid OP CCR Rate,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$117.13 ,$517.50 ,$460.00 
Outpatient Medical Services,LAB,83519,PANCREASTIN LEVEL,301,$885.00 ,$752.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$20.45 ,20.37% based on GA Medicaid OP CCR Rate,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$18.76 ,Pays 102% Medicare OPPS,$796.50 ,90% of total billed charges,$21.27 ,125.18% of custom fee schedule,$608.00 ,68.7% of total billed charges,$708.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$513.30 ,58% of total billed charges,$20.45 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$752.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$796.50 ,$708.00 
Outpatient Medical Services,LAB,86747,.PARVOVIRUS PANEL IGM,302,$150.00 ,$127.50 ,85% of total billed charges,$15.03 ,Pays 100% Medicare OPPS,$15.03 ,Pays 100% Medicare OPPS,$15.03 ,Pays 100% Medicare OPPS,$19.53 ,Pays 130% Medicare OPPS,$22.75 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$15.33 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$23.66 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$15.03 ,Pays 100% Medicare OPPS,$13.52 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$22.75 ,120.37% of custom fee schedule,$15.03 ,Pays 100% Medicare OPPS,$19.53 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$15.03 ,Pays 100% Medicare OPPS,$13.52 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,88312,Blood test to assist with diagnosis,312,$375.00 ,$318.75 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$52.23 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$45.53 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$54.32 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$52.23 ,120.37% of custom fee schedule,$44.10 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,86003,PENICILLIN V IGE,302,$165.00 ,$140.25 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,84681,C- PEPTIDE,301,$415.00 ,$352.75 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$24.05 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$21.22 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$25.01 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$24.05 ,120.37% of custom fee schedule,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,82775,GALACTOSE 1-PHOSPHATE URIDYLTRANSFERASE,301,$795.00 ,$675.75 ,85% of total billed charges,$21.07 ,Pays 100% Medicare OPPS,$21.07 ,Pays 100% Medicare OPPS,$21.07 ,Pays 100% Medicare OPPS,$27.39 ,Pays 130% Medicare OPPS,$31.89 ,20.37% based on GA Medicaid OP CCR Rate,$449.18 ,56.5 percent of total billed charges,$449.18 ,56.5 percent of total billed charges,$449.18 ,56.5 percent of total billed charges,$449.18 ,56.5 percent of total billed charges,$21.49 ,Pays 102% Medicare OPPS,$715.50 ,90% of total billed charges,$33.16 ,125.18% of custom fee schedule,$546.17 ,68.7% of total billed charges,$636.00 ,80 percent of total billed charges,$21.07 ,Pays 100% Medicare OPPS,$18.96 ,Pays 90% Medicare OPPS,$461.10 ,58% of total billed charges,$31.89 ,120.37% of custom fee schedule,$21.07 ,Pays 100% Medicare OPPS,$27.39 ,Pays 130% Medicare OPPS,$675.75 ,85% of total billed charges,$21.07 ,Pays 100% Medicare OPPS,$18.96 ,$715.50 ,$636.00 
Outpatient Medical Services,LAB,85420,...PLASMIN,305,$435.00 ,$369.75 ,85% of total billed charges,$6.53 ,Pays 100% Medicare OPPS,$6.53 ,Pays 100% Medicare OPPS,$6.53 ,Pays 100% Medicare OPPS,$8.48 ,Pays 130% Medicare OPPS,$9.89 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$6.66 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$10.29 ,125.18% of custom fee schedule,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$6.53 ,Pays 100% Medicare OPPS,$5.87 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$9.89 ,120.37% of custom fee schedule,$6.53 ,Pays 100% Medicare OPPS,$8.48 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$6.53 ,Pays 100% Medicare OPPS,$5.87 ,$391.50 ,$348.00 
Outpatient Medical Services,LAB,84106,3RD PORPHYRIN RANDOM URINE,301,$295.00 ,$250.75 ,85% of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.82 ,Pays 100% Medicare OPPS,$5.82 ,Pays 100% Medicare OPPS,$7.56 ,Pays 130% Medicare OPPS,$6.49 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$5.93 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$6.75 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.23 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$6.49 ,120.37% of custom fee schedule,$5.82 ,Pays 100% Medicare OPPS,$7.56 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.23 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,80299,PROLIXIN LVL/FLUPHENAZINE,301,$575.00 ,$488.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$517.50 ,$460.00 
Outpatient Medical Services,LAB,80367,PROPOXYPHENE (DARVON) LEVEL,301,$635.00 ,$539.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$129.35 ,20.37% based on GA Medicaid OP CCR Rate,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$571.50 ,90% of total billed charges,$222.25 ,35% based on GA Medicaid OP CCR Rate,$436.25 ,68.7% of total billed charges,$508.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$368.30 ,58% of total billed charges,$129.35 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$539.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$129.35 ,$571.50 ,$508.00 
Outpatient Medical Services,LAB,84165,.PROTEIN ELECT (IMMUNO),301,$135.00 ,$114.75 ,85% of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$10.74 ,Pays 100% Medicare OPPS,$10.74 ,Pays 100% Medicare OPPS,$13.96 ,Pays 130% Medicare OPPS,$16.26 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$10.95 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$16.91 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$9.66 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$16.26 ,120.37% of custom fee schedule,$10.74 ,Pays 100% Medicare OPPS,$13.96 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$9.66 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,84157,PROTEIN BODY FLUID,300,$135.00 ,$114.75 ,85% of total billed charges,$4.00 ,Pays 100% Medicare OPPS,$4.00 ,Pays 100% Medicare OPPS,$4.00 ,Pays 100% Medicare OPPS,$5.20 ,Pays 130% Medicare OPPS,$5.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.08 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$5.77 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.00 ,Pays 100% Medicare OPPS,$3.60 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$5.55 ,120.37% of custom fee schedule,$4.00 ,Pays 100% Medicare OPPS,$5.20 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$4.00 ,Pays 100% Medicare OPPS,$3.60 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,81240,PROTHROMBIN MUTATION,300,$300.00 ,$255.00 ,85% of total billed charges,$65.69 ,Pays 100% Medicare OPPS,$65.69 ,Pays 100% Medicare OPPS,$65.69 ,Pays 100% Medicare OPPS,$85.39 ,Pays 130% Medicare OPPS,$48.15 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$67.00 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$50.07 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$65.69 ,Pays 100% Medicare OPPS,$59.12 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$48.15 ,120.37% of custom fee schedule,$65.69 ,Pays 100% Medicare OPPS,$85.39 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$65.69 ,Pays 100% Medicare OPPS,$48.15 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,80299,PROZAC (FLUOXETINE),301,$590.00 ,$501.50 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$531.00 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$405.33 ,68.7% of total billed charges,$472.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$342.20 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$501.50 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$531.00 ,$472.00 
Outpatient Medical Services,LAB,83970,PTH INTRAOPERATIVE,301,$525.00 ,$446.25 ,85% of total billed charges,$41.28 ,Pays 100% Medicare OPPS,$41.28 ,Pays 100% Medicare OPPS,$41.28 ,Pays 100% Medicare OPPS,$53.66 ,Pays 130% Medicare OPPS,$62.47 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$42.10 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$64.97 ,125.18% of custom fee schedule,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$41.28 ,Pays 100% Medicare OPPS,$37.15 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$62.47 ,120.37% of custom fee schedule,$41.28 ,Pays 100% Medicare OPPS,$53.66 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$41.28 ,Pays 100% Medicare OPPS,$37.15 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,86430,.RA W/(ARTHRITIS PROFILE),302,$85.00 ,$72.25 ,85% of total billed charges,$6.14 ,Pays 100% Medicare OPPS,$6.14 ,Pays 100% Medicare OPPS,$6.14 ,Pays 100% Medicare OPPS,$7.98 ,Pays 130% Medicare OPPS,$8.59 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$6.26 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$8.94 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$6.14 ,Pays 100% Medicare OPPS,$5.52 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$8.59 ,120.37% of custom fee schedule,$6.14 ,Pays 100% Medicare OPPS,$7.98 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$6.14 ,Pays 100% Medicare OPPS,$5.52 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,86790,RABIES ANTIBODY,302,$320.00 ,$272.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80195,3RD RAPAMYCIN/SIROLIMUS,300,$565.00 ,$480.25 ,85% of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$13.73 ,Pays 100% Medicare OPPS,$13.73 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$20.76 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$14.00 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$21.59 ,125.18% of custom fee schedule,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$12.35 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$20.76 ,120.37% of custom fee schedule,$13.73 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$12.35 ,$508.50 ,$452.00 
Outpatient Medical Services,LAB,86003,RAST EACH ALLERGEN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,84999,"3RD REDUCING SUBSTANCES,STOOL",301,$145.00 ,$123.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$29.54 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$50.75 ,35% based on GA Medicaid OP CCR Rate,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$29.54 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$29.54 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,86256,...ZRETICULIN,300,$320.00 ,$272.00 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,86256,RH ANTIBODY TITER,302,$175.00 ,$148.75 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,84182,RI ANTIBODIES,301,"$1,065.00 ",$905.25 ,85% of total billed charges,$29.21 ,Pays 100% Medicare OPPS,$29.21 ,Pays 100% Medicare OPPS,$29.21 ,Pays 100% Medicare OPPS,$37.97 ,Pays 130% Medicare OPPS,$27.25 ,20.37% based on GA Medicaid OP CCR Rate,$601.73 ,56.5 percent of total billed charges,$601.73 ,56.5 percent of total billed charges,$601.73 ,56.5 percent of total billed charges,$601.73 ,56.5 percent of total billed charges,$29.79 ,Pays 102% Medicare OPPS,$958.50 ,90% of total billed charges,$28.34 ,125.18% of custom fee schedule,$731.66 ,68.7% of total billed charges,$852.00 ,80 percent of total billed charges,$29.21 ,Pays 100% Medicare OPPS,$26.28 ,Pays 90% Medicare OPPS,$617.70 ,58% of total billed charges,$27.25 ,120.37% of custom fee schedule,$29.21 ,Pays 100% Medicare OPPS,$37.97 ,Pays 130% Medicare OPPS,$905.25 ,85% of total billed charges,$29.21 ,Pays 100% Medicare OPPS,$26.28 ,$958.50 ,$852.00 
Outpatient Medical Services,LAB,84252,RIBOFLAVIN (VITAMIN B-2),301,$650.00 ,$552.50 ,85% of total billed charges,$20.23 ,Pays 100% Medicare OPPS,$20.23 ,Pays 100% Medicare OPPS,$20.23 ,Pays 100% Medicare OPPS,$26.31 ,Pays 130% Medicare OPPS,$30.63 ,20.37% based on GA Medicaid OP CCR Rate,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$20.64 ,Pays 102% Medicare OPPS,$585.00 ,90% of total billed charges,$31.86 ,125.18% of custom fee schedule,$446.55 ,68.7% of total billed charges,$520.00 ,80 percent of total billed charges,$20.23 ,Pays 100% Medicare OPPS,$18.21 ,Pays 90% Medicare OPPS,$377.00 ,58% of total billed charges,$30.63 ,120.37% of custom fee schedule,$20.23 ,Pays 100% Medicare OPPS,$26.31 ,Pays 130% Medicare OPPS,$552.50 ,85% of total billed charges,$20.23 ,Pays 100% Medicare OPPS,$18.21 ,$585.00 ,$520.00 
Outpatient Medical Services,LAB,86757,RICKETTSIA IgM,302,$170.00 ,$144.50 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$29.31 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$19.73 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$30.48 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$29.31 ,120.37% of custom fee schedule,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86255,.RICKETTSIAL IgG,300,$125.00 ,$106.25 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,80342,RISPERIDONE LEVEL,301,$545.00 ,$463.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$23.57 ,20.37% based on GA Medicaid OP CCR Rate,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$490.50 ,90% of total billed charges,$24.51 ,125.18% of custom fee schedule,$374.42 ,68.7% of total billed charges,$436.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$316.10 ,58% of total billed charges,$23.57 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$463.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$23.57 ,$490.50 ,$436.00 
Outpatient Medical Services,LAB,85245,3RD RISTOCETIN CO FACTOR ASSA,305,$510.00 ,$433.50 ,85% of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$22.94 ,Pays 100% Medicare OPPS,$22.94 ,Pays 100% Medicare OPPS,$29.82 ,Pays 130% Medicare OPPS,$34.73 ,20.37% based on GA Medicaid OP CCR Rate,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$23.39 ,Pays 102% Medicare OPPS,$459.00 ,90% of total billed charges,$36.11 ,125.18% of custom fee schedule,$350.37 ,68.7% of total billed charges,$408.00 ,80 percent of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$20.64 ,Pays 90% Medicare OPPS,$295.80 ,58% of total billed charges,$34.73 ,120.37% of custom fee schedule,$22.94 ,Pays 100% Medicare OPPS,$29.82 ,Pays 130% Medicare OPPS,$433.50 ,85% of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$20.64 ,$459.00 ,$408.00 
Outpatient Medical Services,LAB,80299,RITALIN LEVEL,301,$450.00 ,$382.50 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$405.00 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$309.15 ,68.7% of total billed charges,$360.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$261.00 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$382.50 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$405.00 ,$360.00 
Outpatient Medical Services,LAB,86757,.ROCKY MOUNT SPOT FEV IgG,302,$170.00 ,$144.50 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$29.31 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$19.73 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$30.48 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$29.31 ,120.37% of custom fee schedule,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86757,.ROCKY MOUNT SPOT FEV IgM,302,$170.00 ,$144.50 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$29.31 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$19.73 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$30.48 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$29.31 ,120.37% of custom fee schedule,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,80299,ROHIPNOL LEVEL,301,$760.00 ,$646.00 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$684.00 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$522.12 ,68.7% of total billed charges,$608.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$440.80 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$646.00 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$684.00 ,$608.00 
Outpatient Medical Services,LAB,86756,RSV ANTIBODY IgM,302,$170.00 ,$144.50 ,85% of total billed charges,$15.89 ,Pays 100% Medicare OPPS,$15.89 ,Pays 100% Medicare OPPS,$15.89 ,Pays 100% Medicare OPPS,$20.65 ,Pays 130% Medicare OPPS,$19.51 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$16.20 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$20.29 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$15.89 ,Pays 100% Medicare OPPS,$14.30 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$19.51 ,120.37% of custom fee schedule,$15.89 ,Pays 100% Medicare OPPS,$20.65 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$15.89 ,Pays 100% Medicare OPPS,$14.30 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86762,Blood test to determine if antibodies exist for rubella,302,$195.00 ,$165.75 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$17.61 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$14.67 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$18.31 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$17.61 ,120.37% of custom fee schedule,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,86762,Blood test to determine if antibodies exist for rubella,302,$195.00 ,$165.75 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$17.61 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$14.67 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$18.31 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$17.61 ,120.37% of custom fee schedule,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,86765,Blood test to determine if antibodies exist for measles,302,$260.00 ,$221.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86765,Blood test to determine if antibodies exist for measles,302,$260.00 ,$221.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86671,SACCHAROMYCES CEREVIS IgG,300,$365.00 ,$310.25 ,85% of total billed charges,$12.25 ,Pays 100% Medicare OPPS,$12.25 ,Pays 100% Medicare OPPS,$12.25 ,Pays 100% Medicare OPPS,$15.92 ,Pays 130% Medicare OPPS,$18.56 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$12.49 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$19.30 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$12.25 ,Pays 100% Medicare OPPS,$11.02 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$18.56 ,120.37% of custom fee schedule,$12.25 ,Pays 100% Medicare OPPS,$15.92 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$12.25 ,Pays 100% Medicare OPPS,$11.02 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86235,SCLERODERMA ANTIBODIES,302,$220.00 ,$187.00 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,80299,SEROQUEL LEVEL,301,$575.00 ,$488.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$517.50 ,$460.00 
Outpatient Medical Services,LAB,84260,"SEROTONIN, WHOLE BLOOD",301,$635.00 ,$539.75 ,85% of total billed charges,$30.98 ,Pays 100% Medicare OPPS,$30.98 ,Pays 100% Medicare OPPS,$30.98 ,Pays 100% Medicare OPPS,$40.27 ,Pays 130% Medicare OPPS,$46.88 ,20.37% based on GA Medicaid OP CCR Rate,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$31.59 ,Pays 102% Medicare OPPS,$571.50 ,90% of total billed charges,$48.76 ,125.18% of custom fee schedule,$436.25 ,68.7% of total billed charges,$508.00 ,80 percent of total billed charges,$30.98 ,Pays 100% Medicare OPPS,$27.88 ,Pays 90% Medicare OPPS,$368.30 ,58% of total billed charges,$46.88 ,120.37% of custom fee schedule,$30.98 ,Pays 100% Medicare OPPS,$40.27 ,Pays 130% Medicare OPPS,$539.75 ,85% of total billed charges,$30.98 ,Pays 100% Medicare OPPS,$27.88 ,$571.50 ,$508.00 
Outpatient Medical Services,LAB,84450,SGOT,301,$175.00 ,$148.75 ,85% of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$5.18 ,Pays 100% Medicare OPPS,$5.18 ,Pays 100% Medicare OPPS,$6.73 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$5.28 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$4.66 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$5.18 ,Pays 100% Medicare OPPS,$6.73 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$4.66 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,84460,Blood test to evaluate liver function,301,$175.00 ,$148.75 ,85% of total billed charges,$5.30 ,Pays 100% Medicare OPPS,$5.30 ,Pays 100% Medicare OPPS,$5.30 ,Pays 100% Medicare OPPS,$6.89 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$5.40 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$5.30 ,Pays 100% Medicare OPPS,$4.77 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$5.30 ,Pays 100% Medicare OPPS,$6.89 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$5.30 ,Pays 100% Medicare OPPS,$4.77 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,86235,.........SMITH AB,302,$170.00 ,$144.50 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86255,SPERM ANTIBODIES,302,$900.00 ,$765.00 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$508.50 ,56.5 percent of total billed charges,$508.50 ,56.5 percent of total billed charges,$508.50 ,56.5 percent of total billed charges,$508.50 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$810.00 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$618.30 ,68.7% of total billed charges,$720.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$522.00 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$765.00 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$810.00 ,$720.00 
Outpatient Medical Services,LAB,86235,.SS-A ANTIBODY (SJOGREN),302,$260.00 ,$221.00 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86235,.SS-B ANTIBODY (SJOGREN),302,$260.00 ,$221.00 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86235,.SSA/SSB (SJOGREN'S AB),302,$110.00 ,$93.50 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,82365,STONE ANALYSIS,301,$300.00 ,$255.00 ,85% of total billed charges,$12.90 ,Pays 100% Medicare OPPS,$12.90 ,Pays 100% Medicare OPPS,$12.90 ,Pays 100% Medicare OPPS,$16.77 ,Pays 130% Medicare OPPS,$19.51 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$13.15 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$20.29 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$12.90 ,Pays 100% Medicare OPPS,$11.61 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$19.51 ,120.37% of custom fee schedule,$12.90 ,Pays 100% Medicare OPPS,$16.77 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$12.90 ,Pays 100% Medicare OPPS,$11.61 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,83735,CATHARTIC SCREEN STOOL,301,$760.00 ,$646.00 ,85% of total billed charges,$6.70 ,Pays 100% Medicare OPPS,$6.70 ,Pays 100% Medicare OPPS,$6.70 ,Pays 100% Medicare OPPS,$8.71 ,Pays 130% Medicare OPPS,$10.14 ,20.37% based on GA Medicaid OP CCR Rate,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$6.83 ,Pays 102% Medicare OPPS,$684.00 ,90% of total billed charges,$10.54 ,125.18% of custom fee schedule,$522.12 ,68.7% of total billed charges,$608.00 ,80 percent of total billed charges,$6.70 ,Pays 100% Medicare OPPS,$6.03 ,Pays 90% Medicare OPPS,$440.80 ,58% of total billed charges,$10.14 ,120.37% of custom fee schedule,$6.70 ,Pays 100% Medicare OPPS,$8.71 ,Pays 130% Medicare OPPS,$646.00 ,85% of total billed charges,$6.70 ,Pays 100% Medicare OPPS,$6.03 ,$684.00 ,$608.00 
Outpatient Medical Services,LAB,82486,"SULFONYLUREA, URINE",301,$545.00 ,$463.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$111.02 ,20.37% based on GA Medicaid OP CCR Rate,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$490.50 ,90% of total billed charges,$190.75 ,35% based on GA Medicaid OP CCR Rate,$374.42 ,68.7% of total billed charges,$436.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$316.10 ,58% of total billed charges,$111.02 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$463.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$111.02 ,$490.50 ,$436.00 
Outpatient Medical Services,LAB,86359,T CELLS COUNT,302,$320.00 ,$272.00 ,85% of total billed charges,$37.72 ,Pays 100% Medicare OPPS,$37.72 ,Pays 100% Medicare OPPS,$37.72 ,Pays 100% Medicare OPPS,$49.04 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$38.48 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$37.08 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$37.72 ,Pays 100% Medicare OPPS,$33.95 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$35.65 ,120.37% of custom fee schedule,$37.72 ,Pays 100% Medicare OPPS,$49.04 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$37.72 ,Pays 100% Medicare OPPS,$33.95 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,84165,.T PROT ELEC F&Q(SPEP W IM,301,$135.00 ,$114.75 ,85% of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$10.74 ,Pays 100% Medicare OPPS,$10.74 ,Pays 100% Medicare OPPS,$13.96 ,Pays 130% Medicare OPPS,$16.26 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$10.95 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$16.91 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$9.66 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$16.26 ,120.37% of custom fee schedule,$10.74 ,Pays 100% Medicare OPPS,$13.96 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$9.66 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,84155,.T PROTEIN (SPEP W IMMUNO),301,$50.00 ,$42.50 ,85% of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.67 ,Pays 100% Medicare OPPS,$3.67 ,Pays 100% Medicare OPPS,$4.77 ,Pays 130% Medicare OPPS,$5.55 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$3.74 ,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$5.77 ,125.18% of custom fee schedule,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.30 ,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$5.55 ,120.37% of custom fee schedule,$3.67 ,Pays 100% Medicare OPPS,$4.77 ,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.30 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,84403,TESTOSTERONE TOTAL LEVEL,301,$350.00 ,$297.50 ,85% of total billed charges,$25.81 ,Pays 100% Medicare OPPS,$25.81 ,Pays 100% Medicare OPPS,$25.81 ,Pays 100% Medicare OPPS,$33.55 ,Pays 130% Medicare OPPS,$39.08 ,20.37% based on GA Medicaid OP CCR Rate,$197.75 ,56.5 percent of total billed charges,$197.75 ,56.5 percent of total billed charges,$197.75 ,56.5 percent of total billed charges,$197.75 ,56.5 percent of total billed charges,$26.32 ,Pays 102% Medicare OPPS,$315.00 ,90% of total billed charges,$40.65 ,125.18% of custom fee schedule,$240.45 ,68.7% of total billed charges,$280.00 ,80 percent of total billed charges,$25.81 ,Pays 100% Medicare OPPS,$23.22 ,Pays 90% Medicare OPPS,$203.00 ,58% of total billed charges,$39.08 ,120.37% of custom fee schedule,$25.81 ,Pays 100% Medicare OPPS,$33.55 ,Pays 130% Medicare OPPS,$297.50 ,85% of total billed charges,$25.81 ,Pays 100% Medicare OPPS,$23.22 ,$315.00 ,$280.00 
Outpatient Medical Services,LAB,80307,Testing for presence of drug,301,$345.00 ,$293.25 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$73.62 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$63.38 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$76.56 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$73.62 ,120.37% of custom fee schedule,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,80307,Testing for presence of drug,301,$345.00 ,$293.25 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$73.62 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$63.38 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$76.56 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$73.62 ,120.37% of custom fee schedule,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,86376,THYROID MICROSOMAL AB,302,$260.00 ,$221.00 ,85% of total billed charges,$14.55 ,Pays 100% Medicare OPPS,$14.55 ,Pays 100% Medicare OPPS,$14.55 ,Pays 100% Medicare OPPS,$18.91 ,Pays 130% Medicare OPPS,$22.03 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$14.84 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$22.91 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$14.55 ,Pays 100% Medicare OPPS,$13.09 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$22.03 ,120.37% of custom fee schedule,$14.55 ,Pays 100% Medicare OPPS,$18.91 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$14.55 ,Pays 100% Medicare OPPS,$13.09 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86376,THYROID PEROXIDASE AB,302,$260.00 ,$221.00 ,85% of total billed charges,$14.55 ,Pays 100% Medicare OPPS,$14.55 ,Pays 100% Medicare OPPS,$14.55 ,Pays 100% Medicare OPPS,$18.91 ,Pays 130% Medicare OPPS,$22.03 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$14.84 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$22.91 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$14.55 ,Pays 100% Medicare OPPS,$13.09 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$22.03 ,120.37% of custom fee schedule,$14.55 ,Pays 100% Medicare OPPS,$18.91 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$14.55 ,Pays 100% Medicare OPPS,$13.09 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,88230,.TISSUE CULTURE NON NEOPLA,311,"$1,220.00 ","$1,037.00 ",85% of total billed charges,$116.49 ,Pays 100% Medicare OPPS,$116.49 ,Pays 100% Medicare OPPS,$116.49 ,Pays 100% Medicare OPPS,$151.43 ,Pays 130% Medicare OPPS,$176.33 ,20.37% based on GA Medicaid OP CCR Rate,$689.30 ,56.5 percent of total billed charges,$689.30 ,56.5 percent of total billed charges,$689.30 ,56.5 percent of total billed charges,$689.30 ,56.5 percent of total billed charges,$118.81 ,Pays 102% Medicare OPPS,"$1,098.00 ",90% of total billed charges,$183.38 ,125.18% of custom fee schedule,$838.14 ,68.7% of total billed charges,$976.00 ,80 percent of total billed charges,$116.49 ,Pays 100% Medicare OPPS,$104.84 ,Pays 90% Medicare OPPS,$707.60 ,58% of total billed charges,$176.33 ,120.37% of custom fee schedule,$116.49 ,Pays 100% Medicare OPPS,$151.43 ,Pays 130% Medicare OPPS,"$1,037.00 ",85% of total billed charges,$116.49 ,Pays 100% Medicare OPPS,$104.84 ,"$1,098.00 ",$976.00 
Outpatient Medical Services,LAB,88237,.TISSUE CULTURE(CHROM FISH,301,"$3,300.00 ","$2,805.00 ",85% of total billed charges,$143.75 ,Pays 100% Medicare OPPS,$143.75 ,Pays 100% Medicare OPPS,$143.75 ,Pays 100% Medicare OPPS,$186.87 ,Pays 130% Medicare OPPS,$133.63 ,20.37% based on GA Medicaid OP CCR Rate,"$1,864.50 ",56.5 percent of total billed charges,"$1,864.50 ",56.5 percent of total billed charges,"$1,864.50 ",56.5 percent of total billed charges,"$1,864.50 ",56.5 percent of total billed charges,$146.62 ,Pays 102% Medicare OPPS,"$2,970.00 ",90% of total billed charges,$138.97 ,125.18% of custom fee schedule,"$2,267.10 ",68.7% of total billed charges,"$2,640.00 ",80 percent of total billed charges,$143.75 ,Pays 100% Medicare OPPS,$129.37 ,Pays 90% Medicare OPPS,"$1,914.00 ",58% of total billed charges,$133.63 ,120.37% of custom fee schedule,$143.75 ,Pays 100% Medicare OPPS,$186.87 ,Pays 130% Medicare OPPS,"$2,805.00 ",85% of total billed charges,$143.75 ,Pays 100% Medicare OPPS,$129.37 ,"$2,970.00 ","$2,640.00 "
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,301,$110.00 ,$93.50 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$14.07 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$9.48 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$14.63 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$14.07 ,120.37% of custom fee schedule,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,80338,TRAZODONE LEVEL,301,$375.00 ,$318.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$131.25 ,35% based on GA Medicaid OP CCR Rate,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$76.39 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,80299,TRILEPTAL,301,$415.00 ,$352.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,84702,.TRIPLE TEST (BETA HCG),301,$85.00 ,$72.25 ,85% of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$15.05 ,Pays 100% Medicare OPPS,$15.05 ,Pays 100% Medicare OPPS,$19.56 ,Pays 130% Medicare OPPS,$9.71 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$15.35 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$10.10 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$13.54 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$9.71 ,120.37% of custom fee schedule,$15.05 ,Pays 100% Medicare OPPS,$19.56 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$9.71 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,82677,.TRIPLE TEST (ESTRIOL),301,$240.00 ,$204.00 ,85% of total billed charges,$24.18 ,Pays 100% Medicare OPPS,$24.18 ,Pays 100% Medicare OPPS,$24.18 ,Pays 100% Medicare OPPS,$31.43 ,Pays 130% Medicare OPPS,$36.60 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$24.66 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$38.07 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$24.18 ,Pays 100% Medicare OPPS,$21.76 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$36.60 ,120.37% of custom fee schedule,$24.18 ,Pays 100% Medicare OPPS,$31.43 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$24.18 ,Pays 100% Medicare OPPS,$21.76 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,82105,.TRIPLE TEST (MAFP),301,$215.00 ,$182.75 ,85% of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$16.77 ,Pays 100% Medicare OPPS,$16.77 ,Pays 100% Medicare OPPS,$21.80 ,Pays 130% Medicare OPPS,$25.40 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$17.10 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$26.41 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$15.09 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$25.40 ,120.37% of custom fee schedule,$16.77 ,Pays 100% Medicare OPPS,$21.80 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$15.09 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,83520,"TRYPTASE, SERUM",300,$245.00 ,$208.25 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$220.50 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$168.32 ,68.7% of total billed charges,$196.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$142.10 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$208.25 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$220.50 ,$196.00 
Outpatient Medical Services,LAB,84443,"Blood test, thyroid stimulating hormone (TSH)",301,$410.00 ,$348.50 ,85% of total billed charges,$16.80 ,Pays 100% Medicare OPPS,$16.80 ,Pays 100% Medicare OPPS,$16.80 ,Pays 100% Medicare OPPS,$21.84 ,Pays 130% Medicare OPPS,$25.42 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$17.13 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$26.44 ,125.18% of custom fee schedule,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$16.80 ,Pays 100% Medicare OPPS,$15.12 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$25.42 ,120.37% of custom fee schedule,$16.80 ,Pays 100% Medicare OPPS,$21.84 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$16.80 ,Pays 100% Medicare OPPS,$15.12 ,$369.00 ,$328.00 
Outpatient Medical Services,LAB,84445,.TSI (THYROID STIM IMMUNOG,301,$240.00 ,$204.00 ,85% of total billed charges,$50.86 ,Pays 100% Medicare OPPS,$50.86 ,Pays 100% Medicare OPPS,$50.86 ,Pays 100% Medicare OPPS,$66.11 ,Pays 130% Medicare OPPS,$12.82 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$51.87 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$13.33 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$50.86 ,Pays 100% Medicare OPPS,$45.77 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$12.82 ,120.37% of custom fee schedule,$50.86 ,Pays 100% Medicare OPPS,$66.11 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$50.86 ,Pays 100% Medicare OPPS,$12.82 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,87207,TZANCK PREP,306,$215.00 ,$182.75 ,85% of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.99 ,Pays 100% Medicare OPPS,$5.99 ,Pays 100% Medicare OPPS,$7.78 ,Pays 130% Medicare OPPS,$9.06 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$6.10 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$9.43 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.39 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$9.06 ,120.37% of custom fee schedule,$5.99 ,Pays 100% Medicare OPPS,$7.78 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.39 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,81002,Manual urinalysis test with examination without using microscope,307,$60.00 ,$51.00 ,85% of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.48 ,Pays 100% Medicare OPPS,$3.48 ,Pays 100% Medicare OPPS,$4.52 ,Pays 130% Medicare OPPS,$3.86 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$3.54 ,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$4.02 ,125.18% of custom fee schedule,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.13 ,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$3.86 ,120.37% of custom fee schedule,$3.48 ,Pays 100% Medicare OPPS,$4.52 ,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.13 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,81002,Manual urinalysis test with examination without using microscope,307,$50.00 ,$42.50 ,85% of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.48 ,Pays 100% Medicare OPPS,$3.48 ,Pays 100% Medicare OPPS,$4.52 ,Pays 130% Medicare OPPS,$3.86 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$3.54 ,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$4.02 ,125.18% of custom fee schedule,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.13 ,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$3.86 ,120.37% of custom fee schedule,$3.48 ,Pays 100% Medicare OPPS,$4.52 ,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.13 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,81002,Manual urinalysis test with examination without using microscope,307,$60.00 ,$51.00 ,85% of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.48 ,Pays 100% Medicare OPPS,$3.48 ,Pays 100% Medicare OPPS,$4.52 ,Pays 130% Medicare OPPS,$3.86 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$3.54 ,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$4.02 ,125.18% of custom fee schedule,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.13 ,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$3.86 ,120.37% of custom fee schedule,$3.48 ,Pays 100% Medicare OPPS,$4.52 ,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.13 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,81002,Manual urinalysis test with examination without using microscope,307,$60.00 ,$51.00 ,85% of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.48 ,Pays 100% Medicare OPPS,$3.48 ,Pays 100% Medicare OPPS,$4.52 ,Pays 130% Medicare OPPS,$3.86 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$3.54 ,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$4.02 ,125.18% of custom fee schedule,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.13 ,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$3.86 ,120.37% of custom fee schedule,$3.48 ,Pays 100% Medicare OPPS,$4.52 ,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,$3.48 ,Pays 100% Medicare OPPS,$3.13 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,84110,URINE FOR WATSON SCHWARTZ,301,$365.00 ,$310.25 ,85% of total billed charges,$8.44 ,Pays 100% Medicare OPPS,$8.44 ,Pays 100% Medicare OPPS,$8.44 ,Pays 100% Medicare OPPS,$10.97 ,Pays 130% Medicare OPPS,$12.78 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$8.60 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$13.29 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$8.44 ,Pays 100% Medicare OPPS,$7.59 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$12.78 ,120.37% of custom fee schedule,$8.44 ,Pays 100% Medicare OPPS,$10.97 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$8.44 ,Pays 100% Medicare OPPS,$7.59 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86334,3RD LIGHT CHAINS-UA IEP,302,$375.00 ,$318.75 ,85% of total billed charges,$22.34 ,Pays 100% Medicare OPPS,$22.34 ,Pays 100% Medicare OPPS,$22.34 ,Pays 100% Medicare OPPS,$29.04 ,Pays 130% Medicare OPPS,$33.81 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$22.78 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$35.16 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$22.34 ,Pays 100% Medicare OPPS,$20.10 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$33.81 ,120.37% of custom fee schedule,$22.34 ,Pays 100% Medicare OPPS,$29.04 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$22.34 ,Pays 100% Medicare OPPS,$20.10 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,80346,VALIUM LEVEL,301,$295.00 ,$250.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$28.00 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$29.12 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$28.00 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$28.00 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,83891,MOLECULE ISOLATE NUCLEIC,300,$735.00 ,$624.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$661.50 ,90% of total billed charges,$257.25 ,35% based on GA Medicaid OP CCR Rate,$504.95 ,68.7% of total billed charges,$588.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$426.30 ,58% of total billed charges,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$624.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$149.72 ,$661.50 ,$588.00 
Outpatient Medical Services,LAB,87252,VIRAL STUDIES,306,$345.00 ,$293.25 ,85% of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$26.07 ,Pays 100% Medicare OPPS,$26.07 ,Pays 100% Medicare OPPS,$33.89 ,Pays 130% Medicare OPPS,$33.46 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$26.59 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$34.80 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$23.46 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$33.46 ,120.37% of custom fee schedule,$26.07 ,Pays 100% Medicare OPPS,$33.89 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$23.46 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,85245,VON WILLEBRAND ANTIGEN,300,$310.00 ,$263.50 ,85% of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$22.94 ,Pays 100% Medicare OPPS,$22.94 ,Pays 100% Medicare OPPS,$29.82 ,Pays 130% Medicare OPPS,$34.73 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$23.39 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$36.11 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$20.64 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$34.73 ,120.37% of custom fee schedule,$22.94 ,Pays 100% Medicare OPPS,$29.82 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$20.64 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,86789,3RD WEST NILE IGG VIRUS (CSF),302,$485.00 ,$412.25 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$17.61 ,20.37% based on GA Medicaid OP CCR Rate,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$14.67 ,Pays 102% Medicare OPPS,$436.50 ,90% of total billed charges,$18.31 ,125.18% of custom fee schedule,$333.20 ,68.7% of total billed charges,$388.00 ,80 percent of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,Pays 90% Medicare OPPS,$281.30 ,58% of total billed charges,$17.61 ,120.37% of custom fee schedule,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$412.25 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,$436.50 ,$388.00 
Outpatient Medical Services,LAB,86789,3RD WEST NILE IGG VIRUS(SERUM),302,$485.00 ,$412.25 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$17.61 ,20.37% based on GA Medicaid OP CCR Rate,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$14.67 ,Pays 102% Medicare OPPS,$436.50 ,90% of total billed charges,$18.31 ,125.18% of custom fee schedule,$333.20 ,68.7% of total billed charges,$388.00 ,80 percent of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,Pays 90% Medicare OPPS,$281.30 ,58% of total billed charges,$17.61 ,120.37% of custom fee schedule,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$412.25 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,$436.50 ,$388.00 
Outpatient Medical Services,LAB,87210,A lab test to screen for evidence of vaginal infection,306,$100.00 ,$85.00 ,85% of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.82 ,Pays 100% Medicare OPPS,$5.82 ,Pays 100% Medicare OPPS,$7.56 ,Pays 130% Medicare OPPS,$6.45 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$5.93 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$6.71 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.23 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$6.45 ,120.37% of custom fee schedule,$5.82 ,Pays 100% Medicare OPPS,$7.56 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.23 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,87102,YEAST  ID,306,$65.00 ,$55.25 ,85% of total billed charges,$8.41 ,Pays 100% Medicare OPPS,$8.41 ,Pays 100% Medicare OPPS,$8.41 ,Pays 100% Medicare OPPS,$10.93 ,Pays 130% Medicare OPPS,$12.72 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$8.57 ,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$13.23 ,125.18% of custom fee schedule,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,$8.41 ,Pays 100% Medicare OPPS,$7.56 ,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$12.72 ,120.37% of custom fee schedule,$8.41 ,Pays 100% Medicare OPPS,$10.93 ,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,$8.41 ,Pays 100% Medicare OPPS,$7.56 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,84182,YO ANTIBODIES,301,"$1,065.00 ",$905.25 ,85% of total billed charges,$29.21 ,Pays 100% Medicare OPPS,$29.21 ,Pays 100% Medicare OPPS,$29.21 ,Pays 100% Medicare OPPS,$37.97 ,Pays 130% Medicare OPPS,$27.25 ,20.37% based on GA Medicaid OP CCR Rate,$601.73 ,56.5 percent of total billed charges,$601.73 ,56.5 percent of total billed charges,$601.73 ,56.5 percent of total billed charges,$601.73 ,56.5 percent of total billed charges,$29.79 ,Pays 102% Medicare OPPS,$958.50 ,90% of total billed charges,$28.34 ,125.18% of custom fee schedule,$731.66 ,68.7% of total billed charges,$852.00 ,80 percent of total billed charges,$29.21 ,Pays 100% Medicare OPPS,$26.28 ,Pays 90% Medicare OPPS,$617.70 ,58% of total billed charges,$27.25 ,120.37% of custom fee schedule,$29.21 ,Pays 100% Medicare OPPS,$37.97 ,Pays 130% Medicare OPPS,$905.25 ,85% of total billed charges,$29.21 ,Pays 100% Medicare OPPS,$26.28 ,$958.50 ,$852.00 
Outpatient Medical Services,LAB,80332,ZOLOFT LEVEL,301,$465.00 ,$395.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$94.72 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$162.75 ,35% based on GA Medicaid OP CCR Rate,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$94.72 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$94.72 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,80299,3RD ZONISAMIDE (ZONEGRAN) LEVEL,301,$395.00 ,$335.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$355.50 ,$316.00 
Outpatient Medical Services,LAB,80342,ZYPREXA  LEVEL,301,$635.00 ,$539.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$23.57 ,20.37% based on GA Medicaid OP CCR Rate,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$571.50 ,90% of total billed charges,$24.51 ,125.18% of custom fee schedule,$436.25 ,68.7% of total billed charges,$508.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$368.30 ,58% of total billed charges,$23.57 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$539.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$23.57 ,$571.50 ,$508.00 
Outpatient Medical Services,LAB,83986,3RD PH BODY FLUID NOT BLOOD,301,$60.00 ,$51.00 ,85% of total billed charges,$3.58 ,Pays 100% Medicare OPPS,$3.58 ,Pays 100% Medicare OPPS,$3.58 ,Pays 100% Medicare OPPS,$4.65 ,Pays 130% Medicare OPPS,$5.42 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$3.65 ,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$5.63 ,125.18% of custom fee schedule,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,$3.58 ,Pays 100% Medicare OPPS,$3.22 ,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$5.42 ,120.37% of custom fee schedule,$3.58 ,Pays 100% Medicare OPPS,$4.65 ,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,$3.58 ,Pays 100% Medicare OPPS,$3.22 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,G0103,Prostate cancer screening; prostate specific antigen test (psa),300,$415.00 ,$352.75 ,85% of total billed charges,$19.30 ,Pays 100% Medicare OPPS,$19.30 ,Pays 100% Medicare OPPS,$19.30 ,Pays 100% Medicare OPPS,$25.10 ,Pays 130% Medicare OPPS,$30.94 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$19.69 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$32.17 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$19.30 ,Pays 100% Medicare OPPS,$17.37 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$30.94 ,120.37% of custom fee schedule,$19.30 ,Pays 100% Medicare OPPS,$25.10 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$19.30 ,Pays 100% Medicare OPPS,$17.37 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,84703,Blood test to assess for pregnancy,301,$190.00 ,$161.50 ,85% of total billed charges,$7.52 ,Pays 100% Medicare OPPS,$7.52 ,Pays 100% Medicare OPPS,$7.52 ,Pays 100% Medicare OPPS,$9.77 ,Pays 130% Medicare OPPS,$9.71 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$7.67 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$10.10 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$7.52 ,Pays 100% Medicare OPPS,$6.76 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$9.71 ,120.37% of custom fee schedule,$7.52 ,Pays 100% Medicare OPPS,$9.77 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$7.52 ,Pays 100% Medicare OPPS,$6.76 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,83520,GM1 IgG,301,$525.00 ,$446.25 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,84153,PSA (prostate specific antigen),301,$210.00 ,$178.50 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.90 ,Pays 130% Medicare OPPS,$27.84 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$18.75 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$28.95 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$27.84 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.90 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,86003,PENICILLIN G IGE,302,$165.00 ,$140.25 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,83519,.ANTI ACETYLCHOLINE RECPT,302,$465.00 ,$395.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$20.45 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$18.76 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$21.27 ,125.18% of custom fee schedule,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$20.45 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,86255,"ENDOMYSIAL, IgA ANTIBODY",302,$295.00 ,$250.75 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,87077,Test of a wound for type of bacterial infection,306,$65.00 ,$55.25 ,85% of total billed charges,$8.08 ,Pays 100% Medicare OPPS,$8.08 ,Pays 100% Medicare OPPS,$8.08 ,Pays 100% Medicare OPPS,$10.50 ,Pays 130% Medicare OPPS,$12.23 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$8.24 ,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$12.72 ,125.18% of custom fee schedule,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,$8.08 ,Pays 100% Medicare OPPS,$7.27 ,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$12.23 ,120.37% of custom fee schedule,$8.08 ,Pays 100% Medicare OPPS,$10.50 ,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,$8.08 ,Pays 100% Medicare OPPS,$7.27 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,306,$220.00 ,$187.00 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,81223,MOLECULE NUCLEIC AMPLI,300,$735.00 ,$624.75 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,"$1,155.55 ",20.37% based on GA Medicaid OP CCR Rate,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$508.98 ,Pays 102% Medicare OPPS,$661.50 ,90% of total billed charges,"$1,201.73 ",125.18% of custom fee schedule,$504.95 ,68.7% of total billed charges,$588.00 ,80 percent of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$449.10 ,Pays 90% Medicare OPPS,$426.30 ,58% of total billed charges,"$1,155.55 ",120.37% of custom fee schedule,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,$624.75 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$415.28 ,"$1,201.73 ",$588.00 
Outpatient Medical Services,LAB,85610,"Blood test, clotting time",301,$170.00 ,$144.50 ,85% of total billed charges,$4.29 ,Pays 100% Medicare OPPS,$4.29 ,Pays 100% Medicare OPPS,$4.29 ,Pays 100% Medicare OPPS,$5.57 ,Pays 130% Medicare OPPS,$5.95 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$4.37 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$6.18 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$4.29 ,Pays 100% Medicare OPPS,$3.86 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$5.95 ,120.37% of custom fee schedule,$4.29 ,Pays 100% Medicare OPPS,$5.57 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$4.29 ,Pays 100% Medicare OPPS,$3.86 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,83892,MOLECULE DIAG,300,$735.00 ,$624.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$661.50 ,90% of total billed charges,$257.25 ,35% based on GA Medicaid OP CCR Rate,$504.95 ,68.7% of total billed charges,$588.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$426.30 ,58% of total billed charges,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$624.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$149.72 ,$661.50 ,$588.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,302,$190.00 ,$161.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,80053,"Blood test, comprehensive group of blood chemicals",301,$545.00 ,$463.25 ,85% of total billed charges,$10.56 ,Pays 100% Medicare OPPS,$10.56 ,Pays 100% Medicare OPPS,$10.56 ,Pays 100% Medicare OPPS,$13.72 ,Pays 130% Medicare OPPS,$16.00 ,20.37% based on GA Medicaid OP CCR Rate,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$10.77 ,Pays 102% Medicare OPPS,$490.50 ,90% of total billed charges,$16.64 ,125.18% of custom fee schedule,$374.42 ,68.7% of total billed charges,$436.00 ,80 percent of total billed charges,$10.56 ,Pays 100% Medicare OPPS,$9.50 ,Pays 90% Medicare OPPS,$316.10 ,58% of total billed charges,$16.00 ,120.37% of custom fee schedule,$10.56 ,Pays 100% Medicare OPPS,$13.72 ,Pays 130% Medicare OPPS,$463.25 ,85% of total billed charges,$10.56 ,Pays 100% Medicare OPPS,$9.50 ,$490.50 ,$436.00 
Outpatient Medical Services,LAB,83835,METANEPHRINES RANDON UA,301,$365.00 ,$310.25 ,85% of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$16.94 ,Pays 100% Medicare OPPS,$16.94 ,Pays 100% Medicare OPPS,$22.02 ,Pays 130% Medicare OPPS,$25.64 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$17.27 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$26.66 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$15.24 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$25.64 ,120.37% of custom fee schedule,$16.94 ,Pays 100% Medicare OPPS,$22.02 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$15.24 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,85610,"Blood test, clotting time",301,$170.00 ,$144.50 ,85% of total billed charges,$4.29 ,Pays 100% Medicare OPPS,$4.29 ,Pays 100% Medicare OPPS,$4.29 ,Pays 100% Medicare OPPS,$5.57 ,Pays 130% Medicare OPPS,$5.95 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$4.37 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$6.18 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$4.29 ,Pays 100% Medicare OPPS,$3.86 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$5.95 ,120.37% of custom fee schedule,$4.29 ,Pays 100% Medicare OPPS,$5.57 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$4.29 ,Pays 100% Medicare OPPS,$3.86 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,85730,Coagulation assessment blood test,305,$195.00 ,$165.75 ,85% of total billed charges,$6.01 ,Pays 100% Medicare OPPS,$6.01 ,Pays 100% Medicare OPPS,$6.01 ,Pays 100% Medicare OPPS,$7.81 ,Pays 130% Medicare OPPS,$9.08 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$6.13 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$9.44 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$6.01 ,Pays 100% Medicare OPPS,$5.40 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$9.08 ,120.37% of custom fee schedule,$6.01 ,Pays 100% Medicare OPPS,$7.81 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$6.01 ,Pays 100% Medicare OPPS,$5.40 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,87081,Medical test to find an infection,306,$220.00 ,$187.00 ,85% of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$6.63 ,Pays 100% Medicare OPPS,$6.63 ,Pays 100% Medicare OPPS,$8.61 ,Pays 130% Medicare OPPS,$10.03 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$6.76 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$10.43 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$5.96 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$10.03 ,120.37% of custom fee schedule,$6.63 ,Pays 100% Medicare OPPS,$8.61 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$5.96 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,86901,RH,300,$85.00 ,$72.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$17.47 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$31.01 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$18.16 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$17.47 ,120.37% of custom fee schedule,$29.87 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$17.47 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,86900,BB ABO TYPE,300,$100.00 ,$85.00 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$4.51 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$4.69 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$4.51 ,120.37% of custom fee schedule,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$4.51 ,$132.76 ,$80.00 
Outpatient Medical Services,LAB,83525,INSULIN 3 SPECIMENS,301,$240.00 ,$204.00 ,85% of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$11.43 ,Pays 100% Medicare OPPS,$11.43 ,Pays 100% Medicare OPPS,$14.85 ,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$11.65 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$18.00 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$10.28 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$17.31 ,120.37% of custom fee schedule,$11.43 ,Pays 100% Medicare OPPS,$14.85 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$10.28 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,83525,INSULIN 4 SPECIMENS,301,$240.00 ,$204.00 ,85% of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$11.43 ,Pays 100% Medicare OPPS,$11.43 ,Pays 100% Medicare OPPS,$14.85 ,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$11.65 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$18.00 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$10.28 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$17.31 ,120.37% of custom fee schedule,$11.43 ,Pays 100% Medicare OPPS,$14.85 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$10.28 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,83525,INSULIN 5 SPECIMENS,301,$240.00 ,$204.00 ,85% of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$11.43 ,Pays 100% Medicare OPPS,$11.43 ,Pays 100% Medicare OPPS,$14.85 ,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$11.65 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$18.00 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$10.28 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$17.31 ,120.37% of custom fee schedule,$11.43 ,Pays 100% Medicare OPPS,$14.85 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$10.28 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,83525,INSULIN 2 SPECIMENS,301,$240.00 ,$204.00 ,85% of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$11.43 ,Pays 100% Medicare OPPS,$11.43 ,Pays 100% Medicare OPPS,$14.85 ,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$11.65 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$18.00 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$10.28 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$17.31 ,120.37% of custom fee schedule,$11.43 ,Pays 100% Medicare OPPS,$14.85 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$10.28 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,82533,CORTISOL MORNING,301,$320.00 ,$272.00 ,85% of total billed charges,$16.30 ,Pays 100% Medicare OPPS,$16.30 ,Pays 100% Medicare OPPS,$16.30 ,Pays 100% Medicare OPPS,$21.19 ,Pays 130% Medicare OPPS,$24.68 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$16.62 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$25.66 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.30 ,Pays 100% Medicare OPPS,$14.67 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$24.68 ,120.37% of custom fee schedule,$16.30 ,Pays 100% Medicare OPPS,$21.19 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.30 ,Pays 100% Medicare OPPS,$14.67 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,82533,CORTISOL EVENING,301,$320.00 ,$272.00 ,85% of total billed charges,$16.30 ,Pays 100% Medicare OPPS,$16.30 ,Pays 100% Medicare OPPS,$16.30 ,Pays 100% Medicare OPPS,$21.19 ,Pays 130% Medicare OPPS,$24.68 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$16.62 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$25.66 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.30 ,Pays 100% Medicare OPPS,$14.67 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$24.68 ,120.37% of custom fee schedule,$16.30 ,Pays 100% Medicare OPPS,$21.19 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.30 ,Pays 100% Medicare OPPS,$14.67 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,306,$310.00 ,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,306,$310.00 ,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,80053,"Blood test, comprehensive group of blood chemicals",301,$450.00 ,$382.50 ,85% of total billed charges,$10.56 ,Pays 100% Medicare OPPS,$10.56 ,Pays 100% Medicare OPPS,$10.56 ,Pays 100% Medicare OPPS,$13.72 ,Pays 130% Medicare OPPS,$16.00 ,20.37% based on GA Medicaid OP CCR Rate,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$10.77 ,Pays 102% Medicare OPPS,$405.00 ,90% of total billed charges,$16.64 ,125.18% of custom fee schedule,$309.15 ,68.7% of total billed charges,$360.00 ,80 percent of total billed charges,$10.56 ,Pays 100% Medicare OPPS,$9.50 ,Pays 90% Medicare OPPS,$261.00 ,58% of total billed charges,$16.00 ,120.37% of custom fee schedule,$10.56 ,Pays 100% Medicare OPPS,$13.72 ,Pays 130% Medicare OPPS,$382.50 ,85% of total billed charges,$10.56 ,Pays 100% Medicare OPPS,$9.50 ,$405.00 ,$360.00 
Outpatient Medical Services,LAB,82525,COPPER LEVEL 24 HR URINE,301,$220.00 ,$187.00 ,85% of total billed charges,$12.41 ,Pays 100% Medicare OPPS,$12.41 ,Pays 100% Medicare OPPS,$12.41 ,Pays 100% Medicare OPPS,$16.13 ,Pays 130% Medicare OPPS,$18.79 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$12.65 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$19.54 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$12.41 ,Pays 100% Medicare OPPS,$11.16 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$18.79 ,120.37% of custom fee schedule,$12.41 ,Pays 100% Medicare OPPS,$16.13 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$12.41 ,Pays 100% Medicare OPPS,$11.16 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,86235,PM-SCL 100 AB,302,$325.00 ,$276.25 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$292.50 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$223.28 ,68.7% of total billed charges,$260.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$188.50 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$276.25 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$292.50 ,$260.00 
Outpatient Medical Services,LAB,86003,RAST FOR HONEYBEE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ALDER TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ALMOND,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ALTERNARIA TENUIS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR APPLE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ASPARAGUS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR AVOCADO,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BAHIA GRASS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BAKER'S YEAST,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BANANA,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BARLEY,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR GREEN BEAN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BEECH TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BEEF,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BERMUDA GRASS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BIRCH TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BLUEBERRY,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BOTRYTIS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BRAZIL NUT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BREWER'S YEAST,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BUCKWHEAT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CABBAGE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CANARY GRASS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CARELESS WEED,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CARROT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CASEIN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CAT DANDER,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CEDAR MT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CELERY,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CEREAL GP,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CHEDDAR CHEESE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CHICKEN MEAT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CHILI PEPPER,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CHOCOLATE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CLAM,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR COCKLEBUR,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR COCKROACH,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR COCONUT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR COD FISH,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR COFFEE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CORN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CORN POLLEN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR COTTONWOOD TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR COW DANDER,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CRAB,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR CUCUMBER,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR DANDELION,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,.RAST FOR DOG EPITHELIUM,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR EGG WHITE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR EGG YOLK,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,3RD RAST FOR EGG WHOLE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ELM TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR EUCALYPTUS TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR FEATHER MIX,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR GARLIC,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR GLUTEN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR GOLDENROD,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR GREEN PEA,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR HAZELNUT(FOOD),302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR HORSE DANDER,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR HOUSE DUST(GREER),302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR HOUSE DUST(HOLLISTER STEIR),302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR FIRE ANT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR JOHNSON GRASS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR JUNE GRASS(KY BLUE),302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR KIWI FRUIT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR LAMB'S QTR,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR LATEX,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR LETTUCE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR LOBSTER,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR MALT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR MANGO,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR MAPLE TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR MEADOW FESCUE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR MELON,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR MILK,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR MOLD ALLERGEN GP,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR MUGWORT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR MULBERRY WHITE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR MUSTARD,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR NUT MIX GP,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR OAK TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR OAT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR OLIVE TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ONION,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ORANGE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ORCHARD GRASS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR OVALBUMIN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR OVAMUCOID,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR OYSTER,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PAPAYA,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PAPER WASP,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PARSLEY,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PEACH,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PEANUT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PECAN NUT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PECAN TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PEPPER BLACK,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PEPPER GREEN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PERENNIAL RYE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR WHITE PINE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PINTO BEAN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PISTACHIO NUT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR PORK,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR POTATO,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR RAGWEED COMMON,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR RAGWEED FALSE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR RAGWEED GAINT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR RAGWEED WESTERN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR RED TOP GRASS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR RICE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ROUGH MARSH ELDER,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ROUGH PIGWEED,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR RUSSIAN THISTLE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR SALAD ALLERGEN GRP,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR SALMON,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR SEAFOOD,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR SESAME SEED,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR SHEEP SORREL,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR SHRIMP,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR SOYBEAN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR STINGING INSECT GROUP,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR STRAWBERRY,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR SUNFLOWER SEED,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR SWEET POTATO,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR SWEET VERNAL GRASS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR SYCAMORE TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR TIMOTHY GRASS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR TOMATOES,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR TROUT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR TUNA,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR TURKEY MEAT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR VEGETABLE GRP,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,"RAST FOR WALNUT, FOOD",302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR WALNUT TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR WHEAT,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR WHITE ASH TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR WHITE BEAN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR WHITE FACE HORNET,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR WILLOW TREE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR WORMWOOD,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR YELLOW HORNET,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR YELLOW JACKET,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,84439,Blood test to evaluate thyroid function,301,$215.00 ,$182.75 ,85% of total billed charges,$9.02 ,Pays 100% Medicare OPPS,$9.02 ,Pays 100% Medicare OPPS,$9.02 ,Pays 100% Medicare OPPS,$11.72 ,Pays 130% Medicare OPPS,$13.65 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$9.20 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$14.20 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$9.02 ,Pays 100% Medicare OPPS,$8.11 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$13.65 ,120.37% of custom fee schedule,$9.02 ,Pays 100% Medicare OPPS,$11.72 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$9.02 ,Pays 100% Medicare OPPS,$8.11 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,83615,3RD LDH BODY FLUID,301,$210.00 ,$178.50 ,85% of total billed charges,$6.04 ,Pays 100% Medicare OPPS,$6.04 ,Pays 100% Medicare OPPS,$6.04 ,Pays 100% Medicare OPPS,$7.85 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$6.16 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$6.04 ,Pays 100% Medicare OPPS,$5.43 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$6.04 ,Pays 100% Medicare OPPS,$7.85 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$6.04 ,Pays 100% Medicare OPPS,$5.43 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,87522,3RD HEP C VIRAL LOAD,306,$940.00 ,$799.00 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$64.84 ,20.37% based on GA Medicaid OP CCR Rate,$531.10 ,56.5 percent of total billed charges,$531.10 ,56.5 percent of total billed charges,$531.10 ,56.5 percent of total billed charges,$531.10 ,56.5 percent of total billed charges,$43.69 ,Pays 102% Medicare OPPS,$846.00 ,90% of total billed charges,$67.43 ,125.18% of custom fee schedule,$645.78 ,68.7% of total billed charges,$752.00 ,80 percent of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,Pays 90% Medicare OPPS,$545.20 ,58% of total billed charges,$64.84 ,120.37% of custom fee schedule,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$799.00 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,$846.00 ,$752.00 
Outpatient Medical Services,LAB,86789,3RD WEST NILE VIRUS ABS(SERUM),302,$485.00 ,$412.25 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$17.61 ,20.37% based on GA Medicaid OP CCR Rate,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$14.67 ,Pays 102% Medicare OPPS,$436.50 ,90% of total billed charges,$18.31 ,125.18% of custom fee schedule,$333.20 ,68.7% of total billed charges,$388.00 ,80 percent of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,Pays 90% Medicare OPPS,$281.30 ,58% of total billed charges,$17.61 ,120.37% of custom fee schedule,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$412.25 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,$436.50 ,$388.00 
Outpatient Medical Services,LAB,86789,3RD WEST NILE IGM VIRUS (CSF),302,$485.00 ,$412.25 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$17.61 ,20.37% based on GA Medicaid OP CCR Rate,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$14.67 ,Pays 102% Medicare OPPS,$436.50 ,90% of total billed charges,$18.31 ,125.18% of custom fee schedule,$333.20 ,68.7% of total billed charges,$388.00 ,80 percent of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,Pays 90% Medicare OPPS,$281.30 ,58% of total billed charges,$17.61 ,120.37% of custom fee schedule,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$412.25 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,$436.50 ,$388.00 
Outpatient Medical Services,LAB,84120,3RD PORPHYRIN FRACTIONATED 24 URINE,301,$295.00 ,$250.75 ,85% of total billed charges,$14.71 ,Pays 100% Medicare OPPS,$14.71 ,Pays 100% Medicare OPPS,$14.71 ,Pays 100% Medicare OPPS,$19.12 ,Pays 130% Medicare OPPS,$22.27 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$15.00 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$23.16 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$14.71 ,Pays 100% Medicare OPPS,$13.23 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$22.27 ,120.37% of custom fee schedule,$14.71 ,Pays 100% Medicare OPPS,$19.12 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$14.71 ,Pays 100% Medicare OPPS,$13.23 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,87491,Test that detects Chlamydia,300,$220.00 ,$187.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$29.70 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$30.88 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$29.70 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$29.70 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,87591,Blood test for an STD,300,$220.00 ,$187.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$25.78 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$26.81 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$25.78 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$25.78 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,306,$275.00 ,$233.75 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,83690,"LIPASE,  PERITONEAL FLUID",301,$300.00 ,$255.00 ,85% of total billed charges,$6.89 ,Pays 100% Medicare OPPS,$6.89 ,Pays 100% Medicare OPPS,$6.89 ,Pays 100% Medicare OPPS,$8.95 ,Pays 130% Medicare OPPS,$10.42 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$7.02 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$10.84 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$6.89 ,Pays 100% Medicare OPPS,$6.20 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$10.42 ,120.37% of custom fee schedule,$6.89 ,Pays 100% Medicare OPPS,$8.95 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$6.89 ,Pays 100% Medicare OPPS,$6.20 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,83520,ALPHA MELANOCYTE STIMULATING HORMONE,300,$875.00 ,$743.75 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$494.38 ,56.5 percent of total billed charges,$494.38 ,56.5 percent of total billed charges,$494.38 ,56.5 percent of total billed charges,$494.38 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$787.50 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$601.13 ,68.7% of total billed charges,$700.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$507.50 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$743.75 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$787.50 ,$700.00 
Outpatient Medical Services,LAB,87205,A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,306,$145.00 ,$123.25 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$3.55 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.35 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$3.69 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.84 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$3.55 ,120.37% of custom fee schedule,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.55 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,83519,3RD ACETYLCHOLINE RECEPTOR BLOCKING AU,301,$265.00 ,$225.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$20.45 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$18.76 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$21.27 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$20.45 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,83519,3RD ACETYLCHOLINE RECEPTOR MODULATING AB,301,$325.00 ,$276.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$20.45 ,20.37% based on GA Medicaid OP CCR Rate,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$18.76 ,Pays 102% Medicare OPPS,$292.50 ,90% of total billed charges,$21.27 ,125.18% of custom fee schedule,$223.28 ,68.7% of total billed charges,$260.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$188.50 ,58% of total billed charges,$20.45 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$276.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$292.50 ,$260.00 
Outpatient Medical Services,LAB,83891,MOLECULAR DIAG ISOL OR EXT PNA (HLA NAR),301,$85.00 ,$72.25 ,85% of total billed charges,$21.25 ,Pays 100% Medicare OPPS,$21.25 ,Pays 100% Medicare OPPS,$21.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$29.75 ,35% based on GA Medicaid OP CCR Rate,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$76.50 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$17.31 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,83894,MOLECULAR DIAG SEP BY GEL (HLA NAR),301,$85.00 ,$72.25 ,85% of total billed charges,$21.25 ,Pays 100% Medicare OPPS,$21.25 ,Pays 100% Medicare OPPS,$21.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$29.75 ,35% based on GA Medicaid OP CCR Rate,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$76.50 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$17.31 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,83896,MOLECULAR DIAG NAP (HLA NAR),301,$85.00 ,$72.25 ,85% of total billed charges,$21.25 ,Pays 100% Medicare OPPS,$21.25 ,Pays 100% Medicare OPPS,$21.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$29.75 ,35% based on GA Medicaid OP CCR Rate,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$76.50 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$17.31 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,83912,MOLECULAR DIAG I&R (HLA NAR),301,$85.00 ,$72.25 ,85% of total billed charges,$21.25 ,Pays 100% Medicare OPPS,$21.25 ,Pays 100% Medicare OPPS,$21.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$29.75 ,35% based on GA Medicaid OP CCR Rate,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$76.50 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$17.31 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,306,$310.00 ,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,306,$310.00 ,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,85379,D DIMER,305,$345.00 ,$293.25 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$15.41 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$10.38 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$16.02 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$15.41 ,120.37% of custom fee schedule,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,80377,"DRUG SCREEN,SERUM(9 PANEL)",301,$40.00 ,$34.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$36.00 ,90% of total billed charges,$14.00 ,35% based on GA Medicaid OP CCR Rate,$27.48 ,68.7% of total billed charges,$32.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$23.20 ,58% of total billed charges,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$34.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$8.15 ,$36.00 ,$32.00 
Outpatient Medical Services,LAB,84560,URIC ACID SYNOVIAL FLUID,301,$150.00 ,$127.50 ,85% of total billed charges,$5.08 ,Pays 100% Medicare OPPS,$5.08 ,Pays 100% Medicare OPPS,$5.08 ,Pays 100% Medicare OPPS,$6.60 ,Pays 130% Medicare OPPS,$7.20 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.18 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$7.49 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.08 ,Pays 100% Medicare OPPS,$4.57 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.20 ,120.37% of custom fee schedule,$5.08 ,Pays 100% Medicare OPPS,$6.60 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.08 ,Pays 100% Medicare OPPS,$4.57 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,82055,...BLOOD ALCOHOL MULLINS,302,$165.00 ,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$33.61 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,84165,PROTEIN ELEC (24H URINE),301,$300.00 ,$255.00 ,85% of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$10.74 ,Pays 100% Medicare OPPS,$10.74 ,Pays 100% Medicare OPPS,$13.96 ,Pays 130% Medicare OPPS,$16.26 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$10.95 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$16.91 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$9.66 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$16.26 ,120.37% of custom fee schedule,$10.74 ,Pays 100% Medicare OPPS,$13.96 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$9.66 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,83901,"MOLECULAR DIAG AMP PNA,MU",301,$35.00 ,$29.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$7.13 ,20.37% based on GA Medicaid OP CCR Rate,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$31.50 ,90% of total billed charges,$12.25 ,35% based on GA Medicaid OP CCR Rate,$24.05 ,68.7% of total billed charges,$28.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$20.30 ,58% of total billed charges,$7.13 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$29.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$7.13 ,$31.50 ,$28.00 
Outpatient Medical Services,LAB,83891,MOLECULAR DIAG ISOL OR EXT PNA,301,$35.00 ,$29.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$7.13 ,20.37% based on GA Medicaid OP CCR Rate,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$31.50 ,90% of total billed charges,$12.25 ,35% based on GA Medicaid OP CCR Rate,$24.05 ,68.7% of total billed charges,$28.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$20.30 ,58% of total billed charges,$7.13 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$29.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$7.13 ,$31.50 ,$28.00 
Outpatient Medical Services,LAB,83912,MOLECULAR DGN I&R,301,$35.00 ,$29.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$7.13 ,20.37% based on GA Medicaid OP CCR Rate,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$31.50 ,90% of total billed charges,$12.25 ,35% based on GA Medicaid OP CCR Rate,$24.05 ,68.7% of total billed charges,$28.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$20.30 ,58% of total billed charges,$7.13 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$29.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$7.13 ,$31.50 ,$28.00 
Outpatient Medical Services,LAB,83900,MOLECULAR DIAG AMP OF PNA,301,$50.00 ,$42.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$10.19 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$17.50 ,35% based on GA Medicaid OP CCR Rate,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$10.19 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$10.19 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,83909,MOLECULAR DIAG SEP & ID,301,$35.00 ,$29.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$7.13 ,20.37% based on GA Medicaid OP CCR Rate,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$31.50 ,90% of total billed charges,$12.25 ,35% based on GA Medicaid OP CCR Rate,$24.05 ,68.7% of total billed charges,$28.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$20.30 ,58% of total billed charges,$7.13 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$29.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$7.13 ,$31.50 ,$28.00 
Outpatient Medical Services,LAB,82664,CHYLOMICRONS,301,$660.00 ,$561.00 ,85% of total billed charges,$61.50 ,Pays 100% Medicare OPPS,$61.50 ,Pays 100% Medicare OPPS,$61.50 ,Pays 100% Medicare OPPS,$79.95 ,Pays 130% Medicare OPPS,$52.00 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$62.73 ,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$54.08 ,125.18% of custom fee schedule,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,$61.50 ,Pays 100% Medicare OPPS,$55.35 ,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$52.00 ,120.37% of custom fee schedule,$61.50 ,Pays 100% Medicare OPPS,$79.95 ,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,$61.50 ,Pays 100% Medicare OPPS,$52.00 ,$594.00 ,$528.00 
Outpatient Medical Services,LAB,86316,NEURON SPECIFIC ENOLASE,302,$265.00 ,$225.25 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$31.49 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$21.22 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$32.75 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$31.49 ,120.37% of custom fee schedule,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,83519,3RD TRYPSIN LEVEL,301,$545.00 ,$463.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$20.45 ,20.37% based on GA Medicaid OP CCR Rate,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$18.76 ,Pays 102% Medicare OPPS,$490.50 ,90% of total billed charges,$21.27 ,125.18% of custom fee schedule,$374.42 ,68.7% of total billed charges,$436.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$316.10 ,58% of total billed charges,$20.45 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$463.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$490.50 ,$436.00 
Outpatient Medical Services,LAB,83891,MOLECULAR DGN ISOL OR EXT (APOE),301,$60.00 ,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$21.00 ,35% based on GA Medicaid OP CCR Rate,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$12.22 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,83892,MOLECULAR DGN ENZYMATIC DIGESTION (APOE),301,$60.00 ,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$21.00 ,35% based on GA Medicaid OP CCR Rate,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$12.22 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,83896,MOLECULAR DGN NAP (APOE),301,$60.00 ,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$21.00 ,35% based on GA Medicaid OP CCR Rate,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$12.22 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,83908,MOLECULAR DGN AMP (APOE),301,$60.00 ,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$21.00 ,35% based on GA Medicaid OP CCR Rate,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$12.22 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,83912,MOLECULAR DGN I&R (APOE),301,$60.00 ,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$21.00 ,35% based on GA Medicaid OP CCR Rate,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$12.22 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,81401,APOE GENOTYPE,301,$525.00 ,$446.25 ,85% of total billed charges,$137.00 ,Pays 100% Medicare OPPS,$137.00 ,Pays 100% Medicare OPPS,$137.00 ,Pays 100% Medicare OPPS,$178.10 ,Pays 130% Medicare OPPS,$134.81 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$139.74 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$140.20 ,125.18% of custom fee schedule,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$137.00 ,Pays 100% Medicare OPPS,$123.30 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$134.81 ,120.37% of custom fee schedule,$137.00 ,Pays 100% Medicare OPPS,$178.10 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$137.00 ,Pays 100% Medicare OPPS,$123.30 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,80150,AMIKACIN PEAK,301,$275.00 ,$233.75 ,85% of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$15.08 ,Pays 100% Medicare OPPS,$15.08 ,Pays 100% Medicare OPPS,$19.60 ,Pays 130% Medicare OPPS,$22.81 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$15.38 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$23.72 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$13.57 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$22.81 ,120.37% of custom fee schedule,$15.08 ,Pays 100% Medicare OPPS,$19.60 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$13.57 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,86905,RBC ANTIBODY TYPING,300,$215.00 ,$182.75 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$5.79 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$266.86 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$6.02 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$235.46 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$5.79 ,120.37% of custom fee schedule,$285.08 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$5.79 ,$370.60 ,$172.00 
Outpatient Medical Services,LAB,86900,"ANTIBODY ID,TITER, AND TYPING",302,$215.00 ,$182.75 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$4.51 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$4.69 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$4.51 ,120.37% of custom fee schedule,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$4.51 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,83519,THYROTROPIN RECPTOR AB,301,$365.00 ,$310.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$20.45 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$18.76 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$21.27 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$20.45 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86003,RAST FOR PENICILLIUM MOLD,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR HOPS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ASPERGILLIS (NIGER),302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR DUST MITE (HOUSE),302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,83519,3RD ACR BINDING AUTOANTIBODY,300,$125.00 ,$106.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$20.45 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$18.76 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$21.27 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$20.45 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,86255,AUTOANTIBODIES TOTAL,300,$125.00 ,$106.25 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,86003,DUST MITE D1,301,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,D2 DUST MITE,300,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,80377,DRUG SCREEN/W ETOH,301,$210.00 ,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$73.50 ,35% based on GA Medicaid OP CCR Rate,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$42.78 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,84478,TRIGLYCERIDES BODY FLUID,300,$285.00 ,$242.25 ,85% of total billed charges,$5.74 ,Pays 100% Medicare OPPS,$5.74 ,Pays 100% Medicare OPPS,$5.74 ,Pays 100% Medicare OPPS,$7.46 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$161.03 ,56.5 percent of total billed charges,$161.03 ,56.5 percent of total billed charges,$161.03 ,56.5 percent of total billed charges,$161.03 ,56.5 percent of total billed charges,$5.85 ,Pays 102% Medicare OPPS,$256.50 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$195.80 ,68.7% of total billed charges,$228.00 ,80 percent of total billed charges,$5.74 ,Pays 100% Medicare OPPS,$5.16 ,Pays 90% Medicare OPPS,$165.30 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$5.74 ,Pays 100% Medicare OPPS,$7.46 ,Pays 130% Medicare OPPS,$242.25 ,85% of total billed charges,$5.74 ,Pays 100% Medicare OPPS,$5.16 ,$256.50 ,$228.00 
Outpatient Medical Services,LAB,82106,ALPHA-FETOPROTEIN BODY FLUID,300,$220.00 ,$187.00 ,85% of total billed charges,$17.00 ,Pays 100% Medicare OPPS,$17.00 ,Pays 100% Medicare OPPS,$17.00 ,Pays 100% Medicare OPPS,$22.10 ,Pays 130% Medicare OPPS,$25.40 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$17.34 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$26.41 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$17.00 ,Pays 100% Medicare OPPS,$15.30 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$25.40 ,120.37% of custom fee schedule,$17.00 ,Pays 100% Medicare OPPS,$22.10 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$17.00 ,Pays 100% Medicare OPPS,$15.30 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,84597,VITAMIN K LEVEL,300,$265.00 ,$225.25 ,85% of total billed charges,$13.72 ,Pays 100% Medicare OPPS,$13.72 ,Pays 100% Medicare OPPS,$13.72 ,Pays 100% Medicare OPPS,$17.83 ,Pays 130% Medicare OPPS,$20.75 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$13.99 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$21.58 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$13.72 ,Pays 100% Medicare OPPS,$12.34 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$20.75 ,120.37% of custom fee schedule,$13.72 ,Pays 100% Medicare OPPS,$17.83 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$13.72 ,Pays 100% Medicare OPPS,$12.34 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,86160,C2 COMPLEMENT,300,$370.00 ,$314.50 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$18.18 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$12.24 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$18.90 ,125.18% of custom fee schedule,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$18.18 ,120.37% of custom fee schedule,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,$333.00 ,$296.00 
Outpatient Medical Services,LAB,87278,LEGIONELLA ANTIGEN FLUID/WASHING EIA,300,$265.00 ,$225.25 ,85% of total billed charges,$15.60 ,Pays 100% Medicare OPPS,$15.60 ,Pays 100% Medicare OPPS,$15.60 ,Pays 100% Medicare OPPS,$20.28 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$15.91 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$15.60 ,Pays 100% Medicare OPPS,$14.04 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$15.60 ,Pays 100% Medicare OPPS,$20.28 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$15.60 ,Pays 100% Medicare OPPS,$14.04 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,82103,ALPHA-1-ANTITRYPSIN STOOL,301,$475.00 ,$403.75 ,85% of total billed charges,$13.44 ,Pays 100% Medicare OPPS,$13.44 ,Pays 100% Medicare OPPS,$13.44 ,Pays 100% Medicare OPPS,$17.47 ,Pays 130% Medicare OPPS,$20.33 ,20.37% based on GA Medicaid OP CCR Rate,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$13.70 ,Pays 102% Medicare OPPS,$427.50 ,90% of total billed charges,$21.14 ,125.18% of custom fee schedule,$326.33 ,68.7% of total billed charges,$380.00 ,80 percent of total billed charges,$13.44 ,Pays 100% Medicare OPPS,$12.09 ,Pays 90% Medicare OPPS,$275.50 ,58% of total billed charges,$20.33 ,120.37% of custom fee schedule,$13.44 ,Pays 100% Medicare OPPS,$17.47 ,Pays 130% Medicare OPPS,$403.75 ,85% of total billed charges,$13.44 ,Pays 100% Medicare OPPS,$12.09 ,$427.50 ,$380.00 
Outpatient Medical Services,LAB,80377,"DRUG SCREEN STUDENT,UA",301,$50.00 ,$42.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$10.19 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$17.50 ,35% based on GA Medicaid OP CCR Rate,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$10.19 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$10.19 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,80367,3RD PORPHYRINS PLASMA,301,$540.00 ,$459.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$486.00 ,90% of total billed charges,$189.00 ,35% based on GA Medicaid OP CCR Rate,$370.98 ,68.7% of total billed charges,$432.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$313.20 ,58% of total billed charges,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$459.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$110.00 ,$486.00 ,$432.00 
Outpatient Medical Services,LAB,86615,3RD BORDTELLA PERTUSSIS IGM,301,$220.00 ,$187.00 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$19.97 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$13.45 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$20.77 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$19.97 ,120.37% of custom fee schedule,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,87081,Medical test to find an infection,301,$220.00 ,$187.00 ,85% of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$6.63 ,Pays 100% Medicare OPPS,$6.63 ,Pays 100% Medicare OPPS,$8.61 ,Pays 130% Medicare OPPS,$10.03 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$6.76 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$10.43 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$5.96 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$10.03 ,120.37% of custom fee schedule,$6.63 ,Pays 100% Medicare OPPS,$8.61 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$5.96 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,86235,.PL-7 AUTOABS,302,$110.00 ,$93.50 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,302,$110.00 ,$93.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,302,$110.00 ,$93.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,302,$110.00 ,$93.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,302,$110.00 ,$93.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,86235,.OJ AUTOABS,301,$175.00 ,$148.75 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,86235,.SRP AUTOABS,301,$175.00 ,$148.75 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,86160,C6 COMPLEMENT,302,$195.00 ,$165.75 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$18.18 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$12.24 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$18.90 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$18.18 ,120.37% of custom fee schedule,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,86160,C7 COMPLEMENT,302,$195.00 ,$165.75 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$18.18 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$12.24 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$18.90 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$18.18 ,120.37% of custom fee schedule,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,86160,C8 COMPLEMENT,302,$195.00 ,$165.75 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$18.18 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$12.24 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$18.90 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$18.18 ,120.37% of custom fee schedule,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,86160,C9 COMPLEMENT,302,$195.00 ,$165.75 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$18.18 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$12.24 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$18.90 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$18.18 ,120.37% of custom fee schedule,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,87899,STREPTOCOCCUS PNEUMONIAE  ANTIGENS URINE,302,$760.00 ,$646.00 ,85% of total billed charges,$16.07 ,Pays 100% Medicare OPPS,$16.07 ,Pays 100% Medicare OPPS,$16.07 ,Pays 100% Medicare OPPS,$20.89 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$16.39 ,Pays 102% Medicare OPPS,$684.00 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$522.12 ,68.7% of total billed charges,$608.00 ,80 percent of total billed charges,$16.07 ,Pays 100% Medicare OPPS,$14.46 ,Pays 90% Medicare OPPS,$440.80 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$16.07 ,Pays 100% Medicare OPPS,$20.89 ,Pays 130% Medicare OPPS,$646.00 ,85% of total billed charges,$16.07 ,Pays 100% Medicare OPPS,$14.46 ,$684.00 ,$608.00 
Outpatient Medical Services,LAB,86692,3RD HEPATITIS D VIRUS IGM AB,301,$795.00 ,$675.75 ,85% of total billed charges,$17.16 ,Pays 100% Medicare OPPS,$17.16 ,Pays 100% Medicare OPPS,$17.16 ,Pays 100% Medicare OPPS,$22.30 ,Pays 130% Medicare OPPS,$25.98 ,20.37% based on GA Medicaid OP CCR Rate,$449.18 ,56.5 percent of total billed charges,$449.18 ,56.5 percent of total billed charges,$449.18 ,56.5 percent of total billed charges,$449.18 ,56.5 percent of total billed charges,$17.50 ,Pays 102% Medicare OPPS,$715.50 ,90% of total billed charges,$27.01 ,125.18% of custom fee schedule,$546.17 ,68.7% of total billed charges,$636.00 ,80 percent of total billed charges,$17.16 ,Pays 100% Medicare OPPS,$15.44 ,Pays 90% Medicare OPPS,$461.10 ,58% of total billed charges,$25.98 ,120.37% of custom fee schedule,$17.16 ,Pays 100% Medicare OPPS,$22.30 ,Pays 130% Medicare OPPS,$675.75 ,85% of total billed charges,$17.16 ,Pays 100% Medicare OPPS,$15.44 ,$715.50 ,$636.00 
Outpatient Medical Services,LAB,83891,.ISOLATION OR EXT NA TPMT,301,$135.00 ,$114.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$47.25 ,35% based on GA Medicaid OP CCR Rate,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$27.50 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,83890,".MOLECULAR DIAG, ISOL TPMT",301,$135.00 ,$114.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$47.25 ,35% based on GA Medicaid OP CCR Rate,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$27.50 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,83901,.MOLECULAR AMP TPMT,301,$135.00 ,$114.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$47.25 ,35% based on GA Medicaid OP CCR Rate,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$27.50 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,83912,.MOLECULAR I&R TPMT,301,$135.00 ,$114.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$47.25 ,35% based on GA Medicaid OP CCR Rate,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$27.50 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,81335,.MUTATION ID TPMT,301,$135.00 ,$114.75 ,85% of total billed charges,$174.81 ,Pays 100% Medicare OPPS,$174.81 ,Pays 100% Medicare OPPS,$174.81 ,Pays 100% Medicare OPPS,$227.25 ,Pays 130% Medicare OPPS,$168.34 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$178.30 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$175.06 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$174.81 ,Pays 100% Medicare OPPS,$157.32 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$168.34 ,120.37% of custom fee schedule,$174.81 ,Pays 100% Medicare OPPS,$227.25 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$174.81 ,Pays 100% Medicare OPPS,$76.28 ,$227.25 ,$108.00 
Outpatient Medical Services,LAB,81401,3RD TPMT GENOTYPE,300,"$1,990.00 ","$1,691.50 ",85% of total billed charges,$137.00 ,Pays 100% Medicare OPPS,$137.00 ,Pays 100% Medicare OPPS,$137.00 ,Pays 100% Medicare OPPS,$178.10 ,Pays 130% Medicare OPPS,$134.81 ,20.37% based on GA Medicaid OP CCR Rate,"$1,124.35 ",56.5 percent of total billed charges,"$1,124.35 ",56.5 percent of total billed charges,"$1,124.35 ",56.5 percent of total billed charges,"$1,124.35 ",56.5 percent of total billed charges,$139.74 ,Pays 102% Medicare OPPS,"$1,791.00 ",90% of total billed charges,$140.20 ,125.18% of custom fee schedule,"$1,367.13 ",68.7% of total billed charges,"$1,592.00 ",80 percent of total billed charges,$137.00 ,Pays 100% Medicare OPPS,$123.30 ,Pays 90% Medicare OPPS,"$1,154.20 ",58% of total billed charges,$134.81 ,120.37% of custom fee schedule,$137.00 ,Pays 100% Medicare OPPS,$178.10 ,Pays 130% Medicare OPPS,"$1,691.50 ",85% of total billed charges,$137.00 ,Pays 100% Medicare OPPS,$123.30 ,"$1,791.00 ","$1,592.00 "
Outpatient Medical Services,LAB,82175,"ARSENIC, BLOOD",301,$165.00 ,$140.25 ,85% of total billed charges,$18.97 ,Pays 100% Medicare OPPS,$18.97 ,Pays 100% Medicare OPPS,$18.97 ,Pays 100% Medicare OPPS,$24.66 ,Pays 130% Medicare OPPS,$28.72 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$19.34 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$29.87 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$18.97 ,Pays 100% Medicare OPPS,$17.07 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$28.72 ,120.37% of custom fee schedule,$18.97 ,Pays 100% Medicare OPPS,$24.66 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$18.97 ,Pays 100% Medicare OPPS,$17.07 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,86235,................RNP ANTIBODY,302,$170.00 ,$144.50 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,84030,PHENYLALANINE PLASMA,301,$260.00 ,$221.00 ,85% of total billed charges,$5.50 ,Pays 100% Medicare OPPS,$5.50 ,Pays 100% Medicare OPPS,$5.50 ,Pays 100% Medicare OPPS,$7.15 ,Pays 130% Medicare OPPS,$8.33 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$5.61 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$8.66 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$5.50 ,Pays 100% Medicare OPPS,$4.95 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$8.33 ,120.37% of custom fee schedule,$5.50 ,Pays 100% Medicare OPPS,$7.15 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$5.50 ,Pays 100% Medicare OPPS,$4.95 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86611,.BARTONELLA HENSELAE IgM,302,$370.00 ,$314.50 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$15.41 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$10.38 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$16.02 ,125.18% of custom fee schedule,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$15.41 ,120.37% of custom fee schedule,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,$333.00 ,$296.00 
Outpatient Medical Services,LAB,80299,.6-METHYLMERCAPTOPURINE,301,$335.00 ,$284.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$301.50 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$230.15 ,68.7% of total billed charges,$268.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$194.30 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$284.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$301.50 ,$268.00 
Outpatient Medical Services,LAB,80299,.6-THIOGUANINE,301,$335.00 ,$284.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$301.50 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$230.15 ,68.7% of total billed charges,$268.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$194.30 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$284.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$301.50 ,$268.00 
Outpatient Medical Services,LAB,84402,.TESTOSTERONE ASSAY,301,$165.00 ,$140.25 ,85% of total billed charges,$25.47 ,Pays 100% Medicare OPPS,$25.47 ,Pays 100% Medicare OPPS,$25.47 ,Pays 100% Medicare OPPS,$33.11 ,Pays 130% Medicare OPPS,$38.53 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$25.97 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$40.07 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$25.47 ,Pays 100% Medicare OPPS,$22.92 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$38.53 ,120.37% of custom fee schedule,$25.47 ,Pays 100% Medicare OPPS,$33.11 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$25.47 ,Pays 100% Medicare OPPS,$22.92 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,84270,.SEX HORMOME GLOBUL,301,$165.00 ,$140.25 ,85% of total billed charges,$21.73 ,Pays 100% Medicare OPPS,$21.73 ,Pays 100% Medicare OPPS,$21.73 ,Pays 100% Medicare OPPS,$28.24 ,Pays 130% Medicare OPPS,$32.89 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$22.16 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$34.20 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$21.73 ,Pays 100% Medicare OPPS,$19.55 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$32.89 ,120.37% of custom fee schedule,$21.73 ,Pays 100% Medicare OPPS,$28.24 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$21.73 ,Pays 100% Medicare OPPS,$19.55 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,82384,CATECHOLAMINE UA 24 HR,301,$415.00 ,$352.75 ,85% of total billed charges,$25.25 ,Pays 100% Medicare OPPS,$25.25 ,Pays 100% Medicare OPPS,$25.25 ,Pays 100% Medicare OPPS,$32.82 ,Pays 130% Medicare OPPS,$38.22 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$25.75 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$39.74 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$25.25 ,Pays 100% Medicare OPPS,$22.72 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$38.22 ,120.37% of custom fee schedule,$25.25 ,Pays 100% Medicare OPPS,$32.82 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$25.25 ,Pays 100% Medicare OPPS,$22.72 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,80307,Testing for presence of drug,301,$80.00 ,$68.00 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$73.62 ,20.37% based on GA Medicaid OP CCR Rate,$45.20 ,56.5 percent of total billed charges,$45.20 ,56.5 percent of total billed charges,$45.20 ,56.5 percent of total billed charges,$45.20 ,56.5 percent of total billed charges,$63.38 ,Pays 102% Medicare OPPS,$72.00 ,90% of total billed charges,$76.56 ,125.18% of custom fee schedule,$54.96 ,68.7% of total billed charges,$64.00 ,80 percent of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,Pays 90% Medicare OPPS,$46.40 ,58% of total billed charges,$73.62 ,120.37% of custom fee schedule,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$68.00 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$45.20 ,$80.78 ,$64.00 
Outpatient Medical Services,LAB,85306,PROTEIN S ANTIGEN FREE,305,$145.00 ,$123.25 ,85% of total billed charges,$15.32 ,Pays 100% Medicare OPPS,$15.32 ,Pays 100% Medicare OPPS,$15.32 ,Pays 100% Medicare OPPS,$19.91 ,Pays 130% Medicare OPPS,$23.20 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$15.62 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$24.12 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$15.32 ,Pays 100% Medicare OPPS,$13.78 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$23.20 ,120.37% of custom fee schedule,$15.32 ,Pays 100% Medicare OPPS,$19.91 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$15.32 ,Pays 100% Medicare OPPS,$13.78 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,84311,PHOSOPOLIPIDS AB,301,$95.00 ,$80.75 ,85% of total billed charges,$8.10 ,Pays 100% Medicare OPPS,$8.10 ,Pays 100% Medicare OPPS,$8.10 ,Pays 100% Medicare OPPS,$10.53 ,Pays 130% Medicare OPPS,$10.58 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$8.26 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$11.00 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$8.10 ,Pays 100% Medicare OPPS,$7.29 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$10.58 ,120.37% of custom fee schedule,$8.10 ,Pays 100% Medicare OPPS,$10.53 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$8.10 ,Pays 100% Medicare OPPS,$7.29 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,87799,3RD BK VIRUS QUANT PCR SERUM,301,$720.00 ,$612.00 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$146.66 ,20.37% based on GA Medicaid OP CCR Rate,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$43.69 ,Pays 102% Medicare OPPS,$648.00 ,90% of total billed charges,$252.00 ,35% based on GA Medicaid OP CCR Rate,$494.64 ,68.7% of total billed charges,$576.00 ,80 percent of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,Pays 90% Medicare OPPS,$417.60 ,58% of total billed charges,$146.66 ,20.37% based on GA Medicaid OP CCR Rate,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$612.00 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,$648.00 ,$576.00 
Outpatient Medical Services,LAB,86003,RAST FOR CRAYFISH,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,83921,3RD METHYLMALONIC ACID URINE,301,$525.00 ,$446.25 ,85% of total billed charges,$21.21 ,Pays 100% Medicare OPPS,$21.21 ,Pays 100% Medicare OPPS,$21.21 ,Pays 100% Medicare OPPS,$27.57 ,Pays 130% Medicare OPPS,$24.92 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$21.63 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$25.91 ,125.18% of custom fee schedule,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$21.21 ,Pays 100% Medicare OPPS,$19.08 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$24.92 ,120.37% of custom fee schedule,$21.21 ,Pays 100% Medicare OPPS,$27.57 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$21.21 ,Pays 100% Medicare OPPS,$19.08 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,86003,RAST FOR RABBIT EPITHELIAL,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86146,.B2 IGG,300,$125.00 ,$106.25 ,85% of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$25.45 ,Pays 100% Medicare OPPS,$25.45 ,Pays 100% Medicare OPPS,$33.08 ,Pays 130% Medicare OPPS,$38.51 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$25.95 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$40.05 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$22.90 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$38.51 ,120.37% of custom fee schedule,$25.45 ,Pays 100% Medicare OPPS,$33.08 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$22.90 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,86146,.B2 IGM,300,$125.00 ,$106.25 ,85% of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$25.45 ,Pays 100% Medicare OPPS,$25.45 ,Pays 100% Medicare OPPS,$33.08 ,Pays 130% Medicare OPPS,$38.51 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$25.95 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$40.05 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$22.90 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$38.51 ,120.37% of custom fee schedule,$25.45 ,Pays 100% Medicare OPPS,$33.08 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$22.90 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,86146,.B2 IGA,300,$125.00 ,$106.25 ,85% of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$25.45 ,Pays 100% Medicare OPPS,$25.45 ,Pays 100% Medicare OPPS,$33.08 ,Pays 130% Medicare OPPS,$38.51 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$25.95 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$40.05 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$22.90 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$38.51 ,120.37% of custom fee schedule,$25.45 ,Pays 100% Medicare OPPS,$33.08 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$22.90 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,301,$125.00 ,$106.25 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,301,$125.00 ,$106.25 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,80299,3RD LACOSAMIDE/VIMPAT,306,$175.00 ,$148.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,80299,FELBAMATE,301,$190.00 ,$161.50 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,87045,.SHIGA TOXIN 1,306,$75.00 ,$63.75 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$15.28 ,20.37% based on GA Medicaid OP CCR Rate,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$9.62 ,Pays 102% Medicare OPPS,$67.50 ,90% of total billed charges,$26.25 ,35% based on GA Medicaid OP CCR Rate,$51.53 ,68.7% of total billed charges,$60.00 ,80 percent of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$8.49 ,Pays 90% Medicare OPPS,$43.50 ,58% of total billed charges,$15.28 ,20.37% based on GA Medicaid OP CCR Rate,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$63.75 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$8.49 ,$67.50 ,$60.00 
Outpatient Medical Services,LAB,87427,.SHIGA TOXIN 2,306,$75.00 ,$63.75 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$12.21 ,Pays 102% Medicare OPPS,$67.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$51.53 ,68.7% of total billed charges,$60.00 ,80 percent of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,Pays 90% Medicare OPPS,$43.50 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$63.75 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,$67.50 ,$60.00 
Outpatient Medical Services,LAB,87045,.CULTURE STOOL,306,$100.00 ,$85.00 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$9.62 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$35.00 ,35% based on GA Medicaid OP CCR Rate,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$8.49 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$8.49 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,86003,RAST FOR CASHEW,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,80376,"DRUG SCREEN, 5 PANEL QUEST",301,$50.00 ,$42.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$10.19 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$17.50 ,35% based on GA Medicaid OP CCR Rate,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$10.19 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$10.19 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,86003,AMOXICILLIN IGE,302,$165.00 ,$140.25 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,86003,AMPICILLIN IGE,302,$165.00 ,$140.25 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,86255,.ENDOMYSIAL IGA,301,$125.00 ,$106.25 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,82088,.ALDOSTERONE,302,$175.00 ,$148.75 ,85% of total billed charges,$40.75 ,Pays 100% Medicare OPPS,$40.75 ,Pays 100% Medicare OPPS,$40.75 ,Pays 100% Medicare OPPS,$52.97 ,Pays 130% Medicare OPPS,$61.69 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$41.56 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$64.15 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$40.75 ,Pays 100% Medicare OPPS,$36.67 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$61.69 ,120.37% of custom fee schedule,$40.75 ,Pays 100% Medicare OPPS,$52.97 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$40.75 ,Pays 100% Medicare OPPS,$36.67 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,84244,.RENIN,302,$110.00 ,$93.50 ,85% of total billed charges,$21.99 ,Pays 100% Medicare OPPS,$21.99 ,Pays 100% Medicare OPPS,$21.99 ,Pays 100% Medicare OPPS,$28.58 ,Pays 130% Medicare OPPS,$33.29 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$22.42 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$34.62 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$21.99 ,Pays 100% Medicare OPPS,$19.79 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$33.29 ,120.37% of custom fee schedule,$21.99 ,Pays 100% Medicare OPPS,$28.58 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$21.99 ,Pays 100% Medicare OPPS,$19.79 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,301,$145.00 ,$123.25 ,85% of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.93 ,Pays 100% Medicare OPPS,$3.93 ,Pays 100% Medicare OPPS,$5.10 ,Pays 130% Medicare OPPS,$5.93 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.00 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$6.17 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.53 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$5.93 ,120.37% of custom fee schedule,$3.93 ,Pays 100% Medicare OPPS,$5.10 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.53 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,84295,I-STAT SODIUM,301,$145.00 ,$123.25 ,85% of total billed charges,$4.80 ,Pays 100% Medicare OPPS,$4.80 ,Pays 100% Medicare OPPS,$4.80 ,Pays 100% Medicare OPPS,$6.25 ,Pays 130% Medicare OPPS,$7.28 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.90 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$7.57 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.80 ,Pays 100% Medicare OPPS,$4.32 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$7.28 ,120.37% of custom fee schedule,$4.80 ,Pays 100% Medicare OPPS,$6.25 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.80 ,Pays 100% Medicare OPPS,$4.32 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,84132,I-STAT POTASSIUM,301,$145.00 ,$123.25 ,85% of total billed charges,$4.76 ,Pays 100% Medicare OPPS,$4.76 ,Pays 100% Medicare OPPS,$4.76 ,Pays 100% Medicare OPPS,$6.18 ,Pays 130% Medicare OPPS,$6.96 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.85 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$7.24 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.76 ,Pays 100% Medicare OPPS,$4.28 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$6.96 ,120.37% of custom fee schedule,$4.76 ,Pays 100% Medicare OPPS,$6.18 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.76 ,Pays 100% Medicare OPPS,$4.28 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82435,I-STAT CHLORIDE,301,$145.00 ,$123.25 ,85% of total billed charges,$4.59 ,Pays 100% Medicare OPPS,$4.59 ,Pays 100% Medicare OPPS,$4.59 ,Pays 100% Medicare OPPS,$5.98 ,Pays 130% Medicare OPPS,$6.96 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.69 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$7.24 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.59 ,Pays 100% Medicare OPPS,$4.13 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$6.96 ,120.37% of custom fee schedule,$4.59 ,Pays 100% Medicare OPPS,$5.98 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.59 ,Pays 100% Medicare OPPS,$4.13 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,84520,I-STAT BUN,301,$150.00 ,$127.50 ,85% of total billed charges,$3.95 ,Pays 100% Medicare OPPS,$3.95 ,Pays 100% Medicare OPPS,$3.95 ,Pays 100% Medicare OPPS,$5.13 ,Pays 130% Medicare OPPS,$5.97 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$4.02 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$6.21 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$3.95 ,Pays 100% Medicare OPPS,$3.55 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$5.97 ,120.37% of custom fee schedule,$3.95 ,Pays 100% Medicare OPPS,$5.13 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$3.95 ,Pays 100% Medicare OPPS,$3.55 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,80047,I-STAT IONIZED CA++,301,$150.00 ,$127.50 ,85% of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$13.73 ,Pays 100% Medicare OPPS,$13.73 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$33.05 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$14.00 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$34.37 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$12.35 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$33.05 ,120.37% of custom fee schedule,$13.73 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$12.35 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,82374,I-STAT TCO2,301,$135.00 ,$114.75 ,85% of total billed charges,$4.88 ,Pays 100% Medicare OPPS,$4.88 ,Pays 100% Medicare OPPS,$4.88 ,Pays 100% Medicare OPPS,$6.34 ,Pays 130% Medicare OPPS,$7.40 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.97 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$7.70 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.88 ,Pays 100% Medicare OPPS,$4.39 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.40 ,120.37% of custom fee schedule,$4.88 ,Pays 100% Medicare OPPS,$6.34 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$4.88 ,Pays 100% Medicare OPPS,$4.39 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,82565,I-STAT CREATININE,301,$150.00 ,$127.50 ,85% of total billed charges,$5.12 ,Pays 100% Medicare OPPS,$5.12 ,Pays 100% Medicare OPPS,$5.12 ,Pays 100% Medicare OPPS,$6.65 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.22 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.12 ,Pays 100% Medicare OPPS,$4.60 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$5.12 ,Pays 100% Medicare OPPS,$6.65 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.12 ,Pays 100% Medicare OPPS,$4.60 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,84484,Blood test to measure a certain protein in the blood to determine heart muscle damage,301,$295.00 ,$250.75 ,85% of total billed charges,$12.47 ,Pays 100% Medicare OPPS,$12.47 ,Pays 100% Medicare OPPS,$12.47 ,Pays 100% Medicare OPPS,$16.21 ,Pays 130% Medicare OPPS,$14.90 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$12.71 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$15.50 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$12.47 ,Pays 100% Medicare OPPS,$11.22 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$14.90 ,120.37% of custom fee schedule,$12.47 ,Pays 100% Medicare OPPS,$16.21 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$12.47 ,Pays 100% Medicare OPPS,$11.22 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,87324,A test of the stool to diagnose Clostridium difficile (C. diff) infection,300,$145.00 ,$123.25 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$12.21 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,87449,.C DIFF ANTIGEN,300,$145.00 ,$123.25 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$12.21 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,86317,.IMMUNOSSAY INFECTIOUS AGENT,301,$60.00 ,$51.00 ,85% of total billed charges,$14.99 ,Pays 100% Medicare OPPS,$14.99 ,Pays 100% Medicare OPPS,$14.99 ,Pays 100% Medicare OPPS,$19.48 ,Pays 130% Medicare OPPS,$18.16 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$15.28 ,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$18.89 ,125.18% of custom fee schedule,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,$14.99 ,Pays 100% Medicare OPPS,$13.49 ,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$18.16 ,120.37% of custom fee schedule,$14.99 ,Pays 100% Medicare OPPS,$19.48 ,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,$14.99 ,Pays 100% Medicare OPPS,$13.49 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,83036,Blood test to measure average blood glucose levels for past 2-3 months,301,$245.00 ,$208.25 ,85% of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$9.71 ,Pays 100% Medicare OPPS,$9.71 ,Pays 100% Medicare OPPS,$12.62 ,Pays 130% Medicare OPPS,$14.69 ,20.37% based on GA Medicaid OP CCR Rate,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$9.90 ,Pays 102% Medicare OPPS,$220.50 ,90% of total billed charges,$15.27 ,125.18% of custom fee schedule,$168.32 ,68.7% of total billed charges,$196.00 ,80 percent of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$8.73 ,Pays 90% Medicare OPPS,$142.10 ,58% of total billed charges,$14.69 ,120.37% of custom fee schedule,$9.71 ,Pays 100% Medicare OPPS,$12.62 ,Pays 130% Medicare OPPS,$208.25 ,85% of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$8.73 ,$220.50 ,$196.00 
Outpatient Medical Services,LAB,82656,3RD PANCREATIC ELASTASE,301,$885.00 ,$752.25 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$796.50 ,90% of total billed charges,$309.75 ,35% based on GA Medicaid OP CCR Rate,$608.00 ,68.7% of total billed charges,$708.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$513.30 ,58% of total billed charges,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$752.25 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$796.50 ,$708.00 
Outpatient Medical Services,LAB,86003,RAST FOR HICKORY WHITE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR WHEY,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ALPHA LACTA ALBUMIN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR BETA LACTOGLOBULIN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,82397,MULLERIAN HORMONE ANTIBODY,302,$215.00 ,$182.75 ,85% of total billed charges,$14.12 ,Pays 100% Medicare OPPS,$14.12 ,Pays 100% Medicare OPPS,$14.12 ,Pays 100% Medicare OPPS,$18.35 ,Pays 130% Medicare OPPS,$21.39 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$14.40 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$22.24 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$14.12 ,Pays 100% Medicare OPPS,$12.70 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$21.39 ,120.37% of custom fee schedule,$14.12 ,Pays 100% Medicare OPPS,$18.35 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$14.12 ,Pays 100% Medicare OPPS,$12.70 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,83018,3RD COBALT BLOOD LEVEL,301,$145.00 ,$123.25 ,85% of total billed charges,$21.96 ,Pays 100% Medicare OPPS,$21.96 ,Pays 100% Medicare OPPS,$21.96 ,Pays 100% Medicare OPPS,$28.54 ,Pays 130% Medicare OPPS,$33.23 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$22.39 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$34.56 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$21.96 ,Pays 100% Medicare OPPS,$19.76 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$33.23 ,120.37% of custom fee schedule,$21.96 ,Pays 100% Medicare OPPS,$28.54 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$21.96 ,Pays 100% Medicare OPPS,$19.76 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,300,$150.00 ,$127.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,82436,CHLORIDE URINE 24 HR,301,$145.00 ,$123.25 ,85% of total billed charges,$5.75 ,Pays 100% Medicare OPPS,$5.75 ,Pays 100% Medicare OPPS,$5.75 ,Pays 100% Medicare OPPS,$7.47 ,Pays 130% Medicare OPPS,$7.61 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$5.86 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$7.91 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$5.75 ,Pays 100% Medicare OPPS,$5.17 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$7.61 ,120.37% of custom fee schedule,$5.75 ,Pays 100% Medicare OPPS,$7.47 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$5.75 ,Pays 100% Medicare OPPS,$5.17 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,86677,Blood test to if peptic ulcers are caused by a certain bacterium,302,$260.00 ,$221.00 ,85% of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$16.85 ,Pays 100% Medicare OPPS,$16.85 ,Pays 100% Medicare OPPS,$21.90 ,Pays 130% Medicare OPPS,$21.97 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$17.18 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$22.85 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$15.16 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$21.97 ,120.37% of custom fee schedule,$16.85 ,Pays 100% Medicare OPPS,$21.90 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$15.16 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,306,$310.00 ,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,80346,CLONAZEPAM LEVEL,301,$320.00 ,$272.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$28.00 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$29.12 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$28.00 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$28.00 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80377,DRUG SCREEN EMH CONTRACT,301,$125.00 ,$106.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$25.46 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$43.75 ,35% based on GA Medicaid OP CCR Rate,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$25.46 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$25.46 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,80299,3RD TPMT LEVEL,301,$720.00 ,$612.00 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$648.00 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$494.64 ,68.7% of total billed charges,$576.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$417.60 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$612.00 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$648.00 ,$576.00 
Outpatient Medical Services,LAB,86003,RAST FOR DUST MITE (DERMATOPHAGOIDES PTE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR DUST MITE (FARINAE),302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR DOG DANDER,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ASPERGILLIS (FUMIGATUS),302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,82043,Urine test to measure albumin,301,$150.00 ,$127.50 ,85% of total billed charges,$5.78 ,Pays 100% Medicare OPPS,$5.78 ,Pays 100% Medicare OPPS,$5.78 ,Pays 100% Medicare OPPS,$7.51 ,Pays 130% Medicare OPPS,$8.76 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.89 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$9.11 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.78 ,Pays 100% Medicare OPPS,$5.20 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$8.76 ,120.37% of custom fee schedule,$5.78 ,Pays 100% Medicare OPPS,$7.51 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.78 ,Pays 100% Medicare OPPS,$5.20 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,89050,.CELL COUNT CSF,300,$135.00 ,$114.75 ,85% of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,$7.16 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.81 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$7.45 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.16 ,120.37% of custom fee schedule,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,89050,WBC BF,305,$95.00 ,$80.75 ,85% of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,$7.16 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$4.81 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$7.45 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$7.16 ,120.37% of custom fee schedule,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,89050,RBC BF,305,$95.00 ,$80.75 ,85% of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,$7.16 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$4.81 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$7.45 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$7.16 ,120.37% of custom fee schedule,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,86003,RAST FOR CEPHALOSPORIN IGE,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR ERYTHROMYCIN,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,81001,Manual urinalysis test with examination with or without using microscope,300,$175.00 ,$148.75 ,85% of total billed charges,$3.17 ,Pays 100% Medicare OPPS,$3.17 ,Pays 100% Medicare OPPS,$3.17 ,Pays 100% Medicare OPPS,$4.12 ,Pays 130% Medicare OPPS,$4.80 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$3.23 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$4.99 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$3.17 ,Pays 100% Medicare OPPS,$2.85 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$4.80 ,120.37% of custom fee schedule,$3.17 ,Pays 100% Medicare OPPS,$4.12 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$3.17 ,Pays 100% Medicare OPPS,$2.85 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,86003,RAST FOR MUCOR RACEMOSUS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86003,RAST FOR R. NIGRICANS,302,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86617,.LYME IGG,302,$100.00 ,$85.00 ,85% of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$15.49 ,Pays 100% Medicare OPPS,$15.49 ,Pays 100% Medicare OPPS,$20.13 ,Pays 130% Medicare OPPS,$23.45 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$15.79 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$24.39 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$13.94 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$23.45 ,120.37% of custom fee schedule,$15.49 ,Pays 100% Medicare OPPS,$20.13 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$13.94 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,86617,.LYME IGM,302,$100.00 ,$85.00 ,85% of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$15.49 ,Pays 100% Medicare OPPS,$15.49 ,Pays 100% Medicare OPPS,$20.13 ,Pays 130% Medicare OPPS,$23.45 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$15.79 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$24.39 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$13.94 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$23.45 ,120.37% of custom fee schedule,$15.49 ,Pays 100% Medicare OPPS,$20.13 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$13.94 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,84442,THYROXINE BINDING GLOBULIN,306,$50.00 ,$42.50 ,85% of total billed charges,$14.78 ,Pays 100% Medicare OPPS,$14.78 ,Pays 100% Medicare OPPS,$14.78 ,Pays 100% Medicare OPPS,$19.21 ,Pays 130% Medicare OPPS,$17.61 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$15.07 ,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$18.31 ,125.18% of custom fee schedule,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,$14.78 ,Pays 100% Medicare OPPS,$13.30 ,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$17.61 ,120.37% of custom fee schedule,$14.78 ,Pays 100% Medicare OPPS,$19.21 ,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,$14.78 ,Pays 100% Medicare OPPS,$13.30 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,83883,.KAPPA/LAMBA,302,$110.00 ,$93.50 ,85% of total billed charges,$13.60 ,Pays 100% Medicare OPPS,$13.60 ,Pays 100% Medicare OPPS,$13.60 ,Pays 100% Medicare OPPS,$17.68 ,Pays 130% Medicare OPPS,$20.58 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$13.87 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$21.41 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$13.60 ,Pays 100% Medicare OPPS,$12.24 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$20.58 ,120.37% of custom fee schedule,$13.60 ,Pays 100% Medicare OPPS,$17.68 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$13.60 ,Pays 100% Medicare OPPS,$12.24 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,87522,POSITIVE HCV,301,$190.00 ,$161.50 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$64.84 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$43.69 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$67.43 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$64.84 ,120.37% of custom fee schedule,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,86609,.BACTERIUM AB,301,$60.00 ,$51.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,86021,POSITIVE ANCA TITER,302,$110.00 ,$93.50 ,85% of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$15.05 ,Pays 100% Medicare OPPS,$15.05 ,Pays 100% Medicare OPPS,$19.56 ,Pays 130% Medicare OPPS,$22.79 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$15.35 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$23.70 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$13.54 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$22.79 ,120.37% of custom fee schedule,$15.05 ,Pays 100% Medicare OPPS,$19.56 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$13.54 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,83520,3RD ADALIMUMAB AND ANTI ADALIMUMAB AB,301,$660.00 ,$561.00 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$594.00 ,$528.00 
Outpatient Medical Services,LAB,85025,"Complete blood cell count, with differential white blood cells, automated",300,$265.00 ,$225.25 ,85% of total billed charges,$7.77 ,Pays 100% Medicare OPPS,$7.77 ,Pays 100% Medicare OPPS,$7.77 ,Pays 100% Medicare OPPS,$10.10 ,Pays 130% Medicare OPPS,$11.76 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$7.92 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$12.23 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$7.77 ,Pays 100% Medicare OPPS,$6.99 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$11.76 ,120.37% of custom fee schedule,$7.77 ,Pays 100% Medicare OPPS,$10.10 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$7.77 ,Pays 100% Medicare OPPS,$6.99 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,82306,Blood test to monitor vitamin D levels,301,$190.00 ,$161.50 ,85% of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$29.60 ,Pays 100% Medicare OPPS,$29.60 ,Pays 100% Medicare OPPS,$38.48 ,Pays 130% Medicare OPPS,$44.80 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$30.19 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$46.59 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$26.64 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$44.80 ,120.37% of custom fee schedule,$29.60 ,Pays 100% Medicare OPPS,$38.48 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$26.64 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,82306,Blood test to monitor vitamin D levels,301,$190.00 ,$161.50 ,85% of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$29.60 ,Pays 100% Medicare OPPS,$29.60 ,Pays 100% Medicare OPPS,$38.48 ,Pays 130% Medicare OPPS,$44.80 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$30.19 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$46.59 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$26.64 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$44.80 ,120.37% of custom fee schedule,$29.60 ,Pays 100% Medicare OPPS,$38.48 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$26.64 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,82306,Blood test to monitor vitamin D levels,301,$190.00 ,$161.50 ,85% of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$29.60 ,Pays 100% Medicare OPPS,$29.60 ,Pays 100% Medicare OPPS,$38.48 ,Pays 130% Medicare OPPS,$44.80 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$30.19 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$46.59 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$26.64 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$44.80 ,120.37% of custom fee schedule,$29.60 ,Pays 100% Medicare OPPS,$38.48 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$26.64 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,86235,SMITH ANTIBODY,302,$165.00 ,$140.25 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$27.14 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$18.28 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$28.23 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$27.14 ,120.37% of custom fee schedule,$17.93 ,Pays 100% Medicare OPPS,$23.30 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$17.93 ,Pays 100% Medicare OPPS,$16.13 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,80307,Testing for presence of drug,301,$215.00 ,$182.75 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$73.62 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$63.38 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$76.56 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$73.62 ,120.37% of custom fee schedule,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,86343,3RD HISTAMINE RELEASE,305,$345.00 ,$293.25 ,85% of total billed charges,$12.46 ,Pays 100% Medicare OPPS,$12.46 ,Pays 100% Medicare OPPS,$12.46 ,Pays 100% Medicare OPPS,$16.19 ,Pays 130% Medicare OPPS,$18.86 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$12.70 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$19.62 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$12.46 ,Pays 100% Medicare OPPS,$11.21 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$18.86 ,120.37% of custom fee schedule,$12.46 ,Pays 100% Medicare OPPS,$16.19 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$12.46 ,Pays 100% Medicare OPPS,$11.21 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,301,$295.00 ,$250.75 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,84479,.T 3 UPTAKE (EFCH),301,$150.00 ,$127.50 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$9.80 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$6.59 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$10.19 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$9.80 ,120.37% of custom fee schedule,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,84436,Blood test to measure a type of thyroid hormone,301,$125.00 ,$106.25 ,85% of total billed charges,$6.87 ,Pays 100% Medicare OPPS,$6.87 ,Pays 100% Medicare OPPS,$6.87 ,Pays 100% Medicare OPPS,$8.93 ,Pays 130% Medicare OPPS,$10.41 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$7.00 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$10.83 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$6.87 ,Pays 100% Medicare OPPS,$6.18 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$10.41 ,120.37% of custom fee schedule,$6.87 ,Pays 100% Medicare OPPS,$8.93 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$6.87 ,Pays 100% Medicare OPPS,$6.18 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,82607,Blood test to measure B-12,301,$190.00 ,$161.50 ,85% of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$15.08 ,Pays 100% Medicare OPPS,$15.08 ,Pays 100% Medicare OPPS,$19.60 ,Pays 130% Medicare OPPS,$22.81 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$15.38 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$23.72 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$13.57 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$22.81 ,120.37% of custom fee schedule,$15.08 ,Pays 100% Medicare OPPS,$19.60 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$13.57 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,82746,.FOLATE SERUM (EFCH),301,$190.00 ,$161.50 ,85% of total billed charges,$14.70 ,Pays 100% Medicare OPPS,$14.70 ,Pays 100% Medicare OPPS,$14.70 ,Pays 100% Medicare OPPS,$19.11 ,Pays 130% Medicare OPPS,$22.26 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$14.99 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$23.15 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$14.70 ,Pays 100% Medicare OPPS,$13.23 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$22.26 ,120.37% of custom fee schedule,$14.70 ,Pays 100% Medicare OPPS,$19.11 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$14.70 ,Pays 100% Medicare OPPS,$13.23 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,86430,.RA TEST (EFCH),302,$190.00 ,$161.50 ,85% of total billed charges,$6.14 ,Pays 100% Medicare OPPS,$6.14 ,Pays 100% Medicare OPPS,$6.14 ,Pays 100% Medicare OPPS,$7.98 ,Pays 130% Medicare OPPS,$8.59 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$6.26 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$8.94 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$6.14 ,Pays 100% Medicare OPPS,$5.52 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$8.59 ,120.37% of custom fee schedule,$6.14 ,Pays 100% Medicare OPPS,$7.98 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$6.14 ,Pays 100% Medicare OPPS,$5.52 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,86060,.ASO (STREPTOZYME) (EFCH),302,$175.00 ,$148.75 ,85% of total billed charges,$7.30 ,Pays 100% Medicare OPPS,$7.30 ,Pays 100% Medicare OPPS,$7.30 ,Pays 100% Medicare OPPS,$9.49 ,Pays 130% Medicare OPPS,$10.58 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$7.44 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$11.00 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$7.30 ,Pays 100% Medicare OPPS,$6.57 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$10.58 ,120.37% of custom fee schedule,$7.30 ,Pays 100% Medicare OPPS,$9.49 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$7.30 ,Pays 100% Medicare OPPS,$6.57 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,83036,Blood test to measure average blood glucose levels for past 2-3 months,301,$245.00 ,$208.25 ,85% of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$9.71 ,Pays 100% Medicare OPPS,$9.71 ,Pays 100% Medicare OPPS,$12.62 ,Pays 130% Medicare OPPS,$14.69 ,20.37% based on GA Medicaid OP CCR Rate,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$9.90 ,Pays 102% Medicare OPPS,$220.50 ,90% of total billed charges,$15.27 ,125.18% of custom fee schedule,$168.32 ,68.7% of total billed charges,$196.00 ,80 percent of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$8.73 ,Pays 90% Medicare OPPS,$142.10 ,58% of total billed charges,$14.69 ,120.37% of custom fee schedule,$9.71 ,Pays 100% Medicare OPPS,$12.62 ,Pays 130% Medicare OPPS,$208.25 ,85% of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$8.73 ,$220.50 ,$196.00 
Outpatient Medical Services,LAB,87088,Culture of the urine to determine bacterial infection,306,$275.00 ,$233.75 ,85% of total billed charges,$8.09 ,Pays 100% Medicare OPPS,$8.09 ,Pays 100% Medicare OPPS,$8.09 ,Pays 100% Medicare OPPS,$10.51 ,Pays 130% Medicare OPPS,$12.25 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$8.25 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$12.74 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$8.09 ,Pays 100% Medicare OPPS,$7.28 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$12.25 ,120.37% of custom fee schedule,$8.09 ,Pays 100% Medicare OPPS,$10.51 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$8.09 ,Pays 100% Medicare OPPS,$7.28 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,85240,3RD FACTOR VIII,300,$135.00 ,$114.75 ,85% of total billed charges,$17.89 ,Pays 100% Medicare OPPS,$17.89 ,Pays 100% Medicare OPPS,$17.89 ,Pays 100% Medicare OPPS,$23.27 ,Pays 130% Medicare OPPS,$27.11 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$18.25 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$28.19 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$17.89 ,Pays 100% Medicare OPPS,$16.10 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.11 ,120.37% of custom fee schedule,$17.89 ,Pays 100% Medicare OPPS,$23.27 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$17.89 ,Pays 100% Medicare OPPS,$16.10 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86790,3RD HEP E VIRUS,306,$525.00 ,$446.25 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,80307,Testing for presence of drug,301,$160.00 ,$136.00 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$73.62 ,20.37% based on GA Medicaid OP CCR Rate,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$63.38 ,Pays 102% Medicare OPPS,$144.00 ,90% of total billed charges,$76.56 ,125.18% of custom fee schedule,$109.92 ,68.7% of total billed charges,$128.00 ,80 percent of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,Pays 90% Medicare OPPS,$92.80 ,58% of total billed charges,$73.62 ,120.37% of custom fee schedule,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$136.00 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,$144.00 ,$128.00 
Outpatient Medical Services,LAB,87798,3RD EBV DNA QUANTITATIVE,301,$660.00 ,$561.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$29.70 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$30.88 ,125.18% of custom fee schedule,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$29.70 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$29.70 ,$594.00 ,$528.00 
Outpatient Medical Services,LAB,83993,CALPROTECTIN STOOL,300,$125.00 ,$106.25 ,85% of total billed charges,$19.63 ,Pays 100% Medicare OPPS,$19.63 ,Pays 100% Medicare OPPS,$19.63 ,Pays 100% Medicare OPPS,$25.51 ,Pays 130% Medicare OPPS,$29.71 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$20.02 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$30.89 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$19.63 ,Pays 100% Medicare OPPS,$17.66 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$29.71 ,120.37% of custom fee schedule,$19.63 ,Pays 100% Medicare OPPS,$25.51 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$19.63 ,Pays 100% Medicare OPPS,$17.66 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,0097U,CULTURE STOOL BY PCR,300,"$1,510.00 ","$1,283.50 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$307.59 ,20.37% based on GA Medicaid OP CCR Rate,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,"$1,359.00 ",90% of total billed charges,$528.50 ,35% based on GA Medicaid OP CCR Rate,"$1,037.37 ",68.7% of total billed charges,"$1,208.00 ",80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$875.80 ,58% of total billed charges,$307.59 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$1,283.50 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,$307.59 ,"$1,359.00 ","$1,208.00 "
Outpatient Medical Services,LAB,86609,.BACTERIUM ANTIBODIES NES,300,$320.00 ,$272.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,86800,.THYROGLOBULIN AB,302,$215.00 ,$182.75 ,85% of total billed charges,$15.91 ,Pays 100% Medicare OPPS,$15.91 ,Pays 100% Medicare OPPS,$15.91 ,Pays 100% Medicare OPPS,$20.68 ,Pays 130% Medicare OPPS,$24.07 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$16.22 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$25.04 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$15.91 ,Pays 100% Medicare OPPS,$14.31 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$24.07 ,120.37% of custom fee schedule,$15.91 ,Pays 100% Medicare OPPS,$20.68 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$15.91 ,Pays 100% Medicare OPPS,$14.31 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,84432,.THYROGLOBULIN PANEL,302,$215.00 ,$182.75 ,85% of total billed charges,$16.05 ,Pays 100% Medicare OPPS,$16.05 ,Pays 100% Medicare OPPS,$16.05 ,Pays 100% Medicare OPPS,$20.87 ,Pays 130% Medicare OPPS,$24.31 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$16.38 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$25.29 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$16.05 ,Pays 100% Medicare OPPS,$14.45 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$24.31 ,120.37% of custom fee schedule,$16.05 ,Pays 100% Medicare OPPS,$20.87 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$16.05 ,Pays 100% Medicare OPPS,$14.45 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,86850,Blood test to screen for antibodies that could harm red blood cells,300,$90.00 ,$76.50 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$18.33 ,20.37% based on GA Medicaid OP CCR Rate,$50.85 ,56.5 percent of total billed charges,$50.85 ,56.5 percent of total billed charges,$50.85 ,56.5 percent of total billed charges,$50.85 ,56.5 percent of total billed charges,$45.53 ,Pays 102% Medicare OPPS,$81.00 ,90% of total billed charges,$19.06 ,125.18% of custom fee schedule,$61.83 ,68.7% of total billed charges,$72.00 ,80 percent of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,Pays 90% Medicare OPPS,$52.20 ,58% of total billed charges,$18.33 ,120.37% of custom fee schedule,$44.10 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$76.50 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$18.33 ,$81.00 ,$72.00 
Outpatient Medical Services,LAB,86870,RC AB ID/EACH PANEL & MEDIA,300,$160.00 ,$136.00 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$7.37 ,20.37% based on GA Medicaid OP CCR Rate,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$266.86 ,Pays 102% Medicare OPPS,$144.00 ,90% of total billed charges,$7.66 ,125.18% of custom fee schedule,$109.92 ,68.7% of total billed charges,$128.00 ,80 percent of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$235.46 ,Pays 90% Medicare OPPS,$92.80 ,58% of total billed charges,$7.37 ,120.37% of custom fee schedule,$285.08 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$136.00 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$7.37 ,$370.60 ,$128.00 
Outpatient Medical Services,LAB,86880,RC DAT EACH ANTISERA (RC),300,$85.00 ,$72.25 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$8.12 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$51.00 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$8.45 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$8.12 ,120.37% of custom fee schedule,$50.55 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$8.12 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,86901,RC RH  TYPE,300,$70.00 ,$59.50 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$17.47 ,20.37% based on GA Medicaid OP CCR Rate,$39.55 ,56.5 percent of total billed charges,$39.55 ,56.5 percent of total billed charges,$39.55 ,56.5 percent of total billed charges,$39.55 ,56.5 percent of total billed charges,$31.01 ,Pays 102% Medicare OPPS,$63.00 ,90% of total billed charges,$18.16 ,125.18% of custom fee schedule,$48.09 ,68.7% of total billed charges,$56.00 ,80 percent of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,Pays 90% Medicare OPPS,$40.60 ,58% of total billed charges,$17.47 ,120.37% of custom fee schedule,$29.87 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$59.50 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$17.47 ,$63.00 ,$56.00 
Outpatient Medical Services,LAB,86922,RC AGT PHASE CROSSMATCH,300,$265.00 ,$225.25 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$53.98 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$136.65 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$92.75 ,35% based on GA Medicaid OP CCR Rate,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$120.57 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$53.98 ,20.37% based on GA Medicaid OP CCR Rate,$138.31 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$53.98 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,36415,Collection of venous blood by venipuncture,302,$40.00 ,$34.00 ,85% of total billed charges,$3.00 ,Pays 100% Medicare OPPS,$3.00 ,Pays 100% Medicare OPPS,$3.00 ,Pays 100% Medicare OPPS,$11.14 ,Pays 130% Medicare OPPS,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$3.06 ,Pays 102% Medicare OPPS,$36.00 ,90% of total billed charges,$14.00 ,35% based on GA Medicaid OP CCR Rate,$27.48 ,68.7% of total billed charges,$32.00 ,80 percent of total billed charges,$3.00 ,Pays 100% Medicare OPPS,$2.70 ,Pays 90% Medicare OPPS,$23.20 ,58% of total billed charges,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,$8.57 ,Pays 100% Medicare OPPS,$11.14 ,Pays 130% Medicare OPPS,$34.00 ,85% of total billed charges,$3.00 ,Pays 100% Medicare OPPS,$2.70 ,$36.00 ,$32.00 
Outpatient Medical Services,LAB,80047,I-STAT BMP,301,$420.00 ,$357.00 ,85% of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$13.73 ,Pays 100% Medicare OPPS,$13.73 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$33.05 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$14.00 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$34.37 ,125.18% of custom fee schedule,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$12.35 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$33.05 ,120.37% of custom fee schedule,$13.73 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$12.35 ,$378.00 ,$336.00 
Outpatient Medical Services,LAB,80048,Basic metabolic panel,301,$420.00 ,$357.00 ,85% of total billed charges,$8.46 ,Pays 100% Medicare OPPS,$8.46 ,Pays 100% Medicare OPPS,$8.46 ,Pays 100% Medicare OPPS,$10.99 ,Pays 130% Medicare OPPS,$12.82 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$8.62 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$13.33 ,125.18% of custom fee schedule,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$8.46 ,Pays 100% Medicare OPPS,$7.61 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$12.82 ,120.37% of custom fee schedule,$8.46 ,Pays 100% Medicare OPPS,$10.99 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$8.46 ,Pays 100% Medicare OPPS,$7.61 ,$378.00 ,$336.00 
Outpatient Medical Services,LAB,80050,General health panel,301,"$1,060.00 ",$901.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$215.92 ,20.37% based on GA Medicaid OP CCR Rate,$598.90 ,56.5 percent of total billed charges,$598.90 ,56.5 percent of total billed charges,$598.90 ,56.5 percent of total billed charges,$598.90 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$954.00 ,90% of total billed charges,$371.00 ,35% based on GA Medicaid OP CCR Rate,$728.22 ,68.7% of total billed charges,$848.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$614.80 ,58% of total billed charges,$215.92 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$901.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$215.92 ,$954.00 ,$848.00 
Outpatient Medical Services,LAB,80051,"Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)",301,$345.00 ,$293.25 ,85% of total billed charges,$7.01 ,Pays 100% Medicare OPPS,$7.01 ,Pays 100% Medicare OPPS,$7.01 ,Pays 100% Medicare OPPS,$9.11 ,Pays 130% Medicare OPPS,$10.62 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$7.15 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$11.04 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$7.01 ,Pays 100% Medicare OPPS,$6.30 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$10.62 ,120.37% of custom fee schedule,$7.01 ,Pays 100% Medicare OPPS,$9.11 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$7.01 ,Pays 100% Medicare OPPS,$6.30 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,80053,"Blood test, comprehensive group of blood chemicals",301,$545.00 ,$463.25 ,85% of total billed charges,$10.56 ,Pays 100% Medicare OPPS,$10.56 ,Pays 100% Medicare OPPS,$10.56 ,Pays 100% Medicare OPPS,$13.72 ,Pays 130% Medicare OPPS,$16.00 ,20.37% based on GA Medicaid OP CCR Rate,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$10.77 ,Pays 102% Medicare OPPS,$490.50 ,90% of total billed charges,$16.64 ,125.18% of custom fee schedule,$374.42 ,68.7% of total billed charges,$436.00 ,80 percent of total billed charges,$10.56 ,Pays 100% Medicare OPPS,$9.50 ,Pays 90% Medicare OPPS,$316.10 ,58% of total billed charges,$16.00 ,120.37% of custom fee schedule,$10.56 ,Pays 100% Medicare OPPS,$13.72 ,Pays 130% Medicare OPPS,$463.25 ,85% of total billed charges,$10.56 ,Pays 100% Medicare OPPS,$9.50 ,$490.50 ,$436.00 
Outpatient Medical Services,LAB,80061,"Blood test, lipids (cholesterol and triglycerides)",301,$395.00 ,$335.75 ,85% of total billed charges,$13.39 ,Pays 100% Medicare OPPS,$13.39 ,Pays 100% Medicare OPPS,$13.39 ,Pays 100% Medicare OPPS,$17.40 ,Pays 130% Medicare OPPS,$20.28 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$13.65 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$21.09 ,125.18% of custom fee schedule,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$13.39 ,Pays 100% Medicare OPPS,$12.05 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$20.28 ,120.37% of custom fee schedule,$13.39 ,Pays 100% Medicare OPPS,$17.40 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$13.39 ,Pays 100% Medicare OPPS,$12.05 ,$355.50 ,$316.00 
Outpatient Medical Services,LAB,80069,Kidney function panel test,301,$485.00 ,$412.25 ,85% of total billed charges,$8.68 ,Pays 100% Medicare OPPS,$8.68 ,Pays 100% Medicare OPPS,$8.68 ,Pays 100% Medicare OPPS,$11.28 ,Pays 130% Medicare OPPS,$13.14 ,20.37% based on GA Medicaid OP CCR Rate,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$8.85 ,Pays 102% Medicare OPPS,$436.50 ,90% of total billed charges,$13.67 ,125.18% of custom fee schedule,$333.20 ,68.7% of total billed charges,$388.00 ,80 percent of total billed charges,$8.68 ,Pays 100% Medicare OPPS,$7.81 ,Pays 90% Medicare OPPS,$281.30 ,58% of total billed charges,$13.14 ,120.37% of custom fee schedule,$8.68 ,Pays 100% Medicare OPPS,$11.28 ,Pays 130% Medicare OPPS,$412.25 ,85% of total billed charges,$8.68 ,Pays 100% Medicare OPPS,$7.81 ,$436.50 ,$388.00 
Outpatient Medical Services,LAB,80074,Acute hepatitis panel,301,$575.00 ,$488.75 ,85% of total billed charges,$47.63 ,Pays 100% Medicare OPPS,$47.63 ,Pays 100% Medicare OPPS,$47.63 ,Pays 100% Medicare OPPS,$61.91 ,Pays 130% Medicare OPPS,$72.09 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$48.58 ,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$74.97 ,125.18% of custom fee schedule,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,$47.63 ,Pays 100% Medicare OPPS,$42.86 ,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$72.09 ,120.37% of custom fee schedule,$47.63 ,Pays 100% Medicare OPPS,$61.91 ,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,$47.63 ,Pays 100% Medicare OPPS,$42.86 ,$517.50 ,$460.00 
Outpatient Medical Services,LAB,80076,Liver function blood test panel,301,$410.00 ,$348.50 ,85% of total billed charges,$8.17 ,Pays 100% Medicare OPPS,$8.17 ,Pays 100% Medicare OPPS,$8.17 ,Pays 100% Medicare OPPS,$10.62 ,Pays 130% Medicare OPPS,$12.37 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$8.33 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$12.87 ,125.18% of custom fee schedule,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$8.17 ,Pays 100% Medicare OPPS,$7.35 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$12.37 ,120.37% of custom fee schedule,$8.17 ,Pays 100% Medicare OPPS,$10.62 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$8.17 ,Pays 100% Medicare OPPS,$7.35 ,$369.00 ,$328.00 
Outpatient Medical Services,LAB,80150,AMIKACIN TROUGH,301,$275.00 ,$233.75 ,85% of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$15.08 ,Pays 100% Medicare OPPS,$15.08 ,Pays 100% Medicare OPPS,$19.60 ,Pays 130% Medicare OPPS,$22.81 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$15.38 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$23.72 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$13.57 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$22.81 ,120.37% of custom fee schedule,$15.08 ,Pays 100% Medicare OPPS,$19.60 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$13.57 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,80152,ELAVIL LEVEL,301,$275.00 ,$233.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$56.02 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$96.25 ,35% based on GA Medicaid OP CCR Rate,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$56.02 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$56.02 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,80346,"BENZODIAZEPINE, SERUM",301,$540.00 ,$459.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$28.00 ,20.37% based on GA Medicaid OP CCR Rate,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$486.00 ,90% of total billed charges,$29.12 ,125.18% of custom fee schedule,$370.98 ,68.7% of total billed charges,$432.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$313.20 ,58% of total billed charges,$28.00 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$459.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$28.00 ,$486.00 ,$432.00 
Outpatient Medical Services,LAB,80158,3RD CYCLOSPORINE,301,$465.00 ,$395.25 ,85% of total billed charges,$18.05 ,Pays 100% Medicare OPPS,$18.05 ,Pays 100% Medicare OPPS,$18.05 ,Pays 100% Medicare OPPS,$23.46 ,Pays 130% Medicare OPPS,$9.03 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$18.41 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$9.39 ,125.18% of custom fee schedule,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$18.05 ,Pays 100% Medicare OPPS,$16.24 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$9.03 ,120.37% of custom fee schedule,$18.05 ,Pays 100% Medicare OPPS,$23.46 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$18.05 ,Pays 100% Medicare OPPS,$9.03 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,80335,DESIPRAMINE LEVEL,301,$295.00 ,$250.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$27.10 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$28.18 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$27.10 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$27.10 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,80162,DIGOXIN (LANOXIN) LEVEL,301,$365.00 ,$310.25 ,85% of total billed charges,$13.28 ,Pays 100% Medicare OPPS,$13.28 ,Pays 100% Medicare OPPS,$13.28 ,Pays 100% Medicare OPPS,$17.26 ,Pays 130% Medicare OPPS,$20.10 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$13.54 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$20.91 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$13.28 ,Pays 100% Medicare OPPS,$11.95 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$20.10 ,120.37% of custom fee schedule,$13.28 ,Pays 100% Medicare OPPS,$17.26 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$13.28 ,Pays 100% Medicare OPPS,$11.95 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,80164,VALPROIC ACID LEVEL,301,$320.00 ,$272.00 ,85% of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$13.54 ,Pays 100% Medicare OPPS,$13.54 ,Pays 100% Medicare OPPS,$17.60 ,Pays 130% Medicare OPPS,$17.18 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.81 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$17.86 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$12.18 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$17.18 ,120.37% of custom fee schedule,$13.54 ,Pays 100% Medicare OPPS,$17.60 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$12.18 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80168,ETHOSUXIMIDE,301,$295.00 ,$250.75 ,85% of total billed charges,$16.34 ,Pays 100% Medicare OPPS,$16.34 ,Pays 100% Medicare OPPS,$16.34 ,Pays 100% Medicare OPPS,$21.24 ,Pays 130% Medicare OPPS,$24.74 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$16.66 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$25.72 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$16.34 ,Pays 100% Medicare OPPS,$14.70 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$24.74 ,120.37% of custom fee schedule,$16.34 ,Pays 100% Medicare OPPS,$21.24 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$16.34 ,Pays 100% Medicare OPPS,$14.70 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,80170,GENTAMICIN RANDOM,301,$320.00 ,$272.00 ,85% of total billed charges,$16.38 ,Pays 100% Medicare OPPS,$16.38 ,Pays 100% Medicare OPPS,$16.38 ,Pays 100% Medicare OPPS,$21.29 ,Pays 130% Medicare OPPS,$24.81 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$16.70 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$25.80 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.38 ,Pays 100% Medicare OPPS,$14.74 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$24.81 ,120.37% of custom fee schedule,$16.38 ,Pays 100% Medicare OPPS,$21.29 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.38 ,Pays 100% Medicare OPPS,$14.74 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80170,GENTAMICIN PEAK,301,$320.00 ,$272.00 ,85% of total billed charges,$16.38 ,Pays 100% Medicare OPPS,$16.38 ,Pays 100% Medicare OPPS,$16.38 ,Pays 100% Medicare OPPS,$21.29 ,Pays 130% Medicare OPPS,$24.81 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$16.70 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$25.80 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.38 ,Pays 100% Medicare OPPS,$14.74 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$24.81 ,120.37% of custom fee schedule,$16.38 ,Pays 100% Medicare OPPS,$21.29 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.38 ,Pays 100% Medicare OPPS,$14.74 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80173,HALOPERIDOL LEVEL,301,$370.00 ,$314.50 ,85% of total billed charges,$15.78 ,Pays 100% Medicare OPPS,$15.78 ,Pays 100% Medicare OPPS,$15.78 ,Pays 100% Medicare OPPS,$20.51 ,Pays 130% Medicare OPPS,$22.04 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$16.09 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$22.92 ,125.18% of custom fee schedule,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$15.78 ,Pays 100% Medicare OPPS,$14.20 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$22.04 ,120.37% of custom fee schedule,$15.78 ,Pays 100% Medicare OPPS,$20.51 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$15.78 ,Pays 100% Medicare OPPS,$14.20 ,$333.00 ,$296.00 
Outpatient Medical Services,LAB,80335,IMIPRAMIME  LEVEL,301,$370.00 ,$314.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$27.10 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$28.18 ,125.18% of custom fee schedule,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$27.10 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$27.10 ,$333.00 ,$296.00 
Outpatient Medical Services,LAB,80170,GENTAMICIN TROUGH,301,$320.00 ,$272.00 ,85% of total billed charges,$16.38 ,Pays 100% Medicare OPPS,$16.38 ,Pays 100% Medicare OPPS,$16.38 ,Pays 100% Medicare OPPS,$21.29 ,Pays 130% Medicare OPPS,$24.81 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$16.70 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$25.80 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.38 ,Pays 100% Medicare OPPS,$14.74 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$24.81 ,120.37% of custom fee schedule,$16.38 ,Pays 100% Medicare OPPS,$21.29 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.38 ,Pays 100% Medicare OPPS,$14.74 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80178,LITHIUM LEVEL,301,$195.00 ,$165.75 ,85% of total billed charges,$6.61 ,Pays 100% Medicare OPPS,$6.61 ,Pays 100% Medicare OPPS,$6.61 ,Pays 100% Medicare OPPS,$8.59 ,Pays 130% Medicare OPPS,$10.01 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$6.74 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$10.41 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$6.61 ,Pays 100% Medicare OPPS,$5.94 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$10.01 ,120.37% of custom fee schedule,$6.61 ,Pays 100% Medicare OPPS,$8.59 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$6.61 ,Pays 100% Medicare OPPS,$5.94 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,80335,NORTRIPTYLINE LEVEL,301,$375.00 ,$318.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$27.10 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$28.18 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$27.10 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$27.10 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,80184,PHENOBARBITAL LEVEL,301,$320.00 ,$272.00 ,85% of total billed charges,$15.30 ,Pays 100% Medicare OPPS,$15.30 ,Pays 100% Medicare OPPS,$15.30 ,Pays 100% Medicare OPPS,$19.89 ,Pays 130% Medicare OPPS,$17.35 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$15.60 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$18.04 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$15.30 ,Pays 100% Medicare OPPS,$13.77 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$17.35 ,120.37% of custom fee schedule,$15.30 ,Pays 100% Medicare OPPS,$19.89 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$15.30 ,Pays 100% Medicare OPPS,$13.77 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80185,DILANTIN LEVEL,301,$320.00 ,$272.00 ,85% of total billed charges,$13.25 ,Pays 100% Medicare OPPS,$13.25 ,Pays 100% Medicare OPPS,$13.25 ,Pays 100% Medicare OPPS,$17.22 ,Pays 130% Medicare OPPS,$20.07 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.51 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$20.87 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$13.25 ,Pays 100% Medicare OPPS,$11.92 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$20.07 ,120.37% of custom fee schedule,$13.25 ,Pays 100% Medicare OPPS,$17.22 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$13.25 ,Pays 100% Medicare OPPS,$11.92 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80186,"DILANTIN,FREE LEVEL",301,$265.00 ,$225.25 ,85% of total billed charges,$13.76 ,Pays 100% Medicare OPPS,$13.76 ,Pays 100% Medicare OPPS,$13.76 ,Pays 100% Medicare OPPS,$17.88 ,Pays 130% Medicare OPPS,$20.84 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$14.03 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$21.67 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$13.76 ,Pays 100% Medicare OPPS,$12.38 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$20.84 ,120.37% of custom fee schedule,$13.76 ,Pays 100% Medicare OPPS,$17.88 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$13.76 ,Pays 100% Medicare OPPS,$12.38 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,80188,MYSOLINE LEVEL,301,$375.00 ,$318.75 ,85% of total billed charges,$16.59 ,Pays 100% Medicare OPPS,$16.59 ,Pays 100% Medicare OPPS,$16.59 ,Pays 100% Medicare OPPS,$21.56 ,Pays 130% Medicare OPPS,$25.11 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$16.92 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$26.11 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$16.59 ,Pays 100% Medicare OPPS,$14.93 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$25.11 ,120.37% of custom fee schedule,$16.59 ,Pays 100% Medicare OPPS,$21.56 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$16.59 ,Pays 100% Medicare OPPS,$14.93 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,80192,PROCAINAMIDE LEVEL,301,$325.00 ,$276.25 ,85% of total billed charges,$16.75 ,Pays 100% Medicare OPPS,$16.75 ,Pays 100% Medicare OPPS,$16.75 ,Pays 100% Medicare OPPS,$21.77 ,Pays 130% Medicare OPPS,$25.36 ,20.37% based on GA Medicaid OP CCR Rate,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$17.08 ,Pays 102% Medicare OPPS,$292.50 ,90% of total billed charges,$26.38 ,125.18% of custom fee schedule,$223.28 ,68.7% of total billed charges,$260.00 ,80 percent of total billed charges,$16.75 ,Pays 100% Medicare OPPS,$15.07 ,Pays 90% Medicare OPPS,$188.50 ,58% of total billed charges,$25.36 ,120.37% of custom fee schedule,$16.75 ,Pays 100% Medicare OPPS,$21.77 ,Pays 130% Medicare OPPS,$276.25 ,85% of total billed charges,$16.75 ,Pays 100% Medicare OPPS,$15.07 ,$292.50 ,$260.00 
Outpatient Medical Services,LAB,80192,PRONESTYL LEVEL,301,$365.00 ,$310.25 ,85% of total billed charges,$16.75 ,Pays 100% Medicare OPPS,$16.75 ,Pays 100% Medicare OPPS,$16.75 ,Pays 100% Medicare OPPS,$21.77 ,Pays 130% Medicare OPPS,$25.36 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$17.08 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$26.38 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$16.75 ,Pays 100% Medicare OPPS,$15.07 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$25.36 ,120.37% of custom fee schedule,$16.75 ,Pays 100% Medicare OPPS,$21.77 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$16.75 ,Pays 100% Medicare OPPS,$15.07 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,80194,QUINIDINE LEVEL,301,$275.00 ,$233.75 ,85% of total billed charges,$14.60 ,Pays 100% Medicare OPPS,$14.60 ,Pays 100% Medicare OPPS,$14.60 ,Pays 100% Medicare OPPS,$18.98 ,Pays 130% Medicare OPPS,$22.09 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$14.89 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$22.97 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$14.60 ,Pays 100% Medicare OPPS,$13.14 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$22.09 ,120.37% of custom fee schedule,$14.60 ,Pays 100% Medicare OPPS,$18.98 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$14.60 ,Pays 100% Medicare OPPS,$13.14 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,80329,SALICYLATE (SERUM TEST),301,$410.00 ,$348.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$30.63 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$31.86 ,125.18% of custom fee schedule,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$30.63 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$30.63 ,$369.00 ,$328.00 
Outpatient Medical Services,LAB,80197,Test is used to measure the amount of the drug in the blood to determine whether the concentration has reached a therapeutic level and is below the to,301,$415.00 ,$352.75 ,85% of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$13.73 ,Pays 100% Medicare OPPS,$13.73 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$20.76 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$14.00 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$21.59 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$12.35 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$20.76 ,120.37% of custom fee schedule,$13.73 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$13.73 ,Pays 100% Medicare OPPS,$12.35 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,80198,THEOPHYLLINE LEVEL,301,$300.00 ,$255.00 ,85% of total billed charges,$14.14 ,Pays 100% Medicare OPPS,$14.14 ,Pays 100% Medicare OPPS,$14.14 ,Pays 100% Medicare OPPS,$18.38 ,Pays 130% Medicare OPPS,$21.41 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$14.42 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$22.27 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$14.14 ,Pays 100% Medicare OPPS,$12.72 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$21.41 ,120.37% of custom fee schedule,$14.14 ,Pays 100% Medicare OPPS,$18.38 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$14.14 ,Pays 100% Medicare OPPS,$12.72 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,80200,TOBRAMYCIN LEVEL,301,$320.00 ,$272.00 ,85% of total billed charges,$16.13 ,Pays 100% Medicare OPPS,$16.13 ,Pays 100% Medicare OPPS,$16.13 ,Pays 100% Medicare OPPS,$20.96 ,Pays 130% Medicare OPPS,$22.68 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$16.45 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$23.58 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.13 ,Pays 100% Medicare OPPS,$14.51 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$22.68 ,120.37% of custom fee schedule,$16.13 ,Pays 100% Medicare OPPS,$20.96 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.13 ,Pays 100% Medicare OPPS,$14.51 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80201,3RD TOPIRAMATE (TOPAMAX) LEVEL,301,$415.00 ,$352.75 ,85% of total billed charges,$11.92 ,Pays 100% Medicare OPPS,$11.92 ,Pays 100% Medicare OPPS,$11.92 ,Pays 100% Medicare OPPS,$15.49 ,Pays 130% Medicare OPPS,$18.04 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$12.15 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$18.76 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$11.92 ,Pays 100% Medicare OPPS,$10.72 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$18.04 ,120.37% of custom fee schedule,$11.92 ,Pays 100% Medicare OPPS,$15.49 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$11.92 ,Pays 100% Medicare OPPS,$10.72 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,80202,VANCOMYCIN LEVEL,301,$365.00 ,$310.25 ,85% of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$13.54 ,Pays 100% Medicare OPPS,$13.54 ,Pays 100% Medicare OPPS,$17.60 ,Pays 130% Medicare OPPS,$17.18 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$13.81 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$17.86 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$12.18 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$17.18 ,120.37% of custom fee schedule,$13.54 ,Pays 100% Medicare OPPS,$17.60 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$12.18 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,80202,VANCOMYCIN PEAK,301,$365.00 ,$310.25 ,85% of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$13.54 ,Pays 100% Medicare OPPS,$13.54 ,Pays 100% Medicare OPPS,$17.60 ,Pays 130% Medicare OPPS,$17.18 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$13.81 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$17.86 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$12.18 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$17.18 ,120.37% of custom fee schedule,$13.54 ,Pays 100% Medicare OPPS,$17.60 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$12.18 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,80202,VANCOMYCIN TROUGH,301,$365.00 ,$310.25 ,85% of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$13.54 ,Pays 100% Medicare OPPS,$13.54 ,Pays 100% Medicare OPPS,$17.60 ,Pays 130% Medicare OPPS,$17.18 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$13.81 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$17.86 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$12.18 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$17.18 ,120.37% of custom fee schedule,$13.54 ,Pays 100% Medicare OPPS,$17.60 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$13.54 ,Pays 100% Medicare OPPS,$12.18 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,80299,AMIODARONE,301,$420.00 ,$357.00 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$18.22 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$19.01 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$18.95 ,125.18% of custom fee schedule,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$18.22 ,120.37% of custom fee schedule,$18.64 ,Pays 100% Medicare OPPS,$24.23 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$18.64 ,Pays 100% Medicare OPPS,$16.77 ,$378.00 ,$336.00 
Outpatient Medical Services,LAB,80323,NICOTINE,301,$175.00 ,$148.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$45.44 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$47.26 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$45.44 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$45.44 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,81001,Manual urinalysis test with examination with or without using microscope,307,$50.00 ,$42.50 ,85% of total billed charges,$3.17 ,Pays 100% Medicare OPPS,$3.17 ,Pays 100% Medicare OPPS,$3.17 ,Pays 100% Medicare OPPS,$4.12 ,Pays 130% Medicare OPPS,$4.80 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$3.23 ,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$4.99 ,125.18% of custom fee schedule,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,$3.17 ,Pays 100% Medicare OPPS,$2.85 ,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$4.80 ,120.37% of custom fee schedule,$3.17 ,Pays 100% Medicare OPPS,$4.12 ,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,$3.17 ,Pays 100% Medicare OPPS,$2.85 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,81003,Automated urinalysis test,307,$95.00 ,$80.75 ,85% of total billed charges,$2.25 ,Pays 100% Medicare OPPS,$2.25 ,Pays 100% Medicare OPPS,$2.25 ,Pays 100% Medicare OPPS,$2.92 ,Pays 130% Medicare OPPS,$3.41 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$2.29 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$3.54 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$2.25 ,Pays 100% Medicare OPPS,$2.02 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$3.41 ,120.37% of custom fee schedule,$2.25 ,Pays 100% Medicare OPPS,$2.92 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$2.25 ,Pays 100% Medicare OPPS,$2.02 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,81015,URINALYSIS MICROSCO,307,$95.00 ,$80.75 ,85% of total billed charges,$3.05 ,Pays 100% Medicare OPPS,$3.05 ,Pays 100% Medicare OPPS,$3.05 ,Pays 100% Medicare OPPS,$3.96 ,Pays 130% Medicare OPPS,$4.60 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$3.11 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$4.78 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$3.05 ,Pays 100% Medicare OPPS,$2.74 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$4.60 ,120.37% of custom fee schedule,$3.05 ,Pays 100% Medicare OPPS,$3.96 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$3.05 ,Pays 100% Medicare OPPS,$2.74 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,81050,.VOLUME MEASUREMENT 24HR,307,$50.00 ,$42.50 ,85% of total billed charges,$3.64 ,Pays 100% Medicare OPPS,$3.64 ,Pays 100% Medicare OPPS,$3.64 ,Pays 100% Medicare OPPS,$4.73 ,Pays 130% Medicare OPPS,$4.54 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$3.71 ,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$4.72 ,125.18% of custom fee schedule,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,$3.64 ,Pays 100% Medicare OPPS,$3.27 ,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$4.54 ,120.37% of custom fee schedule,$3.64 ,Pays 100% Medicare OPPS,$4.73 ,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,$3.64 ,Pays 100% Medicare OPPS,$3.27 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,81373,.HLA CLASS 1 LOCUS,307,$275.00 ,$233.75 ,85% of total billed charges,$127.43 ,Pays 100% Medicare OPPS,$127.43 ,Pays 100% Medicare OPPS,$127.43 ,Pays 100% Medicare OPPS,$165.65 ,Pays 130% Medicare OPPS,$118.44 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$129.97 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$123.18 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$127.43 ,Pays 100% Medicare OPPS,$114.68 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$118.44 ,120.37% of custom fee schedule,$127.43 ,Pays 100% Medicare OPPS,$165.65 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$127.43 ,Pays 100% Medicare OPPS,$114.68 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,81377,.HLA CLASS 2 ANTIGEN,307,$275.00 ,$233.75 ,85% of total billed charges,$94.74 ,Pays 100% Medicare OPPS,$94.74 ,Pays 100% Medicare OPPS,$94.74 ,Pays 100% Medicare OPPS,$123.16 ,Pays 130% Medicare OPPS,$48.15 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$96.63 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$50.07 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$94.74 ,Pays 100% Medicare OPPS,$85.26 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$48.15 ,120.37% of custom fee schedule,$94.74 ,Pays 100% Medicare OPPS,$123.16 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$94.74 ,Pays 100% Medicare OPPS,$48.15 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,81596,FIBRO TEST,301,$365.00 ,$310.25 ,85% of total billed charges,$72.19 ,Pays 100% Medicare OPPS,$72.19 ,Pays 100% Medicare OPPS,$72.19 ,Pays 100% Medicare OPPS,$93.84 ,Pays 130% Medicare OPPS,$69.51 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$73.63 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$72.29 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$72.19 ,Pays 100% Medicare OPPS,$64.97 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$69.51 ,120.37% of custom fee schedule,$72.19 ,Pays 100% Medicare OPPS,$93.84 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$72.19 ,Pays 100% Medicare OPPS,$64.97 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,80329,ACETAMINOPHEN (SERUM TEST),301,$410.00 ,$348.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$30.63 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$31.86 ,125.18% of custom fee schedule,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$30.63 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$30.63 ,$369.00 ,$328.00 
Outpatient Medical Services,LAB,82009,"ACETONE, SERUM",301,$60.00 ,$51.00 ,85% of total billed charges,$4.51 ,Pays 100% Medicare OPPS,$4.51 ,Pays 100% Medicare OPPS,$4.51 ,Pays 100% Medicare OPPS,$5.87 ,Pays 130% Medicare OPPS,$4.97 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$4.61 ,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$5.17 ,125.18% of custom fee schedule,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,$4.51 ,Pays 100% Medicare OPPS,$4.06 ,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$4.97 ,120.37% of custom fee schedule,$4.51 ,Pays 100% Medicare OPPS,$5.87 ,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,$4.51 ,Pays 100% Medicare OPPS,$4.06 ,$54.00 ,$48.00 
Outpatient Medical Services,LAB,82010,3RD .B-HYDROXYBUTYRATE SERUM,301,$145.00 ,$123.25 ,85% of total billed charges,$8.17 ,Pays 100% Medicare OPPS,$8.17 ,Pays 100% Medicare OPPS,$8.17 ,Pays 100% Medicare OPPS,$10.62 ,Pays 130% Medicare OPPS,$12.37 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$8.33 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$12.87 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$8.17 ,Pays 100% Medicare OPPS,$7.35 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$12.37 ,120.37% of custom fee schedule,$8.17 ,Pays 100% Medicare OPPS,$10.62 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$8.17 ,Pays 100% Medicare OPPS,$7.35 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82024,ACTH,301,$465.00 ,$395.25 ,85% of total billed charges,$38.61 ,Pays 100% Medicare OPPS,$38.61 ,Pays 100% Medicare OPPS,$38.61 ,Pays 100% Medicare OPPS,$50.20 ,Pays 130% Medicare OPPS,$58.46 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$39.39 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$60.80 ,125.18% of custom fee schedule,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$38.61 ,Pays 100% Medicare OPPS,$34.75 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$58.46 ,120.37% of custom fee schedule,$38.61 ,Pays 100% Medicare OPPS,$50.20 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$38.61 ,Pays 100% Medicare OPPS,$34.75 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,82040,"ALBUMIN, SERUM",301,$145.00 ,$123.25 ,85% of total billed charges,$4.95 ,Pays 100% Medicare OPPS,$4.95 ,Pays 100% Medicare OPPS,$4.95 ,Pays 100% Medicare OPPS,$6.43 ,Pays 130% Medicare OPPS,$4.36 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$5.04 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$4.53 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.95 ,Pays 100% Medicare OPPS,$4.45 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$4.36 ,120.37% of custom fee schedule,$4.95 ,Pays 100% Medicare OPPS,$6.43 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.95 ,Pays 100% Medicare OPPS,$4.36 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82042,"ALBUMIN, OTHER",301,$145.00 ,$123.25 ,85% of total billed charges,$7.78 ,Pays 100% Medicare OPPS,$7.78 ,Pays 100% Medicare OPPS,$7.78 ,Pays 100% Medicare OPPS,$10.11 ,Pays 130% Medicare OPPS,$7.84 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$7.93 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$8.15 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$7.78 ,Pays 100% Medicare OPPS,$7.00 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$7.84 ,120.37% of custom fee schedule,$7.78 ,Pays 100% Medicare OPPS,$10.11 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$7.78 ,Pays 100% Medicare OPPS,$7.00 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82043,Urine test to measure albumin,307,$275.00 ,$233.75 ,85% of total billed charges,$5.78 ,Pays 100% Medicare OPPS,$5.78 ,Pays 100% Medicare OPPS,$5.78 ,Pays 100% Medicare OPPS,$7.51 ,Pays 130% Medicare OPPS,$8.76 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$5.89 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$9.11 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$5.78 ,Pays 100% Medicare OPPS,$5.20 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$8.76 ,120.37% of custom fee schedule,$5.78 ,Pays 100% Medicare OPPS,$7.51 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$5.78 ,Pays 100% Medicare OPPS,$5.20 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,80320,ALCOHOL (SERUM TEST),301,$410.00 ,$348.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$16.36 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$17.01 ,125.18% of custom fee schedule,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$16.36 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$16.36 ,$369.00 ,$328.00 
Outpatient Medical Services,LAB,82085,ALDOLASE,301,$240.00 ,$204.00 ,85% of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$9.71 ,Pays 100% Medicare OPPS,$9.71 ,Pays 100% Medicare OPPS,$12.62 ,Pays 130% Medicare OPPS,$14.69 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$9.90 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$15.27 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$8.73 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$14.69 ,120.37% of custom fee schedule,$9.71 ,Pays 100% Medicare OPPS,$12.62 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$8.73 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,80307,Testing for presence of drug,301,$300.00 ,$255.00 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$73.62 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$63.38 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$76.56 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$73.62 ,120.37% of custom fee schedule,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,82104,3RD ALPHA-1-ANTITRYPSIN,301,$300.00 ,$255.00 ,85% of total billed charges,$14.46 ,Pays 100% Medicare OPPS,$14.46 ,Pays 100% Medicare OPPS,$14.46 ,Pays 100% Medicare OPPS,$18.79 ,Pays 130% Medicare OPPS,$21.88 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$14.74 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$22.76 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$14.46 ,Pays 100% Medicare OPPS,$13.01 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$21.88 ,120.37% of custom fee schedule,$14.46 ,Pays 100% Medicare OPPS,$18.79 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$14.46 ,Pays 100% Medicare OPPS,$13.01 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,82104,.ALPHA-1 ANTITRYPSIN PHENO,300,$300.00 ,$255.00 ,85% of total billed charges,$14.46 ,Pays 100% Medicare OPPS,$14.46 ,Pays 100% Medicare OPPS,$14.46 ,Pays 100% Medicare OPPS,$18.79 ,Pays 130% Medicare OPPS,$21.88 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$14.74 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$22.76 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$14.46 ,Pays 100% Medicare OPPS,$13.01 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$21.88 ,120.37% of custom fee schedule,$14.46 ,Pays 100% Medicare OPPS,$18.79 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$14.46 ,Pays 100% Medicare OPPS,$13.01 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,82105,MATERNAL SCREEN 1,300,$145.00 ,$123.25 ,85% of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$16.77 ,Pays 100% Medicare OPPS,$16.77 ,Pays 100% Medicare OPPS,$21.80 ,Pays 130% Medicare OPPS,$25.40 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$17.10 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$26.41 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$15.09 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$25.40 ,120.37% of custom fee schedule,$16.77 ,Pays 100% Medicare OPPS,$21.80 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$16.77 ,Pays 100% Medicare OPPS,$15.09 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82108,ALUMINUM LEVEL,301,$240.00 ,$204.00 ,85% of total billed charges,$25.48 ,Pays 100% Medicare OPPS,$25.48 ,Pays 100% Medicare OPPS,$25.48 ,Pays 100% Medicare OPPS,$33.12 ,Pays 130% Medicare OPPS,$25.52 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$25.98 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$26.54 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$25.48 ,Pays 100% Medicare OPPS,$22.93 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$25.52 ,120.37% of custom fee schedule,$25.48 ,Pays 100% Medicare OPPS,$33.12 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$25.48 ,Pays 100% Medicare OPPS,$22.93 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,82128,"3RD AMINO ACID PROFILE,PLASMA",301,"$1,090.00 ",$926.50 ,85% of total billed charges,$13.87 ,Pays 100% Medicare OPPS,$13.87 ,Pays 100% Medicare OPPS,$13.87 ,Pays 100% Medicare OPPS,$18.03 ,Pays 130% Medicare OPPS,$20.98 ,20.37% based on GA Medicaid OP CCR Rate,$615.85 ,56.5 percent of total billed charges,$615.85 ,56.5 percent of total billed charges,$615.85 ,56.5 percent of total billed charges,$615.85 ,56.5 percent of total billed charges,$14.14 ,Pays 102% Medicare OPPS,$981.00 ,90% of total billed charges,$21.82 ,125.18% of custom fee schedule,$748.83 ,68.7% of total billed charges,$872.00 ,80 percent of total billed charges,$13.87 ,Pays 100% Medicare OPPS,$12.48 ,Pays 90% Medicare OPPS,$632.20 ,58% of total billed charges,$20.98 ,120.37% of custom fee schedule,$13.87 ,Pays 100% Medicare OPPS,$18.03 ,Pays 130% Medicare OPPS,$926.50 ,85% of total billed charges,$13.87 ,Pays 100% Medicare OPPS,$12.48 ,$981.00 ,$872.00 
Outpatient Medical Services,LAB,82135,3RD AMINOLEVULINIC ACID,301,$590.00 ,$501.50 ,85% of total billed charges,$16.45 ,Pays 100% Medicare OPPS,$16.45 ,Pays 100% Medicare OPPS,$16.45 ,Pays 100% Medicare OPPS,$21.38 ,Pays 130% Medicare OPPS,$24.92 ,20.37% based on GA Medicaid OP CCR Rate,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$16.77 ,Pays 102% Medicare OPPS,$531.00 ,90% of total billed charges,$25.91 ,125.18% of custom fee schedule,$405.33 ,68.7% of total billed charges,$472.00 ,80 percent of total billed charges,$16.45 ,Pays 100% Medicare OPPS,$14.80 ,Pays 90% Medicare OPPS,$342.20 ,58% of total billed charges,$24.92 ,120.37% of custom fee schedule,$16.45 ,Pays 100% Medicare OPPS,$21.38 ,Pays 130% Medicare OPPS,$501.50 ,85% of total billed charges,$16.45 ,Pays 100% Medicare OPPS,$14.80 ,$531.00 ,$472.00 
Outpatient Medical Services,LAB,82140,AMMONIA LEVEL,301,$410.00 ,$348.50 ,85% of total billed charges,$14.57 ,Pays 100% Medicare OPPS,$14.57 ,Pays 100% Medicare OPPS,$14.57 ,Pays 100% Medicare OPPS,$18.94 ,Pays 130% Medicare OPPS,$14.97 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$14.86 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$15.57 ,125.18% of custom fee schedule,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$14.57 ,Pays 100% Medicare OPPS,$13.11 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$14.97 ,120.37% of custom fee schedule,$14.57 ,Pays 100% Medicare OPPS,$18.94 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$14.57 ,Pays 100% Medicare OPPS,$13.11 ,$369.00 ,$328.00 
Outpatient Medical Services,LAB,82150,AMYLASE ISOENYZMES,301,$325.00 ,$276.25 ,85% of total billed charges,$6.48 ,Pays 100% Medicare OPPS,$6.48 ,Pays 100% Medicare OPPS,$6.48 ,Pays 100% Medicare OPPS,$8.42 ,Pays 130% Medicare OPPS,$9.81 ,20.37% based on GA Medicaid OP CCR Rate,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$6.60 ,Pays 102% Medicare OPPS,$292.50 ,90% of total billed charges,$10.20 ,125.18% of custom fee schedule,$223.28 ,68.7% of total billed charges,$260.00 ,80 percent of total billed charges,$6.48 ,Pays 100% Medicare OPPS,$5.83 ,Pays 90% Medicare OPPS,$188.50 ,58% of total billed charges,$9.81 ,120.37% of custom fee schedule,$6.48 ,Pays 100% Medicare OPPS,$8.42 ,Pays 130% Medicare OPPS,$276.25 ,85% of total billed charges,$6.48 ,Pays 100% Medicare OPPS,$5.83 ,$292.50 ,$260.00 
Outpatient Medical Services,LAB,82157,ANDROSTENEDIONE,301,$85.00 ,$72.25 ,85% of total billed charges,$29.28 ,Pays 100% Medicare OPPS,$29.28 ,Pays 100% Medicare OPPS,$29.28 ,Pays 100% Medicare OPPS,$38.06 ,Pays 130% Medicare OPPS,$44.31 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$29.86 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$46.08 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$29.28 ,Pays 100% Medicare OPPS,$26.35 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$44.31 ,120.37% of custom fee schedule,$29.28 ,Pays 100% Medicare OPPS,$38.06 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$29.28 ,Pays 100% Medicare OPPS,$26.35 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,82164,ACE LEVEL,301,$245.00 ,$208.25 ,85% of total billed charges,$14.60 ,Pays 100% Medicare OPPS,$14.60 ,Pays 100% Medicare OPPS,$14.60 ,Pays 100% Medicare OPPS,$18.98 ,Pays 130% Medicare OPPS,$22.09 ,20.37% based on GA Medicaid OP CCR Rate,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$14.89 ,Pays 102% Medicare OPPS,$220.50 ,90% of total billed charges,$22.97 ,125.18% of custom fee schedule,$168.32 ,68.7% of total billed charges,$196.00 ,80 percent of total billed charges,$14.60 ,Pays 100% Medicare OPPS,$13.14 ,Pays 90% Medicare OPPS,$142.10 ,58% of total billed charges,$22.09 ,120.37% of custom fee schedule,$14.60 ,Pays 100% Medicare OPPS,$18.98 ,Pays 130% Medicare OPPS,$208.25 ,85% of total billed charges,$14.60 ,Pays 100% Medicare OPPS,$13.14 ,$220.50 ,$196.00 
Outpatient Medical Services,LAB,82175,"ARSENIC, URINE 24 HR",301,$365.00 ,$310.25 ,85% of total billed charges,$18.97 ,Pays 100% Medicare OPPS,$18.97 ,Pays 100% Medicare OPPS,$18.97 ,Pays 100% Medicare OPPS,$24.66 ,Pays 130% Medicare OPPS,$28.72 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$19.34 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$29.87 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$18.97 ,Pays 100% Medicare OPPS,$17.07 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$28.72 ,120.37% of custom fee schedule,$18.97 ,Pays 100% Medicare OPPS,$24.66 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$18.97 ,Pays 100% Medicare OPPS,$17.07 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,82180,VITAMIN C LEVEL,301,$215.00 ,$182.75 ,85% of total billed charges,$9.89 ,Pays 100% Medicare OPPS,$9.89 ,Pays 100% Medicare OPPS,$9.89 ,Pays 100% Medicare OPPS,$12.85 ,Pays 130% Medicare OPPS,$13.37 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$10.08 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$13.91 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$9.89 ,Pays 100% Medicare OPPS,$8.90 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$13.37 ,120.37% of custom fee schedule,$9.89 ,Pays 100% Medicare OPPS,$12.85 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$9.89 ,Pays 100% Medicare OPPS,$8.90 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,82232,BETA-2-MICROGLOBULIN,301,$275.00 ,$233.75 ,85% of total billed charges,$16.18 ,Pays 100% Medicare OPPS,$16.18 ,Pays 100% Medicare OPPS,$16.18 ,Pays 100% Medicare OPPS,$21.03 ,Pays 130% Medicare OPPS,$24.50 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$16.50 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$25.47 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$16.18 ,Pays 100% Medicare OPPS,$14.56 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$24.50 ,120.37% of custom fee schedule,$16.18 ,Pays 100% Medicare OPPS,$21.03 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$16.18 ,Pays 100% Medicare OPPS,$14.56 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,82247,"BILIRUBIN, TOTAL",301,$175.00 ,$148.75 ,85% of total billed charges,$5.01 ,Pays 100% Medicare OPPS,$5.01 ,Pays 100% Medicare OPPS,$5.01 ,Pays 100% Medicare OPPS,$6.52 ,Pays 130% Medicare OPPS,$7.61 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$5.12 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$7.91 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$5.01 ,Pays 100% Medicare OPPS,$4.51 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$7.61 ,120.37% of custom fee schedule,$5.01 ,Pays 100% Medicare OPPS,$6.52 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$5.01 ,Pays 100% Medicare OPPS,$4.51 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,82248,Measurement of direct bilirubin,301,$175.00 ,$148.75 ,85% of total billed charges,$5.01 ,Pays 100% Medicare OPPS,$5.01 ,Pays 100% Medicare OPPS,$5.01 ,Pays 100% Medicare OPPS,$6.52 ,Pays 130% Medicare OPPS,$7.61 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$5.12 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$7.91 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$5.01 ,Pays 100% Medicare OPPS,$4.51 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$7.61 ,120.37% of custom fee schedule,$5.01 ,Pays 100% Medicare OPPS,$6.52 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$5.01 ,Pays 100% Medicare OPPS,$4.51 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,82270,OCCULT BLOOD  STOOL #1,301,$135.00 ,$114.75 ,85% of total billed charges,$4.38 ,Pays 100% Medicare OPPS,$4.38 ,Pays 100% Medicare OPPS,$4.38 ,Pays 100% Medicare OPPS,$5.69 ,Pays 130% Medicare OPPS,$4.86 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.46 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$5.06 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.38 ,Pays 100% Medicare OPPS,$3.94 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$4.86 ,120.37% of custom fee schedule,$4.38 ,Pays 100% Medicare OPPS,$5.69 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$4.38 ,Pays 100% Medicare OPPS,$3.94 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,82271,OCCULT BLOOD-OTHER,301,$135.00 ,$114.75 ,85% of total billed charges,$5.32 ,Pays 100% Medicare OPPS,$5.32 ,Pays 100% Medicare OPPS,$5.32 ,Pays 100% Medicare OPPS,$6.91 ,Pays 130% Medicare OPPS,$4.86 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.42 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$5.06 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.32 ,Pays 100% Medicare OPPS,$4.78 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$4.86 ,120.37% of custom fee schedule,$5.32 ,Pays 100% Medicare OPPS,$6.91 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.32 ,Pays 100% Medicare OPPS,$4.78 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,82272,.OCCULT BLOOD DIGITAL EXAM,301,$135.00 ,$114.75 ,85% of total billed charges,$4.23 ,Pays 100% Medicare OPPS,$4.23 ,Pays 100% Medicare OPPS,$4.23 ,Pays 100% Medicare OPPS,$5.49 ,Pays 130% Medicare OPPS,$4.86 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.31 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$5.06 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.23 ,Pays 100% Medicare OPPS,$3.80 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$4.86 ,120.37% of custom fee schedule,$4.23 ,Pays 100% Medicare OPPS,$5.49 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$4.23 ,Pays 100% Medicare OPPS,$3.80 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,82270,HEMOCULT 1-3 SPCMN,300,$95.00 ,$80.75 ,85% of total billed charges,$4.38 ,Pays 100% Medicare OPPS,$4.38 ,Pays 100% Medicare OPPS,$4.38 ,Pays 100% Medicare OPPS,$5.69 ,Pays 130% Medicare OPPS,$4.86 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$4.46 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$5.06 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$4.38 ,Pays 100% Medicare OPPS,$3.94 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$4.86 ,120.37% of custom fee schedule,$4.38 ,Pays 100% Medicare OPPS,$5.69 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$4.38 ,Pays 100% Medicare OPPS,$3.94 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,82300,CADMIUM URINE,301,$85.00 ,$72.25 ,85% of total billed charges,$23.64 ,Pays 100% Medicare OPPS,$23.64 ,Pays 100% Medicare OPPS,$23.64 ,Pays 100% Medicare OPPS,$30.73 ,Pays 130% Medicare OPPS,$35.03 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$24.11 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$36.43 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$23.64 ,Pays 100% Medicare OPPS,$21.27 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$35.03 ,120.37% of custom fee schedule,$23.64 ,Pays 100% Medicare OPPS,$30.73 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$23.64 ,Pays 100% Medicare OPPS,$21.27 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,82306,Blood test to monitor vitamin D levels,301,$500.00 ,$425.00 ,85% of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$29.60 ,Pays 100% Medicare OPPS,$29.60 ,Pays 100% Medicare OPPS,$38.48 ,Pays 130% Medicare OPPS,$44.80 ,20.37% based on GA Medicaid OP CCR Rate,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$30.19 ,Pays 102% Medicare OPPS,$450.00 ,90% of total billed charges,$46.59 ,125.18% of custom fee schedule,$343.50 ,68.7% of total billed charges,$400.00 ,80 percent of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$26.64 ,Pays 90% Medicare OPPS,$290.00 ,58% of total billed charges,$44.80 ,120.37% of custom fee schedule,$29.60 ,Pays 100% Medicare OPPS,$38.48 ,Pays 130% Medicare OPPS,$425.00 ,85% of total billed charges,$29.60 ,Pays 100% Medicare OPPS,$26.64 ,$450.00 ,$400.00 
Outpatient Medical Services,LAB,82308,CALCITONIN,301,$415.00 ,$352.75 ,85% of total billed charges,$26.79 ,Pays 100% Medicare OPPS,$26.79 ,Pays 100% Medicare OPPS,$26.79 ,Pays 100% Medicare OPPS,$34.82 ,Pays 130% Medicare OPPS,$40.53 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$27.32 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$42.15 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$26.79 ,Pays 100% Medicare OPPS,$24.11 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$40.53 ,120.37% of custom fee schedule,$26.79 ,Pays 100% Medicare OPPS,$34.82 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$26.79 ,Pays 100% Medicare OPPS,$24.11 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,82310,CALCIUM SERUM,301,$150.00 ,$127.50 ,85% of total billed charges,$5.16 ,Pays 100% Medicare OPPS,$5.16 ,Pays 100% Medicare OPPS,$5.16 ,Pays 100% Medicare OPPS,$6.70 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.26 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.16 ,Pays 100% Medicare OPPS,$4.64 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$5.16 ,Pays 100% Medicare OPPS,$6.70 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.16 ,Pays 100% Medicare OPPS,$4.64 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,82330,CALCIUM IONIZED,301,$195.00 ,$165.75 ,85% of total billed charges,$13.68 ,Pays 100% Medicare OPPS,$13.68 ,Pays 100% Medicare OPPS,$13.68 ,Pays 100% Medicare OPPS,$17.78 ,Pays 130% Medicare OPPS,$20.68 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$13.95 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$21.51 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$13.68 ,Pays 100% Medicare OPPS,$12.31 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$20.68 ,120.37% of custom fee schedule,$13.68 ,Pays 100% Medicare OPPS,$17.78 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$13.68 ,Pays 100% Medicare OPPS,$12.31 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,82373,.TRANSFERRIN CARBOHYDRATE,301,$210.00 ,$178.50 ,85% of total billed charges,$18.05 ,Pays 100% Medicare OPPS,$18.05 ,Pays 100% Medicare OPPS,$18.05 ,Pays 100% Medicare OPPS,$23.47 ,Pays 130% Medicare OPPS,$9.09 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$18.42 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$9.45 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$18.05 ,Pays 100% Medicare OPPS,$16.25 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$9.09 ,120.37% of custom fee schedule,$18.05 ,Pays 100% Medicare OPPS,$23.47 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$18.05 ,Pays 100% Medicare OPPS,$9.09 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,82374,CO2,301,$135.00 ,$114.75 ,85% of total billed charges,$4.88 ,Pays 100% Medicare OPPS,$4.88 ,Pays 100% Medicare OPPS,$4.88 ,Pays 100% Medicare OPPS,$6.34 ,Pays 130% Medicare OPPS,$7.40 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.97 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$7.70 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.88 ,Pays 100% Medicare OPPS,$4.39 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.40 ,120.37% of custom fee schedule,$4.88 ,Pays 100% Medicare OPPS,$6.34 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$4.88 ,Pays 100% Medicare OPPS,$4.39 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,82375,CARBOXYHEMOGLOBIN LEVEL,301,$240.00 ,$204.00 ,85% of total billed charges,$12.32 ,Pays 100% Medicare OPPS,$12.32 ,Pays 100% Medicare OPPS,$12.32 ,Pays 100% Medicare OPPS,$16.01 ,Pays 130% Medicare OPPS,$4.36 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$12.56 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$4.53 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$12.32 ,Pays 100% Medicare OPPS,$11.08 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$4.36 ,120.37% of custom fee schedule,$12.32 ,Pays 100% Medicare OPPS,$16.01 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$12.32 ,Pays 100% Medicare OPPS,$4.36 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,82378,CEA,301,$365.00 ,$310.25 ,85% of total billed charges,$18.96 ,Pays 100% Medicare OPPS,$18.96 ,Pays 100% Medicare OPPS,$18.96 ,Pays 100% Medicare OPPS,$24.64 ,Pays 130% Medicare OPPS,$28.72 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$19.33 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$29.87 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$18.96 ,Pays 100% Medicare OPPS,$17.06 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$28.72 ,120.37% of custom fee schedule,$18.96 ,Pays 100% Medicare OPPS,$24.64 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$18.96 ,Pays 100% Medicare OPPS,$17.06 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,82379,"CARNITINE,SERUM",300,$415.00 ,$352.75 ,85% of total billed charges,$16.87 ,Pays 100% Medicare OPPS,$16.87 ,Pays 100% Medicare OPPS,$16.87 ,Pays 100% Medicare OPPS,$21.93 ,Pays 130% Medicare OPPS,$25.53 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$17.20 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$26.55 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$16.87 ,Pays 100% Medicare OPPS,$15.18 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$25.53 ,120.37% of custom fee schedule,$16.87 ,Pays 100% Medicare OPPS,$21.93 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$16.87 ,Pays 100% Medicare OPPS,$15.18 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,82380,"CAROTENE, SERUM",301,$260.00 ,$221.00 ,85% of total billed charges,$9.22 ,Pays 100% Medicare OPPS,$9.22 ,Pays 100% Medicare OPPS,$9.22 ,Pays 100% Medicare OPPS,$11.98 ,Pays 130% Medicare OPPS,$13.96 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$9.40 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$14.52 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$9.22 ,Pays 100% Medicare OPPS,$8.29 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$13.96 ,120.37% of custom fee schedule,$9.22 ,Pays 100% Medicare OPPS,$11.98 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$9.22 ,Pays 100% Medicare OPPS,$8.29 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,82384,CATECHOLAMINE UA RANDOM,301,$415.00 ,$352.75 ,85% of total billed charges,$25.25 ,Pays 100% Medicare OPPS,$25.25 ,Pays 100% Medicare OPPS,$25.25 ,Pays 100% Medicare OPPS,$32.82 ,Pays 130% Medicare OPPS,$38.22 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$25.75 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$39.74 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$25.25 ,Pays 100% Medicare OPPS,$22.72 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$38.22 ,120.37% of custom fee schedule,$25.25 ,Pays 100% Medicare OPPS,$32.82 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$25.25 ,Pays 100% Medicare OPPS,$22.72 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,82390,CERULOPLASMIN,301,$240.00 ,$204.00 ,85% of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$10.74 ,Pays 100% Medicare OPPS,$10.74 ,Pays 100% Medicare OPPS,$13.96 ,Pays 130% Medicare OPPS,$16.26 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$10.95 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$16.91 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$9.66 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$16.26 ,120.37% of custom fee schedule,$10.74 ,Pays 100% Medicare OPPS,$13.96 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$9.66 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,82397,IGF BINDING PROTEIN-3,305,$95.00 ,$80.75 ,85% of total billed charges,$14.12 ,Pays 100% Medicare OPPS,$14.12 ,Pays 100% Medicare OPPS,$14.12 ,Pays 100% Medicare OPPS,$18.35 ,Pays 130% Medicare OPPS,$21.39 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$14.40 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$22.24 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$14.12 ,Pays 100% Medicare OPPS,$12.70 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$21.39 ,120.37% of custom fee schedule,$14.12 ,Pays 100% Medicare OPPS,$18.35 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$14.12 ,Pays 100% Medicare OPPS,$12.70 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,82435,CHLORIDE  SERUM,301,$145.00 ,$123.25 ,85% of total billed charges,$4.59 ,Pays 100% Medicare OPPS,$4.59 ,Pays 100% Medicare OPPS,$4.59 ,Pays 100% Medicare OPPS,$5.98 ,Pays 130% Medicare OPPS,$6.96 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.69 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$7.24 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.59 ,Pays 100% Medicare OPPS,$4.13 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$6.96 ,120.37% of custom fee schedule,$4.59 ,Pays 100% Medicare OPPS,$5.98 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.59 ,Pays 100% Medicare OPPS,$4.13 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82436,CHLORIDE URINE SPOT,301,$145.00 ,$123.25 ,85% of total billed charges,$5.75 ,Pays 100% Medicare OPPS,$5.75 ,Pays 100% Medicare OPPS,$5.75 ,Pays 100% Medicare OPPS,$7.47 ,Pays 130% Medicare OPPS,$7.61 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$5.86 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$7.91 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$5.75 ,Pays 100% Medicare OPPS,$5.17 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$7.61 ,120.37% of custom fee schedule,$5.75 ,Pays 100% Medicare OPPS,$7.47 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$5.75 ,Pays 100% Medicare OPPS,$5.17 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82438,CHLORIDE BODY FLUID,301,$145.00 ,$123.25 ,85% of total billed charges,$5.00 ,Pays 100% Medicare OPPS,$5.00 ,Pays 100% Medicare OPPS,$5.00 ,Pays 100% Medicare OPPS,$6.50 ,Pays 130% Medicare OPPS,$7.40 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$5.10 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$7.70 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$5.00 ,Pays 100% Medicare OPPS,$4.50 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$7.40 ,120.37% of custom fee schedule,$5.00 ,Pays 100% Medicare OPPS,$6.50 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$5.00 ,Pays 100% Medicare OPPS,$4.50 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82465,CHOLESTEROL,301,$175.00 ,$148.75 ,85% of total billed charges,$4.34 ,Pays 100% Medicare OPPS,$4.34 ,Pays 100% Medicare OPPS,$4.34 ,Pays 100% Medicare OPPS,$5.65 ,Pays 130% Medicare OPPS,$6.58 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$4.43 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$6.85 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$4.34 ,Pays 100% Medicare OPPS,$3.91 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$6.58 ,120.37% of custom fee schedule,$4.34 ,Pays 100% Medicare OPPS,$5.65 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$4.34 ,Pays 100% Medicare OPPS,$3.91 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,82480,"CHOLINESTERASE, PLASMA",301,$320.00 ,$272.00 ,85% of total billed charges,$7.87 ,Pays 100% Medicare OPPS,$7.87 ,Pays 100% Medicare OPPS,$7.87 ,Pays 100% Medicare OPPS,$10.23 ,Pays 130% Medicare OPPS,$11.93 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$8.02 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$12.41 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$7.87 ,Pays 100% Medicare OPPS,$7.08 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$11.93 ,120.37% of custom fee schedule,$7.87 ,Pays 100% Medicare OPPS,$10.23 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$7.87 ,Pays 100% Medicare OPPS,$7.08 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,82482,"CHOLINESTERASE, RBC",301,$320.00 ,$272.00 ,85% of total billed charges,$9.81 ,Pays 100% Medicare OPPS,$9.81 ,Pays 100% Medicare OPPS,$9.81 ,Pays 100% Medicare OPPS,$12.75 ,Pays 130% Medicare OPPS,$11.64 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$10.00 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$12.10 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$9.81 ,Pays 100% Medicare OPPS,$8.82 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$11.64 ,120.37% of custom fee schedule,$9.81 ,Pays 100% Medicare OPPS,$12.75 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$9.81 ,Pays 100% Medicare OPPS,$8.82 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,82775,"DIURETIC PANEL, URINE",301,$590.00 ,$501.50 ,85% of total billed charges,$21.07 ,Pays 100% Medicare OPPS,$21.07 ,Pays 100% Medicare OPPS,$21.07 ,Pays 100% Medicare OPPS,$27.39 ,Pays 130% Medicare OPPS,$31.89 ,20.37% based on GA Medicaid OP CCR Rate,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$21.49 ,Pays 102% Medicare OPPS,$531.00 ,90% of total billed charges,$33.16 ,125.18% of custom fee schedule,$405.33 ,68.7% of total billed charges,$472.00 ,80 percent of total billed charges,$21.07 ,Pays 100% Medicare OPPS,$18.96 ,Pays 90% Medicare OPPS,$342.20 ,58% of total billed charges,$31.89 ,120.37% of custom fee schedule,$21.07 ,Pays 100% Medicare OPPS,$27.39 ,Pays 130% Medicare OPPS,$501.50 ,85% of total billed charges,$21.07 ,Pays 100% Medicare OPPS,$18.96 ,$531.00 ,$472.00 
Outpatient Medical Services,LAB,82495,CHROMIUM RBC LEVEL,301,$120.00 ,$102.00 ,85% of total billed charges,$20.28 ,Pays 100% Medicare OPPS,$20.28 ,Pays 100% Medicare OPPS,$20.28 ,Pays 100% Medicare OPPS,$26.36 ,Pays 130% Medicare OPPS,$30.71 ,20.37% based on GA Medicaid OP CCR Rate,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$20.68 ,Pays 102% Medicare OPPS,$108.00 ,90% of total billed charges,$31.93 ,125.18% of custom fee schedule,$82.44 ,68.7% of total billed charges,$96.00 ,80 percent of total billed charges,$20.28 ,Pays 100% Medicare OPPS,$18.25 ,Pays 90% Medicare OPPS,$69.60 ,58% of total billed charges,$30.71 ,120.37% of custom fee schedule,$20.28 ,Pays 100% Medicare OPPS,$26.36 ,Pays 130% Medicare OPPS,$102.00 ,85% of total billed charges,$20.28 ,Pays 100% Medicare OPPS,$18.25 ,$108.00 ,$96.00 
Outpatient Medical Services,LAB,82507,CITRATE URINE,301,$465.00 ,$395.25 ,85% of total billed charges,$27.80 ,Pays 100% Medicare OPPS,$27.80 ,Pays 100% Medicare OPPS,$27.80 ,Pays 100% Medicare OPPS,$36.14 ,Pays 130% Medicare OPPS,$42.09 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$28.35 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$43.78 ,125.18% of custom fee schedule,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$27.80 ,Pays 100% Medicare OPPS,$25.02 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$42.09 ,120.37% of custom fee schedule,$27.80 ,Pays 100% Medicare OPPS,$36.14 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$27.80 ,Pays 100% Medicare OPPS,$25.02 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,82523,N-TELOPEPTIDES (NTx) RANDOM URINE,301,$720.00 ,$612.00 ,85% of total billed charges,$18.68 ,Pays 100% Medicare OPPS,$18.68 ,Pays 100% Medicare OPPS,$18.68 ,Pays 100% Medicare OPPS,$24.28 ,Pays 130% Medicare OPPS,$28.29 ,20.37% based on GA Medicaid OP CCR Rate,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$19.05 ,Pays 102% Medicare OPPS,$648.00 ,90% of total billed charges,$29.42 ,125.18% of custom fee schedule,$494.64 ,68.7% of total billed charges,$576.00 ,80 percent of total billed charges,$18.68 ,Pays 100% Medicare OPPS,$16.81 ,Pays 90% Medicare OPPS,$417.60 ,58% of total billed charges,$28.29 ,120.37% of custom fee schedule,$18.68 ,Pays 100% Medicare OPPS,$24.28 ,Pays 130% Medicare OPPS,$612.00 ,85% of total billed charges,$18.68 ,Pays 100% Medicare OPPS,$16.81 ,$648.00 ,$576.00 
Outpatient Medical Services,LAB,82525,COPPER LEVEL,301,$220.00 ,$187.00 ,85% of total billed charges,$12.41 ,Pays 100% Medicare OPPS,$12.41 ,Pays 100% Medicare OPPS,$12.41 ,Pays 100% Medicare OPPS,$16.13 ,Pays 130% Medicare OPPS,$18.79 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$12.65 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$19.54 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$12.41 ,Pays 100% Medicare OPPS,$11.16 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$18.79 ,120.37% of custom fee schedule,$12.41 ,Pays 100% Medicare OPPS,$16.13 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$12.41 ,Pays 100% Medicare OPPS,$11.16 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,82530,CORTISOL FREE URINE 24 HR,301,$375.00 ,$318.75 ,85% of total billed charges,$16.71 ,Pays 100% Medicare OPPS,$16.71 ,Pays 100% Medicare OPPS,$16.71 ,Pays 100% Medicare OPPS,$21.72 ,Pays 130% Medicare OPPS,$25.30 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$17.04 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$26.31 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$16.71 ,Pays 100% Medicare OPPS,$15.03 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$25.30 ,120.37% of custom fee schedule,$16.71 ,Pays 100% Medicare OPPS,$21.72 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$16.71 ,Pays 100% Medicare OPPS,$15.03 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,82530,3RD CORTISOL FREE SERUM,301,$910.00 ,$773.50 ,85% of total billed charges,$16.71 ,Pays 100% Medicare OPPS,$16.71 ,Pays 100% Medicare OPPS,$16.71 ,Pays 100% Medicare OPPS,$21.72 ,Pays 130% Medicare OPPS,$25.30 ,20.37% based on GA Medicaid OP CCR Rate,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,$17.04 ,Pays 102% Medicare OPPS,$819.00 ,90% of total billed charges,$26.31 ,125.18% of custom fee schedule,$625.17 ,68.7% of total billed charges,$728.00 ,80 percent of total billed charges,$16.71 ,Pays 100% Medicare OPPS,$15.03 ,Pays 90% Medicare OPPS,$527.80 ,58% of total billed charges,$25.30 ,120.37% of custom fee schedule,$16.71 ,Pays 100% Medicare OPPS,$21.72 ,Pays 130% Medicare OPPS,$773.50 ,85% of total billed charges,$16.71 ,Pays 100% Medicare OPPS,$15.03 ,$819.00 ,$728.00 
Outpatient Medical Services,LAB,82533,CORTISOL RANDOM,301,$320.00 ,$272.00 ,85% of total billed charges,$16.30 ,Pays 100% Medicare OPPS,$16.30 ,Pays 100% Medicare OPPS,$16.30 ,Pays 100% Medicare OPPS,$21.19 ,Pays 130% Medicare OPPS,$24.68 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$16.62 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$25.66 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.30 ,Pays 100% Medicare OPPS,$14.67 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$24.68 ,120.37% of custom fee schedule,$16.30 ,Pays 100% Medicare OPPS,$21.19 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.30 ,Pays 100% Medicare OPPS,$14.67 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,82540,3RD CREATINE 24 HR URINE,301,$320.00 ,$272.00 ,85% of total billed charges,$4.63 ,Pays 100% Medicare OPPS,$4.63 ,Pays 100% Medicare OPPS,$4.63 ,Pays 100% Medicare OPPS,$6.03 ,Pays 130% Medicare OPPS,$7.02 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$4.73 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$7.30 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$4.63 ,Pays 100% Medicare OPPS,$4.17 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$7.02 ,120.37% of custom fee schedule,$4.63 ,Pays 100% Medicare OPPS,$6.03 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$4.63 ,Pays 100% Medicare OPPS,$4.17 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,82550,CPK,301,$210.00 ,$178.50 ,85% of total billed charges,$6.51 ,Pays 100% Medicare OPPS,$6.51 ,Pays 100% Medicare OPPS,$6.51 ,Pays 100% Medicare OPPS,$8.46 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$6.64 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$6.51 ,Pays 100% Medicare OPPS,$5.85 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$6.51 ,Pays 100% Medicare OPPS,$8.46 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$6.51 ,Pays 100% Medicare OPPS,$5.85 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,82552,CPK ISOENZYMES,301,$320.00 ,$272.00 ,85% of total billed charges,$13.39 ,Pays 100% Medicare OPPS,$13.39 ,Pays 100% Medicare OPPS,$13.39 ,Pays 100% Medicare OPPS,$17.40 ,Pays 130% Medicare OPPS,$20.27 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.65 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$21.08 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$13.39 ,Pays 100% Medicare OPPS,$12.05 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$20.27 ,120.37% of custom fee schedule,$13.39 ,Pays 100% Medicare OPPS,$17.40 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$13.39 ,Pays 100% Medicare OPPS,$12.05 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,82553,Blood test to detect heart enzymes,301,$295.00 ,$250.75 ,85% of total billed charges,$11.55 ,Pays 100% Medicare OPPS,$11.55 ,Pays 100% Medicare OPPS,$11.55 ,Pays 100% Medicare OPPS,$15.01 ,Pays 130% Medicare OPPS,$17.48 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$11.78 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$18.18 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$11.55 ,Pays 100% Medicare OPPS,$10.39 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$17.48 ,120.37% of custom fee schedule,$11.55 ,Pays 100% Medicare OPPS,$15.01 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$11.55 ,Pays 100% Medicare OPPS,$10.39 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,82565,"CREATININE, SERUM",301,$150.00 ,$127.50 ,85% of total billed charges,$5.12 ,Pays 100% Medicare OPPS,$5.12 ,Pays 100% Medicare OPPS,$5.12 ,Pays 100% Medicare OPPS,$6.65 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.22 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.12 ,Pays 100% Medicare OPPS,$4.60 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$5.12 ,Pays 100% Medicare OPPS,$6.65 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.12 ,Pays 100% Medicare OPPS,$4.60 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,82575,.CREA CLR (24HR UA CC),301,$215.00 ,$182.75 ,85% of total billed charges,$9.46 ,Pays 100% Medicare OPPS,$9.46 ,Pays 100% Medicare OPPS,$9.46 ,Pays 100% Medicare OPPS,$12.29 ,Pays 130% Medicare OPPS,$14.30 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$9.64 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$14.87 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$9.46 ,Pays 100% Medicare OPPS,$8.51 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$14.30 ,120.37% of custom fee schedule,$9.46 ,Pays 100% Medicare OPPS,$12.29 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$9.46 ,Pays 100% Medicare OPPS,$8.51 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,82585,CRYOFIBRINOGEN,301,$465.00 ,$395.25 ,85% of total billed charges,$14.14 ,Pays 100% Medicare OPPS,$14.14 ,Pays 100% Medicare OPPS,$14.14 ,Pays 100% Medicare OPPS,$18.38 ,Pays 130% Medicare OPPS,$12.98 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$14.42 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$13.49 ,125.18% of custom fee schedule,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$14.14 ,Pays 100% Medicare OPPS,$12.72 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$12.98 ,120.37% of custom fee schedule,$14.14 ,Pays 100% Medicare OPPS,$18.38 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$14.14 ,Pays 100% Medicare OPPS,$12.72 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,82595,"CRYOGLOBULIN, QUALITATIVE",301,$135.00 ,$114.75 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$9.80 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$6.59 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$10.19 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$9.80 ,120.37% of custom fee schedule,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,82607,Blood test to measure B-12,301,$190.00 ,$161.50 ,85% of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$15.08 ,Pays 100% Medicare OPPS,$15.08 ,Pays 100% Medicare OPPS,$19.60 ,Pays 130% Medicare OPPS,$22.81 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$15.38 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$23.72 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$13.57 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$22.81 ,120.37% of custom fee schedule,$15.08 ,Pays 100% Medicare OPPS,$19.60 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$13.57 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,82608,B-12 BINDING CAPACITY,301,$190.00 ,$161.50 ,85% of total billed charges,$14.32 ,Pays 100% Medicare OPPS,$14.32 ,Pays 100% Medicare OPPS,$14.32 ,Pays 100% Medicare OPPS,$18.61 ,Pays 130% Medicare OPPS,$21.68 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$14.60 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$22.54 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$14.32 ,Pays 100% Medicare OPPS,$12.88 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$21.68 ,120.37% of custom fee schedule,$14.32 ,Pays 100% Medicare OPPS,$18.61 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$14.32 ,Pays 100% Medicare OPPS,$12.88 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,82610,CYSTATIN C,301,$150.00 ,$127.50 ,85% of total billed charges,$18.52 ,Pays 100% Medicare OPPS,$18.52 ,Pays 100% Medicare OPPS,$18.52 ,Pays 100% Medicare OPPS,$24.07 ,Pays 130% Medicare OPPS,$20.58 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$18.89 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$21.41 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$18.52 ,Pays 100% Medicare OPPS,$16.66 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$20.58 ,120.37% of custom fee schedule,$18.52 ,Pays 100% Medicare OPPS,$24.07 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$18.52 ,Pays 100% Medicare OPPS,$16.66 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,82626,DHEA,301,$345.00 ,$293.25 ,85% of total billed charges,$25.27 ,Pays 100% Medicare OPPS,$25.27 ,Pays 100% Medicare OPPS,$25.27 ,Pays 100% Medicare OPPS,$32.85 ,Pays 130% Medicare OPPS,$38.25 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$25.77 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$39.78 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$25.27 ,Pays 100% Medicare OPPS,$22.74 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$38.25 ,120.37% of custom fee schedule,$25.27 ,Pays 100% Medicare OPPS,$32.85 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$25.27 ,Pays 100% Medicare OPPS,$22.74 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,82627,Blood test to measure an enzyme in the blood,301,$345.00 ,$293.25 ,85% of total billed charges,$22.23 ,Pays 100% Medicare OPPS,$22.23 ,Pays 100% Medicare OPPS,$22.23 ,Pays 100% Medicare OPPS,$28.89 ,Pays 130% Medicare OPPS,$33.66 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$22.67 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$35.00 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$22.23 ,Pays 100% Medicare OPPS,$20.00 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$33.66 ,120.37% of custom fee schedule,$22.23 ,Pays 100% Medicare OPPS,$28.89 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$22.23 ,Pays 100% Medicare OPPS,$20.00 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,82652,"VITAMIN D (1,25 Di) D2",301,$465.00 ,$395.25 ,85% of total billed charges,$38.50 ,Pays 100% Medicare OPPS,$38.50 ,Pays 100% Medicare OPPS,$38.50 ,Pays 100% Medicare OPPS,$50.05 ,Pays 130% Medicare OPPS,$58.26 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$39.27 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$60.59 ,125.18% of custom fee schedule,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$38.50 ,Pays 100% Medicare OPPS,$34.65 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$58.26 ,120.37% of custom fee schedule,$38.50 ,Pays 100% Medicare OPPS,$50.05 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$38.50 ,Pays 100% Medicare OPPS,$34.65 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,82664,ELECTROPHORETIC TECHNIQUE,301,$345.00 ,$293.25 ,85% of total billed charges,$61.50 ,Pays 100% Medicare OPPS,$61.50 ,Pays 100% Medicare OPPS,$61.50 ,Pays 100% Medicare OPPS,$79.95 ,Pays 130% Medicare OPPS,$52.00 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$62.73 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$54.08 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$61.50 ,Pays 100% Medicare OPPS,$55.35 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$52.00 ,120.37% of custom fee schedule,$61.50 ,Pays 100% Medicare OPPS,$79.95 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$61.50 ,Pays 100% Medicare OPPS,$52.00 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,82668,ERYTHROPOIETIN,301,$365.00 ,$310.25 ,85% of total billed charges,$18.79 ,Pays 100% Medicare OPPS,$18.79 ,Pays 100% Medicare OPPS,$18.79 ,Pays 100% Medicare OPPS,$24.42 ,Pays 130% Medicare OPPS,$28.44 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$19.16 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$29.58 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$18.79 ,Pays 100% Medicare OPPS,$16.91 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$28.44 ,120.37% of custom fee schedule,$18.79 ,Pays 100% Medicare OPPS,$24.42 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$18.79 ,Pays 100% Medicare OPPS,$16.91 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,82670,Blood test to measure a type of estrogen in the blood,301,$450.00 ,$382.50 ,85% of total billed charges,$27.94 ,Pays 100% Medicare OPPS,$27.94 ,Pays 100% Medicare OPPS,$27.94 ,Pays 100% Medicare OPPS,$36.32 ,Pays 130% Medicare OPPS,$42.30 ,20.37% based on GA Medicaid OP CCR Rate,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$28.49 ,Pays 102% Medicare OPPS,$405.00 ,90% of total billed charges,$43.99 ,125.18% of custom fee schedule,$309.15 ,68.7% of total billed charges,$360.00 ,80 percent of total billed charges,$27.94 ,Pays 100% Medicare OPPS,$25.14 ,Pays 90% Medicare OPPS,$261.00 ,58% of total billed charges,$42.30 ,120.37% of custom fee schedule,$27.94 ,Pays 100% Medicare OPPS,$36.32 ,Pays 130% Medicare OPPS,$382.50 ,85% of total billed charges,$27.94 ,Pays 100% Medicare OPPS,$25.14 ,$405.00 ,$360.00 
Outpatient Medical Services,LAB,82677,"ESTRIOL, TOTAL",301,$345.00 ,$293.25 ,85% of total billed charges,$24.18 ,Pays 100% Medicare OPPS,$24.18 ,Pays 100% Medicare OPPS,$24.18 ,Pays 100% Medicare OPPS,$31.43 ,Pays 130% Medicare OPPS,$36.60 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$24.66 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$38.07 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$24.18 ,Pays 100% Medicare OPPS,$21.76 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$36.60 ,120.37% of custom fee schedule,$24.18 ,Pays 100% Medicare OPPS,$31.43 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$24.18 ,Pays 100% Medicare OPPS,$21.76 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,82679,ESTRONE LEVEL,301,$415.00 ,$352.75 ,85% of total billed charges,$24.95 ,Pays 100% Medicare OPPS,$24.95 ,Pays 100% Medicare OPPS,$24.95 ,Pays 100% Medicare OPPS,$32.43 ,Pays 130% Medicare OPPS,$37.78 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$25.44 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$39.29 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$24.95 ,Pays 100% Medicare OPPS,$22.45 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$37.78 ,120.37% of custom fee schedule,$24.95 ,Pays 100% Medicare OPPS,$32.43 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$24.95 ,Pays 100% Medicare OPPS,$22.45 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,82693,ETHYLENE GLYCOL,301,$375.00 ,$318.75 ,85% of total billed charges,$14.90 ,Pays 100% Medicare OPPS,$14.90 ,Pays 100% Medicare OPPS,$14.90 ,Pays 100% Medicare OPPS,$19.37 ,Pays 130% Medicare OPPS,$22.56 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$15.19 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$23.46 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$14.90 ,Pays 100% Medicare OPPS,$13.41 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$22.56 ,120.37% of custom fee schedule,$14.90 ,Pays 100% Medicare OPPS,$19.37 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$14.90 ,Pays 100% Medicare OPPS,$13.41 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,82728,Test to determine level of iron in the blood,301,$215.00 ,$182.75 ,85% of total billed charges,$13.63 ,Pays 100% Medicare OPPS,$13.63 ,Pays 100% Medicare OPPS,$13.63 ,Pays 100% Medicare OPPS,$17.71 ,Pays 130% Medicare OPPS,$20.62 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$13.90 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$21.44 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$13.63 ,Pays 100% Medicare OPPS,$12.26 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$20.62 ,120.37% of custom fee schedule,$13.63 ,Pays 100% Medicare OPPS,$17.71 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$13.63 ,Pays 100% Medicare OPPS,$12.26 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,82731,FETAL FIBRONECTIN,300,"$1,510.00 ","$1,283.50 ",85% of total billed charges,$64.41 ,Pays 100% Medicare OPPS,$64.41 ,Pays 100% Medicare OPPS,$64.41 ,Pays 100% Medicare OPPS,$83.73 ,Pays 130% Medicare OPPS,$97.49 ,20.37% based on GA Medicaid OP CCR Rate,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$65.69 ,Pays 102% Medicare OPPS,"$1,359.00 ",90% of total billed charges,$101.38 ,125.18% of custom fee schedule,"$1,037.37 ",68.7% of total billed charges,"$1,208.00 ",80 percent of total billed charges,$64.41 ,Pays 100% Medicare OPPS,$57.96 ,Pays 90% Medicare OPPS,$875.80 ,58% of total billed charges,$97.49 ,120.37% of custom fee schedule,$64.41 ,Pays 100% Medicare OPPS,$83.73 ,Pays 130% Medicare OPPS,"$1,283.50 ",85% of total billed charges,$64.41 ,Pays 100% Medicare OPPS,$57.96 ,"$1,359.00 ","$1,208.00 "
Outpatient Medical Services,LAB,82746,FOLATE SERUM,301,$190.00 ,$161.50 ,85% of total billed charges,$14.70 ,Pays 100% Medicare OPPS,$14.70 ,Pays 100% Medicare OPPS,$14.70 ,Pays 100% Medicare OPPS,$19.11 ,Pays 130% Medicare OPPS,$22.26 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$14.99 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$23.15 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$14.70 ,Pays 100% Medicare OPPS,$13.23 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$22.26 ,120.37% of custom fee schedule,$14.70 ,Pays 100% Medicare OPPS,$19.11 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$14.70 ,Pays 100% Medicare OPPS,$13.23 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,85014,RBC FOLATE,301,$310.00 ,$263.50 ,85% of total billed charges,$2.37 ,Pays 100% Medicare OPPS,$2.37 ,Pays 100% Medicare OPPS,$2.37 ,Pays 100% Medicare OPPS,$3.08 ,Pays 130% Medicare OPPS,$3.59 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$2.41 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$3.73 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$2.37 ,Pays 100% Medicare OPPS,$2.13 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$3.59 ,120.37% of custom fee schedule,$2.37 ,Pays 100% Medicare OPPS,$3.08 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$2.37 ,Pays 100% Medicare OPPS,$2.13 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,82757,FRUCTOSE SEMEN,301,$365.00 ,$310.25 ,85% of total billed charges,$17.34 ,Pays 100% Medicare OPPS,$17.34 ,Pays 100% Medicare OPPS,$17.34 ,Pays 100% Medicare OPPS,$22.54 ,Pays 130% Medicare OPPS,$26.26 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$17.68 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$27.31 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$17.34 ,Pays 100% Medicare OPPS,$15.60 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$26.26 ,120.37% of custom fee schedule,$17.34 ,Pays 100% Medicare OPPS,$22.54 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$17.34 ,Pays 100% Medicare OPPS,$15.60 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,84378,GALACTOSE-1- PHOSPHATE RBC LEVEL,300,$735.00 ,$624.75 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$17.44 ,20.37% based on GA Medicaid OP CCR Rate,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$661.50 ,90% of total billed charges,$18.14 ,125.18% of custom fee schedule,$504.95 ,68.7% of total billed charges,$588.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$426.30 ,58% of total billed charges,$17.44 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$624.75 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$661.50 ,$588.00 
Outpatient Medical Services,LAB,82784,Test to determine levels of immunoglobulins in the blood,301,$95.00 ,$80.75 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$14.07 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$9.48 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$14.63 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$14.07 ,120.37% of custom fee schedule,$9.30 ,Pays 100% Medicare OPPS,$12.09 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$9.30 ,Pays 100% Medicare OPPS,$8.37 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,83520,IGE,301,$260.00 ,$221.00 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,82787,.IMMUNO G (IgG SUBCLASSES,301,$110.00 ,$93.50 ,85% of total billed charges,$8.02 ,Pays 100% Medicare OPPS,$8.02 ,Pays 100% Medicare OPPS,$8.02 ,Pays 100% Medicare OPPS,$10.42 ,Pays 130% Medicare OPPS,$12.13 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$8.18 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$12.62 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$8.02 ,Pays 100% Medicare OPPS,$7.21 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$12.13 ,120.37% of custom fee schedule,$8.02 ,Pays 100% Medicare OPPS,$10.42 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$8.02 ,Pays 100% Medicare OPPS,$7.21 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,82941,"GASTRIN, SERUM",301,$260.00 ,$221.00 ,85% of total billed charges,$17.63 ,Pays 100% Medicare OPPS,$17.63 ,Pays 100% Medicare OPPS,$17.63 ,Pays 100% Medicare OPPS,$22.91 ,Pays 130% Medicare OPPS,$26.70 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$17.98 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$27.76 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$17.63 ,Pays 100% Medicare OPPS,$15.86 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$26.70 ,120.37% of custom fee schedule,$17.63 ,Pays 100% Medicare OPPS,$22.91 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$17.63 ,Pays 100% Medicare OPPS,$15.86 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,82943,GLUCAGON,301,$345.00 ,$293.25 ,85% of total billed charges,$14.29 ,Pays 100% Medicare OPPS,$14.29 ,Pays 100% Medicare OPPS,$14.29 ,Pays 100% Medicare OPPS,$18.57 ,Pays 130% Medicare OPPS,$21.63 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$14.57 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$22.49 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$14.29 ,Pays 100% Medicare OPPS,$12.86 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$21.63 ,120.37% of custom fee schedule,$14.29 ,Pays 100% Medicare OPPS,$18.57 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$14.29 ,Pays 100% Medicare OPPS,$12.86 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,82945,3RD GLUCOSE BODY FLUID,301,$145.00 ,$123.25 ,85% of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.93 ,Pays 100% Medicare OPPS,$3.93 ,Pays 100% Medicare OPPS,$5.10 ,Pays 130% Medicare OPPS,$5.93 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.00 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$6.17 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.53 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$5.93 ,120.37% of custom fee schedule,$3.93 ,Pays 100% Medicare OPPS,$5.10 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.53 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82947,Quantitative measure of glucose build up in the blood over time,301,$145.00 ,$123.25 ,85% of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.93 ,Pays 100% Medicare OPPS,$3.93 ,Pays 100% Medicare OPPS,$5.10 ,Pays 130% Medicare OPPS,$5.93 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.00 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$6.17 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.53 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$5.93 ,120.37% of custom fee schedule,$3.93 ,Pays 100% Medicare OPPS,$5.10 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$3.93 ,Pays 100% Medicare OPPS,$3.53 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82948,.GLUCOSE STRIP/BEDSIDE,301,$115.00 ,$97.75 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$4.80 ,20.37% based on GA Medicaid OP CCR Rate,$64.98 ,56.5 percent of total billed charges,$64.98 ,56.5 percent of total billed charges,$64.98 ,56.5 percent of total billed charges,$64.98 ,56.5 percent of total billed charges,$5.14 ,Pays 102% Medicare OPPS,$103.50 ,90% of total billed charges,$4.99 ,125.18% of custom fee schedule,$79.01 ,68.7% of total billed charges,$92.00 ,80 percent of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,Pays 90% Medicare OPPS,$66.70 ,58% of total billed charges,$4.80 ,120.37% of custom fee schedule,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$97.75 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,$103.50 ,$92.00 
Outpatient Medical Services,LAB,82950,Test of glucose level in the blood,301,$145.00 ,$123.25 ,85% of total billed charges,$4.75 ,Pays 100% Medicare OPPS,$4.75 ,Pays 100% Medicare OPPS,$4.75 ,Pays 100% Medicare OPPS,$6.17 ,Pays 130% Medicare OPPS,$7.20 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.84 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$7.49 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.75 ,Pays 100% Medicare OPPS,$4.27 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$7.20 ,120.37% of custom fee schedule,$4.75 ,Pays 100% Medicare OPPS,$6.17 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.75 ,Pays 100% Medicare OPPS,$4.27 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82951,Test to predict likelihood of gestational diabetes,301,$175.00 ,$148.75 ,85% of total billed charges,$12.87 ,Pays 100% Medicare OPPS,$12.87 ,Pays 100% Medicare OPPS,$12.87 ,Pays 100% Medicare OPPS,$16.73 ,Pays 130% Medicare OPPS,$19.49 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$13.12 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$20.27 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$12.87 ,Pays 100% Medicare OPPS,$11.58 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$19.49 ,120.37% of custom fee schedule,$12.87 ,Pays 100% Medicare OPPS,$16.73 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$12.87 ,Pays 100% Medicare OPPS,$11.58 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,82952,.GTT ADDITIONAL,301,$145.00 ,$123.25 ,85% of total billed charges,$3.92 ,Pays 100% Medicare OPPS,$3.92 ,Pays 100% Medicare OPPS,$3.92 ,Pays 100% Medicare OPPS,$5.09 ,Pays 130% Medicare OPPS,$5.93 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$3.99 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$6.17 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$3.92 ,Pays 100% Medicare OPPS,$3.52 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$5.93 ,120.37% of custom fee schedule,$3.92 ,Pays 100% Medicare OPPS,$5.09 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$3.92 ,Pays 100% Medicare OPPS,$3.52 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82955,G6PD QUANT,301,$275.00 ,$233.75 ,85% of total billed charges,$9.69 ,Pays 100% Medicare OPPS,$9.69 ,Pays 100% Medicare OPPS,$9.69 ,Pays 100% Medicare OPPS,$12.61 ,Pays 130% Medicare OPPS,$11.82 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$9.89 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$12.29 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$9.69 ,Pays 100% Medicare OPPS,$8.72 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$11.82 ,120.37% of custom fee schedule,$9.69 ,Pays 100% Medicare OPPS,$12.61 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$9.69 ,Pays 100% Medicare OPPS,$8.72 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,82948,FINGERSTICK BLOOD SUGAR,301,$165.00 ,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$4.80 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$5.14 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$4.99 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$4.80 ,120.37% of custom fee schedule,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,82948,NS2 GLUCOSE STRIP/BEDSIDE,301,$165.00 ,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$4.80 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$5.14 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$4.99 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$4.80 ,120.37% of custom fee schedule,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,82948,ER GLUCOSE STRIP/BEDSIDE,301,$165.00 ,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$4.80 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$5.14 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$4.99 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$4.80 ,120.37% of custom fee schedule,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,82948,MON GLUCOSE STRIP/BEDSIDE,301,$165.00 ,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$4.80 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$5.14 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$4.99 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$4.80 ,120.37% of custom fee schedule,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,82948,L/D GLUCOSE STRIP/BEDSIDE,301,$165.00 ,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$4.80 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$5.14 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$4.99 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$4.80 ,120.37% of custom fee schedule,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,82948,REC GLUCOSE STRIP/BEDSIDE,301,$165.00 ,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$4.80 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$5.14 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$4.99 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$4.80 ,120.37% of custom fee schedule,$5.04 ,Pays 100% Medicare OPPS,$6.55 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$5.04 ,Pays 100% Medicare OPPS,$4.53 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,82977,GGT,301,$175.00 ,$148.75 ,85% of total billed charges,$7.20 ,Pays 100% Medicare OPPS,$7.20 ,Pays 100% Medicare OPPS,$7.20 ,Pays 100% Medicare OPPS,$9.36 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$7.34 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$7.20 ,Pays 100% Medicare OPPS,$6.48 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$7.20 ,Pays 100% Medicare OPPS,$9.36 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$7.20 ,Pays 100% Medicare OPPS,$6.48 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,82985,FRUCTOSAMINE LEVEL,301,$215.00 ,$182.75 ,85% of total billed charges,$16.76 ,Pays 100% Medicare OPPS,$16.76 ,Pays 100% Medicare OPPS,$16.76 ,Pays 100% Medicare OPPS,$21.78 ,Pays 130% Medicare OPPS,$22.81 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$17.09 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$23.72 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$16.76 ,Pays 100% Medicare OPPS,$15.08 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$22.81 ,120.37% of custom fee schedule,$16.76 ,Pays 100% Medicare OPPS,$21.78 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$16.76 ,Pays 100% Medicare OPPS,$15.08 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,83001,Test of hormone in the blood,301,$375.00 ,$318.75 ,85% of total billed charges,$18.57 ,Pays 100% Medicare OPPS,$18.57 ,Pays 100% Medicare OPPS,$18.57 ,Pays 100% Medicare OPPS,$24.15 ,Pays 130% Medicare OPPS,$28.13 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$18.95 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$29.25 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$18.57 ,Pays 100% Medicare OPPS,$16.72 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$28.13 ,120.37% of custom fee schedule,$18.57 ,Pays 100% Medicare OPPS,$24.15 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$18.57 ,Pays 100% Medicare OPPS,$16.72 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,83002,Test of hormone in the blood,301,$365.00 ,$310.25 ,85% of total billed charges,$18.52 ,Pays 100% Medicare OPPS,$18.52 ,Pays 100% Medicare OPPS,$18.52 ,Pays 100% Medicare OPPS,$24.07 ,Pays 130% Medicare OPPS,$28.03 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$18.89 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$29.15 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$18.52 ,Pays 100% Medicare OPPS,$16.66 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$28.03 ,120.37% of custom fee schedule,$18.52 ,Pays 100% Medicare OPPS,$24.07 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$18.52 ,Pays 100% Medicare OPPS,$16.66 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,83003,GROWTH HORMONE LEVEL,301,$320.00 ,$272.00 ,85% of total billed charges,$16.67 ,Pays 100% Medicare OPPS,$16.67 ,Pays 100% Medicare OPPS,$16.67 ,Pays 100% Medicare OPPS,$21.67 ,Pays 130% Medicare OPPS,$21.55 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$17.00 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$22.41 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.67 ,Pays 100% Medicare OPPS,$15.00 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$21.55 ,120.37% of custom fee schedule,$16.67 ,Pays 100% Medicare OPPS,$21.67 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.67 ,Pays 100% Medicare OPPS,$15.00 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,83010,3RD HAPTOGLOBIN LEVEL,301,$260.00 ,$221.00 ,85% of total billed charges,$12.58 ,Pays 100% Medicare OPPS,$12.58 ,Pays 100% Medicare OPPS,$12.58 ,Pays 100% Medicare OPPS,$16.35 ,Pays 130% Medicare OPPS,$5.65 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$12.83 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$5.87 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$12.58 ,Pays 100% Medicare OPPS,$11.32 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$5.65 ,120.37% of custom fee schedule,$12.58 ,Pays 100% Medicare OPPS,$16.35 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$12.58 ,Pays 100% Medicare OPPS,$5.65 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,83013,Test of breath for a stomach bacterium,301,$145.00 ,$123.25 ,85% of total billed charges,$67.36 ,Pays 100% Medicare OPPS,$67.36 ,Pays 100% Medicare OPPS,$67.36 ,Pays 100% Medicare OPPS,$87.56 ,Pays 130% Medicare OPPS,$80.08 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$68.70 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$83.28 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$67.36 ,Pays 100% Medicare OPPS,$60.62 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$80.08 ,120.37% of custom fee schedule,$67.36 ,Pays 100% Medicare OPPS,$87.56 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$67.36 ,Pays 100% Medicare OPPS,$60.62 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,82175,"ARSENIC, OTHER",301,$610.00 ,$518.50 ,85% of total billed charges,$18.97 ,Pays 100% Medicare OPPS,$18.97 ,Pays 100% Medicare OPPS,$18.97 ,Pays 100% Medicare OPPS,$24.66 ,Pays 130% Medicare OPPS,$28.72 ,20.37% based on GA Medicaid OP CCR Rate,$344.65 ,56.5 percent of total billed charges,$344.65 ,56.5 percent of total billed charges,$344.65 ,56.5 percent of total billed charges,$344.65 ,56.5 percent of total billed charges,$19.34 ,Pays 102% Medicare OPPS,$549.00 ,90% of total billed charges,$29.87 ,125.18% of custom fee schedule,$419.07 ,68.7% of total billed charges,$488.00 ,80 percent of total billed charges,$18.97 ,Pays 100% Medicare OPPS,$17.07 ,Pays 90% Medicare OPPS,$353.80 ,58% of total billed charges,$28.72 ,120.37% of custom fee schedule,$18.97 ,Pays 100% Medicare OPPS,$24.66 ,Pays 130% Medicare OPPS,$518.50 ,85% of total billed charges,$18.97 ,Pays 100% Medicare OPPS,$17.07 ,$549.00 ,$488.00 
Outpatient Medical Services,LAB,83018,HEAVY METALS (BLOOD),301,$195.00 ,$165.75 ,85% of total billed charges,$21.96 ,Pays 100% Medicare OPPS,$21.96 ,Pays 100% Medicare OPPS,$21.96 ,Pays 100% Medicare OPPS,$28.54 ,Pays 130% Medicare OPPS,$33.23 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$22.39 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$34.56 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$21.96 ,Pays 100% Medicare OPPS,$19.76 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$33.23 ,120.37% of custom fee schedule,$21.96 ,Pays 100% Medicare OPPS,$28.54 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$21.96 ,Pays 100% Medicare OPPS,$19.76 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,83021,HEMOGLOBIN ELECTROPHORESIS,301,$320.00 ,$272.00 ,85% of total billed charges,$18.05 ,Pays 100% Medicare OPPS,$18.05 ,Pays 100% Medicare OPPS,$18.05 ,Pays 100% Medicare OPPS,$23.47 ,Pays 130% Medicare OPPS,$9.09 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$18.42 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$9.45 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$18.05 ,Pays 100% Medicare OPPS,$16.25 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$9.09 ,120.37% of custom fee schedule,$18.05 ,Pays 100% Medicare OPPS,$23.47 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$18.05 ,Pays 100% Medicare OPPS,$9.09 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,83036,Blood test to measure average blood glucose levels for past 2-3 months,301,$245.00 ,$208.25 ,85% of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$9.71 ,Pays 100% Medicare OPPS,$9.71 ,Pays 100% Medicare OPPS,$12.62 ,Pays 130% Medicare OPPS,$14.69 ,20.37% based on GA Medicaid OP CCR Rate,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$9.90 ,Pays 102% Medicare OPPS,$220.50 ,90% of total billed charges,$15.27 ,125.18% of custom fee schedule,$168.32 ,68.7% of total billed charges,$196.00 ,80 percent of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$8.73 ,Pays 90% Medicare OPPS,$142.10 ,58% of total billed charges,$14.69 ,120.37% of custom fee schedule,$9.71 ,Pays 100% Medicare OPPS,$12.62 ,Pays 130% Medicare OPPS,$208.25 ,85% of total billed charges,$9.71 ,Pays 100% Medicare OPPS,$8.73 ,$220.50 ,$196.00 
Outpatient Medical Services,LAB,83088,3RD HISTAMINE LEVEL,301,$500.00 ,$425.00 ,85% of total billed charges,$29.53 ,Pays 100% Medicare OPPS,$29.53 ,Pays 100% Medicare OPPS,$29.53 ,Pays 100% Medicare OPPS,$38.38 ,Pays 130% Medicare OPPS,$44.69 ,20.37% based on GA Medicaid OP CCR Rate,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$30.12 ,Pays 102% Medicare OPPS,$450.00 ,90% of total billed charges,$46.48 ,125.18% of custom fee schedule,$343.50 ,68.7% of total billed charges,$400.00 ,80 percent of total billed charges,$29.53 ,Pays 100% Medicare OPPS,$26.57 ,Pays 90% Medicare OPPS,$290.00 ,58% of total billed charges,$44.69 ,120.37% of custom fee schedule,$29.53 ,Pays 100% Medicare OPPS,$38.38 ,Pays 130% Medicare OPPS,$425.00 ,85% of total billed charges,$29.53 ,Pays 100% Medicare OPPS,$26.57 ,$450.00 ,$400.00 
Outpatient Medical Services,LAB,83090,"HOMOCYSTEINE, SERUM",301,$510.00 ,$433.50 ,85% of total billed charges,$17.92 ,Pays 100% Medicare OPPS,$17.92 ,Pays 100% Medicare OPPS,$17.92 ,Pays 100% Medicare OPPS,$23.29 ,Pays 130% Medicare OPPS,$25.53 ,20.37% based on GA Medicaid OP CCR Rate,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$18.27 ,Pays 102% Medicare OPPS,$459.00 ,90% of total billed charges,$26.55 ,125.18% of custom fee schedule,$350.37 ,68.7% of total billed charges,$408.00 ,80 percent of total billed charges,$17.92 ,Pays 100% Medicare OPPS,$16.12 ,Pays 90% Medicare OPPS,$295.80 ,58% of total billed charges,$25.53 ,120.37% of custom fee schedule,$17.92 ,Pays 100% Medicare OPPS,$23.29 ,Pays 130% Medicare OPPS,$433.50 ,85% of total billed charges,$17.92 ,Pays 100% Medicare OPPS,$16.12 ,$459.00 ,$408.00 
Outpatient Medical Services,LAB,83586,17 HYDROXYCORTICOSTEROIDS,301,$320.00 ,$272.00 ,85% of total billed charges,$12.80 ,Pays 100% Medicare OPPS,$12.80 ,Pays 100% Medicare OPPS,$12.80 ,Pays 100% Medicare OPPS,$16.64 ,Pays 130% Medicare OPPS,$19.02 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.05 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$19.78 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.80 ,Pays 100% Medicare OPPS,$11.52 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$19.02 ,120.37% of custom fee schedule,$12.80 ,Pays 100% Medicare OPPS,$16.64 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.80 ,Pays 100% Medicare OPPS,$11.52 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,83497,"5 HIAA, UA",301,$300.00 ,$255.00 ,85% of total billed charges,$12.90 ,Pays 100% Medicare OPPS,$12.90 ,Pays 100% Medicare OPPS,$12.90 ,Pays 100% Medicare OPPS,$16.77 ,Pays 130% Medicare OPPS,$19.51 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$13.15 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$20.29 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$12.90 ,Pays 100% Medicare OPPS,$11.61 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$19.51 ,120.37% of custom fee schedule,$12.90 ,Pays 100% Medicare OPPS,$16.77 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$12.90 ,Pays 100% Medicare OPPS,$11.61 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,83498,"HYDROXYPROGESTERONE,17-AL",301,$375.00 ,$318.75 ,85% of total billed charges,$27.17 ,Pays 100% Medicare OPPS,$27.17 ,Pays 100% Medicare OPPS,$27.17 ,Pays 100% Medicare OPPS,$35.32 ,Pays 130% Medicare OPPS,$41.12 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$27.71 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$42.76 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$27.17 ,Pays 100% Medicare OPPS,$24.45 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$41.12 ,120.37% of custom fee schedule,$27.17 ,Pays 100% Medicare OPPS,$35.32 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$27.17 ,Pays 100% Medicare OPPS,$24.45 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,83500,"HYDROXYPROLINE, TOTAL",301,$725.00 ,$616.25 ,85% of total billed charges,$22.65 ,Pays 100% Medicare OPPS,$22.65 ,Pays 100% Medicare OPPS,$22.65 ,Pays 100% Medicare OPPS,$29.44 ,Pays 130% Medicare OPPS,$34.29 ,20.37% based on GA Medicaid OP CCR Rate,$409.63 ,56.5 percent of total billed charges,$409.63 ,56.5 percent of total billed charges,$409.63 ,56.5 percent of total billed charges,$409.63 ,56.5 percent of total billed charges,$23.10 ,Pays 102% Medicare OPPS,$652.50 ,90% of total billed charges,$35.66 ,125.18% of custom fee schedule,$498.08 ,68.7% of total billed charges,$580.00 ,80 percent of total billed charges,$22.65 ,Pays 100% Medicare OPPS,$20.38 ,Pays 90% Medicare OPPS,$420.50 ,58% of total billed charges,$34.29 ,120.37% of custom fee schedule,$22.65 ,Pays 100% Medicare OPPS,$29.44 ,Pays 130% Medicare OPPS,$616.25 ,85% of total billed charges,$22.65 ,Pays 100% Medicare OPPS,$20.38 ,$652.50 ,$580.00 
Outpatient Medical Services,LAB,86316,3RD CHROMOGRANIN-A,301,$375.00 ,$318.75 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$31.49 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$21.22 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$32.75 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$31.49 ,120.37% of custom fee schedule,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,83516,Chemical test of the blood to measure presence or concentration of a substance in the blood,301,$295.00 ,$250.75 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,83525,INSULIN LEVEL,301,$240.00 ,$204.00 ,85% of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$11.43 ,Pays 100% Medicare OPPS,$11.43 ,Pays 100% Medicare OPPS,$14.85 ,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$11.65 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$18.00 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$10.28 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$17.31 ,120.37% of custom fee schedule,$11.43 ,Pays 100% Medicare OPPS,$14.85 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$11.43 ,Pays 100% Medicare OPPS,$10.28 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,83540,Blood test to measure the amount of iron that is in transit in the body,301,$120.00 ,$102.00 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$9.81 ,20.37% based on GA Medicaid OP CCR Rate,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$6.59 ,Pays 102% Medicare OPPS,$108.00 ,90% of total billed charges,$10.20 ,125.18% of custom fee schedule,$82.44 ,68.7% of total billed charges,$96.00 ,80 percent of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,Pays 90% Medicare OPPS,$69.60 ,58% of total billed charges,$9.81 ,120.37% of custom fee schedule,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$102.00 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,$108.00 ,$96.00 
Outpatient Medical Services,LAB,83550,Blood test that measures the amount of iron carried in the blood,301,$265.00 ,$225.25 ,85% of total billed charges,$8.74 ,Pays 100% Medicare OPPS,$8.74 ,Pays 100% Medicare OPPS,$8.74 ,Pays 100% Medicare OPPS,$11.36 ,Pays 130% Medicare OPPS,$13.23 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$8.91 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$13.76 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$8.74 ,Pays 100% Medicare OPPS,$7.86 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$13.23 ,120.37% of custom fee schedule,$8.74 ,Pays 100% Medicare OPPS,$11.36 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$8.74 ,Pays 100% Medicare OPPS,$7.86 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,83586,"17 KETOGENIC STEROID, UA",301,$320.00 ,$272.00 ,85% of total billed charges,$12.80 ,Pays 100% Medicare OPPS,$12.80 ,Pays 100% Medicare OPPS,$12.80 ,Pays 100% Medicare OPPS,$16.64 ,Pays 130% Medicare OPPS,$19.02 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.05 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$19.78 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.80 ,Pays 100% Medicare OPPS,$11.52 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$19.02 ,120.37% of custom fee schedule,$12.80 ,Pays 100% Medicare OPPS,$16.64 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.80 ,Pays 100% Medicare OPPS,$11.52 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,83586,"17 KETOSTEROIDS, TOTAL",301,$275.00 ,$233.75 ,85% of total billed charges,$12.80 ,Pays 100% Medicare OPPS,$12.80 ,Pays 100% Medicare OPPS,$12.80 ,Pays 100% Medicare OPPS,$16.64 ,Pays 130% Medicare OPPS,$19.02 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$13.05 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$19.78 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$12.80 ,Pays 100% Medicare OPPS,$11.52 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$19.02 ,120.37% of custom fee schedule,$12.80 ,Pays 100% Medicare OPPS,$16.64 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$12.80 ,Pays 100% Medicare OPPS,$11.52 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,83605,RT LACTIC ACID,301,$295.00 ,$250.75 ,85% of total billed charges,$11.57 ,Pays 100% Medicare OPPS,$11.57 ,Pays 100% Medicare OPPS,$11.57 ,Pays 100% Medicare OPPS,$15.04 ,Pays 130% Medicare OPPS,$16.17 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$11.80 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$16.81 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$11.57 ,Pays 100% Medicare OPPS,$10.41 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$16.17 ,120.37% of custom fee schedule,$11.57 ,Pays 100% Medicare OPPS,$15.04 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$11.57 ,Pays 100% Medicare OPPS,$10.41 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,83615,LDH,301,$210.00 ,$178.50 ,85% of total billed charges,$6.04 ,Pays 100% Medicare OPPS,$6.04 ,Pays 100% Medicare OPPS,$6.04 ,Pays 100% Medicare OPPS,$7.85 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$6.16 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$6.04 ,Pays 100% Medicare OPPS,$5.43 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$6.04 ,Pays 100% Medicare OPPS,$7.85 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$6.04 ,Pays 100% Medicare OPPS,$5.43 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,83625,LDH ISOENZYMES,301,$320.00 ,$272.00 ,85% of total billed charges,$12.79 ,Pays 100% Medicare OPPS,$12.79 ,Pays 100% Medicare OPPS,$12.79 ,Pays 100% Medicare OPPS,$16.62 ,Pays 130% Medicare OPPS,$17.51 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.04 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$18.21 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.79 ,Pays 100% Medicare OPPS,$11.51 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$17.51 ,120.37% of custom fee schedule,$12.79 ,Pays 100% Medicare OPPS,$16.62 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.79 ,Pays 100% Medicare OPPS,$11.51 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,83655,Blood test to determine the concentration of lead in the blood,301,$240.00 ,$204.00 ,85% of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$12.11 ,Pays 100% Medicare OPPS,$12.11 ,Pays 100% Medicare OPPS,$15.74 ,Pays 130% Medicare OPPS,$12.04 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$12.35 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$12.52 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$10.89 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$12.04 ,120.37% of custom fee schedule,$12.11 ,Pays 100% Medicare OPPS,$15.74 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$10.89 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,83661,L/S RATIO,301,$420.00 ,$357.00 ,85% of total billed charges,$21.99 ,Pays 100% Medicare OPPS,$21.99 ,Pays 100% Medicare OPPS,$21.99 ,Pays 100% Medicare OPPS,$28.58 ,Pays 130% Medicare OPPS,$33.27 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$22.42 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$34.60 ,125.18% of custom fee schedule,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$21.99 ,Pays 100% Medicare OPPS,$19.79 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$33.27 ,120.37% of custom fee schedule,$21.99 ,Pays 100% Medicare OPPS,$28.58 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$21.99 ,Pays 100% Medicare OPPS,$19.79 ,$378.00 ,$336.00 
Outpatient Medical Services,LAB,83690,LIPASE LEVEL,301,$300.00 ,$255.00 ,85% of total billed charges,$6.89 ,Pays 100% Medicare OPPS,$6.89 ,Pays 100% Medicare OPPS,$6.89 ,Pays 100% Medicare OPPS,$8.95 ,Pays 130% Medicare OPPS,$10.42 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$7.02 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$10.84 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$6.89 ,Pays 100% Medicare OPPS,$6.20 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$10.42 ,120.37% of custom fee schedule,$6.89 ,Pays 100% Medicare OPPS,$8.95 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$6.89 ,Pays 100% Medicare OPPS,$6.20 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,83695,LIPOPROTEIN (a),301,$365.00 ,$310.25 ,85% of total billed charges,$14.32 ,Pays 100% Medicare OPPS,$14.32 ,Pays 100% Medicare OPPS,$14.32 ,Pays 100% Medicare OPPS,$18.61 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$14.60 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$14.32 ,Pays 100% Medicare OPPS,$12.88 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$14.32 ,Pays 100% Medicare OPPS,$18.61 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$14.32 ,Pays 100% Medicare OPPS,$12.88 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,83701,.LIPOPROTEIN BKDWN;HI RESO,300,$220.00 ,$187.00 ,85% of total billed charges,$33.86 ,Pays 100% Medicare OPPS,$33.86 ,Pays 100% Medicare OPPS,$33.86 ,Pays 100% Medicare OPPS,$44.01 ,Pays 130% Medicare OPPS,$37.57 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$34.53 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$39.07 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$33.86 ,Pays 100% Medicare OPPS,$30.47 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$37.57 ,120.37% of custom fee schedule,$33.86 ,Pays 100% Medicare OPPS,$44.01 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$33.86 ,Pays 100% Medicare OPPS,$30.47 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,83718,Blood test to measure the level of lipoproteins in the blood,301,$135.00 ,$114.75 ,85% of total billed charges,$8.19 ,Pays 100% Medicare OPPS,$8.19 ,Pays 100% Medicare OPPS,$8.19 ,Pays 100% Medicare OPPS,$10.64 ,Pays 130% Medicare OPPS,$12.40 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$8.35 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$12.89 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$8.19 ,Pays 100% Medicare OPPS,$7.37 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$12.40 ,120.37% of custom fee schedule,$8.19 ,Pays 100% Medicare OPPS,$10.64 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$8.19 ,Pays 100% Medicare OPPS,$7.37 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,83721,DIRECT LDL,301,$145.00 ,$123.25 ,85% of total billed charges,$10.50 ,Pays 100% Medicare OPPS,$10.50 ,Pays 100% Medicare OPPS,$10.50 ,Pays 100% Medicare OPPS,$13.65 ,Pays 130% Medicare OPPS,$14.44 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$10.71 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$15.02 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$10.50 ,Pays 100% Medicare OPPS,$9.45 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$14.44 ,120.37% of custom fee schedule,$10.50 ,Pays 100% Medicare OPPS,$13.65 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$10.50 ,Pays 100% Medicare OPPS,$9.45 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,83735,MAGNESIUM LEVEL,301,$190.00 ,$161.50 ,85% of total billed charges,$6.70 ,Pays 100% Medicare OPPS,$6.70 ,Pays 100% Medicare OPPS,$6.70 ,Pays 100% Medicare OPPS,$8.71 ,Pays 130% Medicare OPPS,$10.14 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$6.83 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$10.54 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$6.70 ,Pays 100% Medicare OPPS,$6.03 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$10.14 ,120.37% of custom fee schedule,$6.70 ,Pays 100% Medicare OPPS,$8.71 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$6.70 ,Pays 100% Medicare OPPS,$6.03 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,83785,MANGANESE SERUM LEVEL,300,$320.00 ,$272.00 ,85% of total billed charges,$26.65 ,Pays 100% Medicare OPPS,$26.65 ,Pays 100% Medicare OPPS,$26.65 ,Pays 100% Medicare OPPS,$34.64 ,Pays 130% Medicare OPPS,$37.22 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$27.18 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$38.71 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$26.65 ,Pays 100% Medicare OPPS,$23.98 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$37.22 ,120.37% of custom fee schedule,$26.65 ,Pays 100% Medicare OPPS,$34.64 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$26.65 ,Pays 100% Medicare OPPS,$23.98 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,80369,MEPROBAMATE SERUM LEVEL,301,$420.00 ,$357.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$26.69 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$27.75 ,125.18% of custom fee schedule,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$26.69 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$26.69 ,$378.00 ,$336.00 
Outpatient Medical Services,LAB,83825,MERCURY 24 HOUR URINE,301,$320.00 ,$272.00 ,85% of total billed charges,$16.26 ,Pays 100% Medicare OPPS,$16.26 ,Pays 100% Medicare OPPS,$16.26 ,Pays 100% Medicare OPPS,$21.13 ,Pays 130% Medicare OPPS,$24.62 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$16.58 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$25.60 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$16.26 ,Pays 100% Medicare OPPS,$14.63 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$24.62 ,120.37% of custom fee schedule,$16.26 ,Pays 100% Medicare OPPS,$21.13 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$16.26 ,Pays 100% Medicare OPPS,$14.63 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,83835,METANEPHRINES 24 URINE,301,$365.00 ,$310.25 ,85% of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$16.94 ,Pays 100% Medicare OPPS,$16.94 ,Pays 100% Medicare OPPS,$22.02 ,Pays 130% Medicare OPPS,$25.64 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$17.27 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$26.66 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$15.24 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$25.64 ,120.37% of custom fee schedule,$16.94 ,Pays 100% Medicare OPPS,$22.02 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$15.24 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,83873,"MYELIN BASIC PROTEIN,CSF",301,$510.00 ,$433.50 ,85% of total billed charges,$17.20 ,Pays 100% Medicare OPPS,$17.20 ,Pays 100% Medicare OPPS,$17.20 ,Pays 100% Medicare OPPS,$22.36 ,Pays 130% Medicare OPPS,$26.05 ,20.37% based on GA Medicaid OP CCR Rate,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$17.54 ,Pays 102% Medicare OPPS,$459.00 ,90% of total billed charges,$27.09 ,125.18% of custom fee schedule,$350.37 ,68.7% of total billed charges,$408.00 ,80 percent of total billed charges,$17.20 ,Pays 100% Medicare OPPS,$15.48 ,Pays 90% Medicare OPPS,$295.80 ,58% of total billed charges,$26.05 ,120.37% of custom fee schedule,$17.20 ,Pays 100% Medicare OPPS,$22.36 ,Pays 130% Medicare OPPS,$433.50 ,85% of total billed charges,$17.20 ,Pays 100% Medicare OPPS,$15.48 ,$459.00 ,$408.00 
Outpatient Medical Services,LAB,83874,MYOGLOBIN SERUM,301,$320.00 ,$272.00 ,85% of total billed charges,$12.92 ,Pays 100% Medicare OPPS,$12.92 ,Pays 100% Medicare OPPS,$12.92 ,Pays 100% Medicare OPPS,$16.79 ,Pays 130% Medicare OPPS,$19.55 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$13.17 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$20.33 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.92 ,Pays 100% Medicare OPPS,$11.62 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$19.55 ,120.37% of custom fee schedule,$12.92 ,Pays 100% Medicare OPPS,$16.79 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.92 ,Pays 100% Medicare OPPS,$11.62 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,83880,Blood test used to diagnose heart failure,301,$420.00 ,$357.00 ,85% of total billed charges,$39.26 ,Pays 100% Medicare OPPS,$39.26 ,Pays 100% Medicare OPPS,$39.26 ,Pays 100% Medicare OPPS,$51.03 ,Pays 130% Medicare OPPS,$51.39 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$40.04 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$53.44 ,125.18% of custom fee schedule,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$39.26 ,Pays 100% Medicare OPPS,$35.33 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$51.39 ,120.37% of custom fee schedule,$39.26 ,Pays 100% Medicare OPPS,$51.03 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$39.26 ,Pays 100% Medicare OPPS,$35.33 ,$378.00 ,$336.00 
Outpatient Medical Services,LAB,83883,3RD LIGHT CHAINS-SERUM IEP,302,$375.00 ,$318.75 ,85% of total billed charges,$13.60 ,Pays 100% Medicare OPPS,$13.60 ,Pays 100% Medicare OPPS,$13.60 ,Pays 100% Medicare OPPS,$17.68 ,Pays 130% Medicare OPPS,$20.58 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$13.87 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$21.41 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$13.60 ,Pays 100% Medicare OPPS,$12.24 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$20.58 ,120.37% of custom fee schedule,$13.60 ,Pays 100% Medicare OPPS,$17.68 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$13.60 ,Pays 100% Medicare OPPS,$12.24 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,83890,MOLECULAR DIAG,301,$210.00 ,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$73.50 ,35% based on GA Medicaid OP CCR Rate,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$42.78 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,83891,"MOLECULAR DIAG,ISO/E HPNA",301,$45.00 ,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$40.50 ,90% of total billed charges,$15.75 ,35% based on GA Medicaid OP CCR Rate,$30.92 ,68.7% of total billed charges,$36.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$26.10 ,58% of total billed charges,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$9.17 ,$40.50 ,$36.00 
Outpatient Medical Services,LAB,83892,.ENZYMATIC DIGESTION,301,$35.00 ,$29.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$7.13 ,20.37% based on GA Medicaid OP CCR Rate,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,$19.78 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$31.50 ,90% of total billed charges,$12.25 ,35% based on GA Medicaid OP CCR Rate,$24.05 ,68.7% of total billed charges,$28.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$20.30 ,58% of total billed charges,$7.13 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$29.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$7.13 ,$31.50 ,$28.00 
Outpatient Medical Services,LAB,83893,"MOLECULAR DIAG, DOT",301,$45.00 ,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$40.50 ,90% of total billed charges,$15.75 ,35% based on GA Medicaid OP CCR Rate,$30.92 ,68.7% of total billed charges,$36.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$26.10 ,58% of total billed charges,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$9.17 ,$40.50 ,$36.00 
Outpatient Medical Services,LAB,83894,MOLECULAR DGN SEP,300,$210.00 ,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$73.50 ,35% based on GA Medicaid OP CCR Rate,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$42.78 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,83896,MOLECULAR DGN NAP (C FG X,301,$65.00 ,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$22.75 ,35% based on GA Medicaid OP CCR Rate,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$13.24 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,83897,MOLECULAR DGN NAT (C FG X,301,$65.00 ,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$22.75 ,35% based on GA Medicaid OP CCR Rate,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$13.24 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,81223,3RD CYSTIC FIBROSIS BUCAL SME,301,$110.00 ,$93.50 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,"$1,155.55 ",20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$508.98 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,"$1,201.73 ",125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$449.10 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,"$1,155.55 ",120.37% of custom fee schedule,$499.00 ,Pays 100% Medicare OPPS,$648.70 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$499.00 ,Pays 100% Medicare OPPS,$62.15 ,"$1,201.73 ",$88.00 
Outpatient Medical Services,LAB,83900,MOLECULAR DIAG AMP OF PNA(HLA NAR),301,$85.00 ,$72.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$29.75 ,35% based on GA Medicaid OP CCR Rate,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$17.31 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,83901,"MOLECULAR DIAG AMP PNA,MU",301,$65.00 ,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$22.75 ,35% based on GA Medicaid OP CCR Rate,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$13.24 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,83903,"MOLECULAR DIAG, MUT SCAN",301,$500.00 ,$425.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$101.85 ,20.37% based on GA Medicaid OP CCR Rate,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$450.00 ,90% of total billed charges,$175.00 ,35% based on GA Medicaid OP CCR Rate,$343.50 ,68.7% of total billed charges,$400.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$290.00 ,58% of total billed charges,$101.85 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$425.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$101.85 ,$450.00 ,$400.00 
Outpatient Medical Services,LAB,83904,"MOLECULAR DIAG, MUT ID",301,$45.00 ,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,$25.43 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$40.50 ,90% of total billed charges,$15.75 ,35% based on GA Medicaid OP CCR Rate,$30.92 ,68.7% of total billed charges,$36.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$26.10 ,58% of total billed charges,$9.17 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$38.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$9.17 ,$40.50 ,$36.00 
Outpatient Medical Services,LAB,83905,MOLECULAR DGN MUT BY TRAN,300,$70.00 ,$59.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$14.26 ,20.37% based on GA Medicaid OP CCR Rate,$39.55 ,56.5 percent of total billed charges,$39.55 ,56.5 percent of total billed charges,$39.55 ,56.5 percent of total billed charges,$39.55 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$63.00 ,90% of total billed charges,$24.50 ,35% based on GA Medicaid OP CCR Rate,$48.09 ,68.7% of total billed charges,$56.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$40.60 ,58% of total billed charges,$14.26 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$59.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$14.26 ,$63.00 ,$56.00 
Outpatient Medical Services,LAB,83909,MOLECULAR DIAG SEP & ID (HLA NAR),301,$85.00 ,$72.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$29.75 ,35% based on GA Medicaid OP CCR Rate,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$17.31 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,83912,MOLECULAR DGN I&R (C FG X,301,$65.00 ,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$22.75 ,35% based on GA Medicaid OP CCR Rate,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$13.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$13.24 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,81355,MUTATION ID,301,$20.00 ,$17.00 ,85% of total billed charges,$88.20 ,Pays 100% Medicare OPPS,$88.20 ,Pays 100% Medicare OPPS,$88.20 ,Pays 100% Medicare OPPS,$114.66 ,Pays 130% Medicare OPPS,$86.67 ,20.37% based on GA Medicaid OP CCR Rate,$11.30 ,56.5 percent of total billed charges,$11.30 ,56.5 percent of total billed charges,$11.30 ,56.5 percent of total billed charges,$11.30 ,56.5 percent of total billed charges,$89.96 ,Pays 102% Medicare OPPS,$18.00 ,90% of total billed charges,$90.13 ,125.18% of custom fee schedule,$13.74 ,68.7% of total billed charges,$16.00 ,80 percent of total billed charges,$88.20 ,Pays 100% Medicare OPPS,$79.38 ,Pays 90% Medicare OPPS,$11.60 ,58% of total billed charges,$86.67 ,120.37% of custom fee schedule,$88.20 ,Pays 100% Medicare OPPS,$114.66 ,Pays 130% Medicare OPPS,$17.00 ,85% of total billed charges,$88.20 ,Pays 100% Medicare OPPS,$11.30 ,$114.66 ,$16.00 
Outpatient Medical Services,LAB,83915,3RD 5' NUCLEOTIDASE,302,$165.00 ,$140.25 ,85% of total billed charges,$11.15 ,Pays 100% Medicare OPPS,$11.15 ,Pays 100% Medicare OPPS,$11.15 ,Pays 100% Medicare OPPS,$14.49 ,Pays 130% Medicare OPPS,$16.88 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$11.37 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$17.55 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$11.15 ,Pays 100% Medicare OPPS,$10.03 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$16.88 ,120.37% of custom fee schedule,$11.15 ,Pays 100% Medicare OPPS,$14.49 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$11.15 ,Pays 100% Medicare OPPS,$10.03 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,83916,OLIGOCLONAL BANDS IgG (CSF),301,$415.00 ,$352.75 ,85% of total billed charges,$27.39 ,Pays 100% Medicare OPPS,$27.39 ,Pays 100% Medicare OPPS,$27.39 ,Pays 100% Medicare OPPS,$35.60 ,Pays 130% Medicare OPPS,$30.43 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$27.93 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$31.65 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$27.39 ,Pays 100% Medicare OPPS,$24.65 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$30.43 ,120.37% of custom fee schedule,$27.39 ,Pays 100% Medicare OPPS,$35.60 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$27.39 ,Pays 100% Medicare OPPS,$24.65 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,83918,"ORGANIC ACID PROFIL,URINE",301,"$1,090.00 ",$926.50 ,85% of total billed charges,$23.60 ,Pays 100% Medicare OPPS,$23.60 ,Pays 100% Medicare OPPS,$23.60 ,Pays 100% Medicare OPPS,$30.68 ,Pays 130% Medicare OPPS,$24.92 ,20.37% based on GA Medicaid OP CCR Rate,$615.85 ,56.5 percent of total billed charges,$615.85 ,56.5 percent of total billed charges,$615.85 ,56.5 percent of total billed charges,$615.85 ,56.5 percent of total billed charges,$24.07 ,Pays 102% Medicare OPPS,$981.00 ,90% of total billed charges,$25.91 ,125.18% of custom fee schedule,$748.83 ,68.7% of total billed charges,$872.00 ,80 percent of total billed charges,$23.60 ,Pays 100% Medicare OPPS,$21.24 ,Pays 90% Medicare OPPS,$632.20 ,58% of total billed charges,$24.92 ,120.37% of custom fee schedule,$23.60 ,Pays 100% Medicare OPPS,$30.68 ,Pays 130% Medicare OPPS,$926.50 ,85% of total billed charges,$23.60 ,Pays 100% Medicare OPPS,$21.24 ,$981.00 ,$872.00 
Outpatient Medical Services,LAB,83921,3RD METHYLMALONIC ACID SERUM,301,$525.00 ,$446.25 ,85% of total billed charges,$21.21 ,Pays 100% Medicare OPPS,$21.21 ,Pays 100% Medicare OPPS,$21.21 ,Pays 100% Medicare OPPS,$27.57 ,Pays 130% Medicare OPPS,$24.92 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$21.63 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$25.91 ,125.18% of custom fee schedule,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$21.21 ,Pays 100% Medicare OPPS,$19.08 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$24.92 ,120.37% of custom fee schedule,$21.21 ,Pays 100% Medicare OPPS,$27.57 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$21.21 ,Pays 100% Medicare OPPS,$19.08 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,80365,OPIATES LEVEL,302,$525.00 ,$446.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$106.94 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$183.75 ,35% based on GA Medicaid OP CCR Rate,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$106.94 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$106.94 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,83930,OSMOLALITY SERUM,301,$195.00 ,$165.75 ,85% of total billed charges,$6.61 ,Pays 100% Medicare OPPS,$6.61 ,Pays 100% Medicare OPPS,$6.61 ,Pays 100% Medicare OPPS,$8.59 ,Pays 130% Medicare OPPS,$10.01 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$6.74 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$10.41 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$6.61 ,Pays 100% Medicare OPPS,$5.94 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$10.01 ,120.37% of custom fee schedule,$6.61 ,Pays 100% Medicare OPPS,$8.59 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$6.61 ,Pays 100% Medicare OPPS,$5.94 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,83935,OSMOLALITY URINE,301,$195.00 ,$165.75 ,85% of total billed charges,$6.82 ,Pays 100% Medicare OPPS,$6.82 ,Pays 100% Medicare OPPS,$6.82 ,Pays 100% Medicare OPPS,$8.86 ,Pays 130% Medicare OPPS,$10.32 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$6.95 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$10.73 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$6.82 ,Pays 100% Medicare OPPS,$6.13 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$10.32 ,120.37% of custom fee schedule,$6.82 ,Pays 100% Medicare OPPS,$8.86 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$6.82 ,Pays 100% Medicare OPPS,$6.13 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,83937,OSTEOCALCIN LEVEL,301,$295.00 ,$250.75 ,85% of total billed charges,$29.85 ,Pays 100% Medicare OPPS,$29.85 ,Pays 100% Medicare OPPS,$29.85 ,Pays 100% Medicare OPPS,$38.80 ,Pays 130% Medicare OPPS,$45.19 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$30.44 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$46.99 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$29.85 ,Pays 100% Medicare OPPS,$26.86 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$45.19 ,120.37% of custom fee schedule,$29.85 ,Pays 100% Medicare OPPS,$38.80 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$29.85 ,Pays 100% Medicare OPPS,$26.86 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,83945,OXALIC ACID URINE,301,$195.00 ,$165.75 ,85% of total billed charges,$14.45 ,Pays 100% Medicare OPPS,$14.45 ,Pays 100% Medicare OPPS,$14.45 ,Pays 100% Medicare OPPS,$18.78 ,Pays 130% Medicare OPPS,$19.49 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$14.73 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$20.27 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$14.45 ,Pays 100% Medicare OPPS,$13.00 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$19.49 ,120.37% of custom fee schedule,$14.45 ,Pays 100% Medicare OPPS,$18.78 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$14.45 ,Pays 100% Medicare OPPS,$13.00 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,83970,PARATHYROID HORMONE (PTH),301,$590.00 ,$501.50 ,85% of total billed charges,$41.28 ,Pays 100% Medicare OPPS,$41.28 ,Pays 100% Medicare OPPS,$41.28 ,Pays 100% Medicare OPPS,$53.66 ,Pays 130% Medicare OPPS,$62.47 ,20.37% based on GA Medicaid OP CCR Rate,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$42.10 ,Pays 102% Medicare OPPS,$531.00 ,90% of total billed charges,$64.97 ,125.18% of custom fee schedule,$405.33 ,68.7% of total billed charges,$472.00 ,80 percent of total billed charges,$41.28 ,Pays 100% Medicare OPPS,$37.15 ,Pays 90% Medicare OPPS,$342.20 ,58% of total billed charges,$62.47 ,120.37% of custom fee schedule,$41.28 ,Pays 100% Medicare OPPS,$53.66 ,Pays 130% Medicare OPPS,$501.50 ,85% of total billed charges,$41.28 ,Pays 100% Medicare OPPS,$37.15 ,$531.00 ,$472.00 
Outpatient Medical Services,LAB,83986,PH STOOL,301,$320.00 ,$272.00 ,85% of total billed charges,$3.58 ,Pays 100% Medicare OPPS,$3.58 ,Pays 100% Medicare OPPS,$3.58 ,Pays 100% Medicare OPPS,$4.65 ,Pays 130% Medicare OPPS,$5.42 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$3.65 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$5.63 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$3.58 ,Pays 100% Medicare OPPS,$3.22 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$5.42 ,120.37% of custom fee schedule,$3.58 ,Pays 100% Medicare OPPS,$4.65 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$3.58 ,Pays 100% Medicare OPPS,$3.22 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,84066,.ACID PHOS PROSTATIC,301,$465.00 ,$395.25 ,85% of total billed charges,$9.66 ,Pays 100% Medicare OPPS,$9.66 ,Pays 100% Medicare OPPS,$9.66 ,Pays 100% Medicare OPPS,$12.55 ,Pays 130% Medicare OPPS,$14.62 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$9.85 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$15.21 ,125.18% of custom fee schedule,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$9.66 ,Pays 100% Medicare OPPS,$8.69 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$14.62 ,120.37% of custom fee schedule,$9.66 ,Pays 100% Medicare OPPS,$12.55 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$9.66 ,Pays 100% Medicare OPPS,$8.69 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,84075,ALK PHOSP,301,$150.00 ,$127.50 ,85% of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$5.18 ,Pays 100% Medicare OPPS,$5.18 ,Pays 100% Medicare OPPS,$6.73 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.28 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$4.66 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$5.18 ,Pays 100% Medicare OPPS,$6.73 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$4.66 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,84080,ALKALINE PHOSPHATASE ISO,301,$260.00 ,$221.00 ,85% of total billed charges,$14.78 ,Pays 100% Medicare OPPS,$14.78 ,Pays 100% Medicare OPPS,$14.78 ,Pays 100% Medicare OPPS,$19.21 ,Pays 130% Medicare OPPS,$22.38 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$15.07 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$23.27 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$14.78 ,Pays 100% Medicare OPPS,$13.30 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$22.38 ,120.37% of custom fee schedule,$14.78 ,Pays 100% Medicare OPPS,$19.21 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$14.78 ,Pays 100% Medicare OPPS,$13.30 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,84100,PHOSPHORUS LEVEL,301,$150.00 ,$127.50 ,85% of total billed charges,$4.74 ,Pays 100% Medicare OPPS,$4.74 ,Pays 100% Medicare OPPS,$4.74 ,Pays 100% Medicare OPPS,$6.16 ,Pays 130% Medicare OPPS,$7.19 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$4.83 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$7.47 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$4.74 ,Pays 100% Medicare OPPS,$4.26 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.19 ,120.37% of custom fee schedule,$4.74 ,Pays 100% Medicare OPPS,$6.16 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$4.74 ,Pays 100% Medicare OPPS,$4.26 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,84105,PHOSPHORUS URINE,301,$150.00 ,$127.50 ,85% of total billed charges,$5.78 ,Pays 100% Medicare OPPS,$5.78 ,Pays 100% Medicare OPPS,$5.78 ,Pays 100% Medicare OPPS,$7.51 ,Pays 130% Medicare OPPS,$7.84 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.89 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$8.15 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.78 ,Pays 100% Medicare OPPS,$5.20 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.84 ,120.37% of custom fee schedule,$5.78 ,Pays 100% Medicare OPPS,$7.51 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.78 ,Pays 100% Medicare OPPS,$5.20 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,84106,....PBG (,301,$420.00 ,$357.00 ,85% of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.82 ,Pays 100% Medicare OPPS,$5.82 ,Pays 100% Medicare OPPS,$7.56 ,Pays 130% Medicare OPPS,$6.49 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$5.93 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$6.75 ,125.18% of custom fee schedule,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.23 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$6.49 ,120.37% of custom fee schedule,$5.82 ,Pays 100% Medicare OPPS,$7.56 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.23 ,$378.00 ,$336.00 
Outpatient Medical Services,LAB,84110,PORPHOBILINOGEN RANDOM URINE,301,$435.00 ,$369.75 ,85% of total billed charges,$8.44 ,Pays 100% Medicare OPPS,$8.44 ,Pays 100% Medicare OPPS,$8.44 ,Pays 100% Medicare OPPS,$10.97 ,Pays 130% Medicare OPPS,$12.78 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$8.60 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$13.29 ,125.18% of custom fee schedule,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$8.44 ,Pays 100% Medicare OPPS,$7.59 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$12.78 ,120.37% of custom fee schedule,$8.44 ,Pays 100% Medicare OPPS,$10.97 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$8.44 ,Pays 100% Medicare OPPS,$7.59 ,$391.50 ,$348.00 
Outpatient Medical Services,LAB,84120,URINALYSIS PORPHYRINS,301,$260.00 ,$221.00 ,85% of total billed charges,$14.71 ,Pays 100% Medicare OPPS,$14.71 ,Pays 100% Medicare OPPS,$14.71 ,Pays 100% Medicare OPPS,$19.12 ,Pays 130% Medicare OPPS,$22.27 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$15.00 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$23.16 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$14.71 ,Pays 100% Medicare OPPS,$13.23 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$22.27 ,120.37% of custom fee schedule,$14.71 ,Pays 100% Medicare OPPS,$19.12 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$14.71 ,Pays 100% Medicare OPPS,$13.23 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,84132,POTASSIUM SERUM,301,$145.00 ,$123.25 ,85% of total billed charges,$4.76 ,Pays 100% Medicare OPPS,$4.76 ,Pays 100% Medicare OPPS,$4.76 ,Pays 100% Medicare OPPS,$6.18 ,Pays 130% Medicare OPPS,$6.96 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.85 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$7.24 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.76 ,Pays 100% Medicare OPPS,$4.28 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$6.96 ,120.37% of custom fee schedule,$4.76 ,Pays 100% Medicare OPPS,$6.18 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.76 ,Pays 100% Medicare OPPS,$4.28 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,84133,POTASSIUM URINE SPOT,301,$145.00 ,$123.25 ,85% of total billed charges,$4.73 ,Pays 100% Medicare OPPS,$4.73 ,Pays 100% Medicare OPPS,$4.73 ,Pays 100% Medicare OPPS,$6.14 ,Pays 130% Medicare OPPS,$6.51 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.82 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$6.77 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.73 ,Pays 100% Medicare OPPS,$4.25 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$6.51 ,120.37% of custom fee schedule,$4.73 ,Pays 100% Medicare OPPS,$6.14 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.73 ,Pays 100% Medicare OPPS,$4.25 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,84134,Blood test to measure level of prealbumin,301,$275.00 ,$233.75 ,85% of total billed charges,$14.59 ,Pays 100% Medicare OPPS,$14.59 ,Pays 100% Medicare OPPS,$14.59 ,Pays 100% Medicare OPPS,$18.96 ,Pays 130% Medicare OPPS,$22.08 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$14.88 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$22.96 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$14.59 ,Pays 100% Medicare OPPS,$13.13 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$22.08 ,120.37% of custom fee schedule,$14.59 ,Pays 100% Medicare OPPS,$18.96 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$14.59 ,Pays 100% Medicare OPPS,$13.13 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,84140,3RD PREGNENOLONE,302,$215.00 ,$182.75 ,85% of total billed charges,$20.67 ,Pays 100% Medicare OPPS,$20.67 ,Pays 100% Medicare OPPS,$20.67 ,Pays 100% Medicare OPPS,$26.87 ,Pays 130% Medicare OPPS,$31.30 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$21.08 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$32.55 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$20.67 ,Pays 100% Medicare OPPS,$18.60 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$31.30 ,120.37% of custom fee schedule,$20.67 ,Pays 100% Medicare OPPS,$26.87 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$20.67 ,Pays 100% Medicare OPPS,$18.60 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,84144,PROGESTERONE LEVEL,301,$365.00 ,$310.25 ,85% of total billed charges,$20.86 ,Pays 100% Medicare OPPS,$20.86 ,Pays 100% Medicare OPPS,$20.86 ,Pays 100% Medicare OPPS,$27.11 ,Pays 130% Medicare OPPS,$30.83 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$21.27 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$32.06 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$20.86 ,Pays 100% Medicare OPPS,$18.77 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$30.83 ,120.37% of custom fee schedule,$20.86 ,Pays 100% Medicare OPPS,$27.11 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$20.86 ,Pays 100% Medicare OPPS,$18.77 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,84145,PROCALCITONIN,301,$415.00 ,$352.75 ,85% of total billed charges,$27.22 ,Pays 100% Medicare OPPS,$27.22 ,Pays 100% Medicare OPPS,$27.22 ,Pays 100% Medicare OPPS,$35.38 ,Pays 130% Medicare OPPS,$28.96 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$27.76 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$30.12 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$27.22 ,Pays 100% Medicare OPPS,$24.49 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$28.96 ,120.37% of custom fee schedule,$27.22 ,Pays 100% Medicare OPPS,$35.38 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$27.22 ,Pays 100% Medicare OPPS,$24.49 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,84146,PROLACTIN LEVEL,301,$410.00 ,$348.50 ,85% of total billed charges,$19.38 ,Pays 100% Medicare OPPS,$19.38 ,Pays 100% Medicare OPPS,$19.38 ,Pays 100% Medicare OPPS,$25.19 ,Pays 130% Medicare OPPS,$29.33 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$19.76 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$30.51 ,125.18% of custom fee schedule,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$19.38 ,Pays 100% Medicare OPPS,$17.44 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$29.33 ,120.37% of custom fee schedule,$19.38 ,Pays 100% Medicare OPPS,$25.19 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$19.38 ,Pays 100% Medicare OPPS,$17.44 ,$369.00 ,$328.00 
Outpatient Medical Services,LAB,84153,PSA (prostate specific antigen),301,$415.00 ,$352.75 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.90 ,Pays 130% Medicare OPPS,$27.84 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$18.75 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$28.95 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$27.84 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.90 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,84154,PSA (prostate specific antigen) measurement,301,$210.00 ,$178.50 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.90 ,Pays 130% Medicare OPPS,$27.84 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$18.75 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$28.95 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$27.84 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.90 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,84155,PROTEIN TOTAL SERUM,301,$135.00 ,$114.75 ,85% of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.67 ,Pays 100% Medicare OPPS,$3.67 ,Pays 100% Medicare OPPS,$4.77 ,Pays 130% Medicare OPPS,$5.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$3.74 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$5.77 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.30 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$5.55 ,120.37% of custom fee schedule,$3.67 ,Pays 100% Medicare OPPS,$4.77 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.30 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,84156,PROTEIN URINE,301,$150.00 ,$127.50 ,85% of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.67 ,Pays 100% Medicare OPPS,$3.67 ,Pays 100% Medicare OPPS,$4.77 ,Pays 130% Medicare OPPS,$5.55 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$3.74 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$5.77 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.30 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$5.55 ,120.37% of custom fee schedule,$3.67 ,Pays 100% Medicare OPPS,$4.77 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.30 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,84157,PROTEIN CSF,301,$135.00 ,$114.75 ,85% of total billed charges,$4.00 ,Pays 100% Medicare OPPS,$4.00 ,Pays 100% Medicare OPPS,$4.00 ,Pays 100% Medicare OPPS,$5.20 ,Pays 130% Medicare OPPS,$5.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.08 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$5.77 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.00 ,Pays 100% Medicare OPPS,$3.60 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$5.55 ,120.37% of custom fee schedule,$4.00 ,Pays 100% Medicare OPPS,$5.20 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$4.00 ,Pays 100% Medicare OPPS,$3.60 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,84181,".PROTEIN, WESTERN BLOT",300,$170.00 ,$144.50 ,85% of total billed charges,$17.03 ,Pays 100% Medicare OPPS,$17.03 ,Pays 100% Medicare OPPS,$17.03 ,Pays 100% Medicare OPPS,$22.13 ,Pays 130% Medicare OPPS,$25.78 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$17.37 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$26.81 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$17.03 ,Pays 100% Medicare OPPS,$15.32 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$25.78 ,120.37% of custom fee schedule,$17.03 ,Pays 100% Medicare OPPS,$22.13 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$17.03 ,Pays 100% Medicare OPPS,$15.32 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,84202,PROTOPORPHYRIN FREE RBC,301,$260.00 ,$221.00 ,85% of total billed charges,$14.35 ,Pays 100% Medicare OPPS,$14.35 ,Pays 100% Medicare OPPS,$14.35 ,Pays 100% Medicare OPPS,$18.65 ,Pays 130% Medicare OPPS,$21.73 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$14.63 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$22.59 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$14.35 ,Pays 100% Medicare OPPS,$12.91 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$21.73 ,120.37% of custom fee schedule,$14.35 ,Pays 100% Medicare OPPS,$18.65 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$14.35 ,Pays 100% Medicare OPPS,$12.91 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,84206,PROINSULIN LEVEL,301,$520.00 ,$442.00 ,85% of total billed charges,$26.69 ,Pays 100% Medicare OPPS,$26.69 ,Pays 100% Medicare OPPS,$26.69 ,Pays 100% Medicare OPPS,$34.69 ,Pays 130% Medicare OPPS,$26.96 ,20.37% based on GA Medicaid OP CCR Rate,$293.80 ,56.5 percent of total billed charges,$293.80 ,56.5 percent of total billed charges,$293.80 ,56.5 percent of total billed charges,$293.80 ,56.5 percent of total billed charges,$27.22 ,Pays 102% Medicare OPPS,$468.00 ,90% of total billed charges,$28.04 ,125.18% of custom fee schedule,$357.24 ,68.7% of total billed charges,$416.00 ,80 percent of total billed charges,$26.69 ,Pays 100% Medicare OPPS,$24.02 ,Pays 90% Medicare OPPS,$301.60 ,58% of total billed charges,$26.96 ,120.37% of custom fee schedule,$26.69 ,Pays 100% Medicare OPPS,$34.69 ,Pays 130% Medicare OPPS,$442.00 ,85% of total billed charges,$26.69 ,Pays 100% Medicare OPPS,$24.02 ,$468.00 ,$416.00 
Outpatient Medical Services,LAB,84207,VITAMIN B6,301,$220.00 ,$187.00 ,85% of total billed charges,$28.10 ,Pays 100% Medicare OPPS,$28.10 ,Pays 100% Medicare OPPS,$28.10 ,Pays 100% Medicare OPPS,$36.53 ,Pays 130% Medicare OPPS,$42.53 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$28.66 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$44.23 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$28.10 ,Pays 100% Medicare OPPS,$25.29 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$42.53 ,120.37% of custom fee schedule,$28.10 ,Pays 100% Medicare OPPS,$36.53 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$28.10 ,Pays 100% Medicare OPPS,$25.29 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,84210,PYRUVATE,301,$675.00 ,$573.75 ,85% of total billed charges,$14.48 ,Pays 100% Medicare OPPS,$14.48 ,Pays 100% Medicare OPPS,$14.48 ,Pays 100% Medicare OPPS,$18.82 ,Pays 130% Medicare OPPS,$16.43 ,20.37% based on GA Medicaid OP CCR Rate,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$14.76 ,Pays 102% Medicare OPPS,$607.50 ,90% of total billed charges,$17.09 ,125.18% of custom fee schedule,$463.73 ,68.7% of total billed charges,$540.00 ,80 percent of total billed charges,$14.48 ,Pays 100% Medicare OPPS,$13.03 ,Pays 90% Medicare OPPS,$391.50 ,58% of total billed charges,$16.43 ,120.37% of custom fee schedule,$14.48 ,Pays 100% Medicare OPPS,$18.82 ,Pays 130% Medicare OPPS,$573.75 ,85% of total billed charges,$14.48 ,Pays 100% Medicare OPPS,$13.03 ,$607.50 ,$540.00 
Outpatient Medical Services,LAB,84233,PROGESTERONE RECEPTOR,301,$545.00 ,$463.25 ,85% of total billed charges,$87.88 ,Pays 100% Medicare OPPS,$87.88 ,Pays 100% Medicare OPPS,$87.88 ,Pays 100% Medicare OPPS,$114.24 ,Pays 130% Medicare OPPS,$97.49 ,20.37% based on GA Medicaid OP CCR Rate,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$89.63 ,Pays 102% Medicare OPPS,$490.50 ,90% of total billed charges,$101.38 ,125.18% of custom fee schedule,$374.42 ,68.7% of total billed charges,$436.00 ,80 percent of total billed charges,$87.88 ,Pays 100% Medicare OPPS,$79.09 ,Pays 90% Medicare OPPS,$316.10 ,58% of total billed charges,$97.49 ,120.37% of custom fee schedule,$87.88 ,Pays 100% Medicare OPPS,$114.24 ,Pays 130% Medicare OPPS,$463.25 ,85% of total billed charges,$87.88 ,Pays 100% Medicare OPPS,$79.09 ,$490.50 ,$436.00 
Outpatient Medical Services,LAB,84234,...............PROG RECPT (E&P ASSAY),301,$545.00 ,$463.25 ,85% of total billed charges,$64.88 ,Pays 100% Medicare OPPS,$64.88 ,Pays 100% Medicare OPPS,$64.88 ,Pays 100% Medicare OPPS,$84.34 ,Pays 130% Medicare OPPS,$98.20 ,20.37% based on GA Medicaid OP CCR Rate,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$66.17 ,Pays 102% Medicare OPPS,$490.50 ,90% of total billed charges,$102.12 ,125.18% of custom fee schedule,$374.42 ,68.7% of total billed charges,$436.00 ,80 percent of total billed charges,$64.88 ,Pays 100% Medicare OPPS,$58.39 ,Pays 90% Medicare OPPS,$316.10 ,58% of total billed charges,$98.20 ,120.37% of custom fee schedule,$64.88 ,Pays 100% Medicare OPPS,$84.34 ,Pays 130% Medicare OPPS,$463.25 ,85% of total billed charges,$64.88 ,Pays 100% Medicare OPPS,$58.39 ,$490.50 ,$436.00 
Outpatient Medical Services,LAB,83519,3RD ACETYLCHOLINE RECEPTOR BINDING AB,301,$465.00 ,$395.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$20.45 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$18.76 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$21.27 ,125.18% of custom fee schedule,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$20.45 ,120.37% of custom fee schedule,$18.39 ,Pays 100% Medicare OPPS,$23.92 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$18.39 ,Pays 100% Medicare OPPS,$16.55 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,84244,RENIN LEVEL,301,$410.00 ,$348.50 ,85% of total billed charges,$21.99 ,Pays 100% Medicare OPPS,$21.99 ,Pays 100% Medicare OPPS,$21.99 ,Pays 100% Medicare OPPS,$28.58 ,Pays 130% Medicare OPPS,$33.29 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$22.42 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$34.62 ,125.18% of custom fee schedule,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$21.99 ,Pays 100% Medicare OPPS,$19.79 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$33.29 ,120.37% of custom fee schedule,$21.99 ,Pays 100% Medicare OPPS,$28.58 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$21.99 ,Pays 100% Medicare OPPS,$19.79 ,$369.00 ,$328.00 
Outpatient Medical Services,LAB,84255,SELENIUM LEVEL,301,$145.00 ,$123.25 ,85% of total billed charges,$25.53 ,Pays 100% Medicare OPPS,$25.53 ,Pays 100% Medicare OPPS,$25.53 ,Pays 100% Medicare OPPS,$33.18 ,Pays 130% Medicare OPPS,$38.64 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$26.04 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$40.18 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$25.53 ,Pays 100% Medicare OPPS,$22.97 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$38.64 ,120.37% of custom fee schedule,$25.53 ,Pays 100% Medicare OPPS,$33.18 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$25.53 ,Pays 100% Medicare OPPS,$22.97 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,84260,"SEROTONIN, SERUM",301,$635.00 ,$539.75 ,85% of total billed charges,$30.98 ,Pays 100% Medicare OPPS,$30.98 ,Pays 100% Medicare OPPS,$30.98 ,Pays 100% Medicare OPPS,$40.27 ,Pays 130% Medicare OPPS,$46.88 ,20.37% based on GA Medicaid OP CCR Rate,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$31.59 ,Pays 102% Medicare OPPS,$571.50 ,90% of total billed charges,$48.76 ,125.18% of custom fee schedule,$436.25 ,68.7% of total billed charges,$508.00 ,80 percent of total billed charges,$30.98 ,Pays 100% Medicare OPPS,$27.88 ,Pays 90% Medicare OPPS,$368.30 ,58% of total billed charges,$46.88 ,120.37% of custom fee schedule,$30.98 ,Pays 100% Medicare OPPS,$40.27 ,Pays 130% Medicare OPPS,$539.75 ,85% of total billed charges,$30.98 ,Pays 100% Medicare OPPS,$27.88 ,$571.50 ,$508.00 
Outpatient Medical Services,LAB,84270,SEX HORMONE BINDING GLOBULIN,309,$135.00 ,$114.75 ,85% of total billed charges,$21.73 ,Pays 100% Medicare OPPS,$21.73 ,Pays 100% Medicare OPPS,$21.73 ,Pays 100% Medicare OPPS,$28.24 ,Pays 130% Medicare OPPS,$32.89 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$22.16 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$34.20 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$21.73 ,Pays 100% Medicare OPPS,$19.55 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$32.89 ,120.37% of custom fee schedule,$21.73 ,Pays 100% Medicare OPPS,$28.24 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$21.73 ,Pays 100% Medicare OPPS,$19.55 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,84275,LASA (SIALIC ACID),301,$485.00 ,$412.25 ,85% of total billed charges,$13.44 ,Pays 100% Medicare OPPS,$13.44 ,Pays 100% Medicare OPPS,$13.44 ,Pays 100% Medicare OPPS,$17.47 ,Pays 130% Medicare OPPS,$20.33 ,20.37% based on GA Medicaid OP CCR Rate,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$13.70 ,Pays 102% Medicare OPPS,$436.50 ,90% of total billed charges,$21.14 ,125.18% of custom fee schedule,$333.20 ,68.7% of total billed charges,$388.00 ,80 percent of total billed charges,$13.44 ,Pays 100% Medicare OPPS,$12.09 ,Pays 90% Medicare OPPS,$281.30 ,58% of total billed charges,$20.33 ,120.37% of custom fee schedule,$13.44 ,Pays 100% Medicare OPPS,$17.47 ,Pays 130% Medicare OPPS,$412.25 ,85% of total billed charges,$13.44 ,Pays 100% Medicare OPPS,$12.09 ,$436.50 ,$388.00 
Outpatient Medical Services,LAB,84295,SODIUM SERUM,301,$145.00 ,$123.25 ,85% of total billed charges,$4.80 ,Pays 100% Medicare OPPS,$4.80 ,Pays 100% Medicare OPPS,$4.80 ,Pays 100% Medicare OPPS,$6.25 ,Pays 130% Medicare OPPS,$7.28 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.90 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$7.57 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.80 ,Pays 100% Medicare OPPS,$4.32 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$7.28 ,120.37% of custom fee schedule,$4.80 ,Pays 100% Medicare OPPS,$6.25 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.80 ,Pays 100% Medicare OPPS,$4.32 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,84300,SODIUM URINE SPOT,301,$145.00 ,$123.25 ,85% of total billed charges,$5.05 ,Pays 100% Medicare OPPS,$5.05 ,Pays 100% Medicare OPPS,$5.05 ,Pays 100% Medicare OPPS,$6.57 ,Pays 130% Medicare OPPS,$5.24 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$5.16 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$5.45 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$5.05 ,Pays 100% Medicare OPPS,$4.55 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$5.24 ,120.37% of custom fee schedule,$5.05 ,Pays 100% Medicare OPPS,$6.57 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$5.05 ,Pays 100% Medicare OPPS,$4.55 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,84302,SODIUM FECES,301,$145.00 ,$123.25 ,85% of total billed charges,$4.86 ,Pays 100% Medicare OPPS,$4.86 ,Pays 100% Medicare OPPS,$4.86 ,Pays 100% Medicare OPPS,$6.31 ,Pays 130% Medicare OPPS,$5.24 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.95 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$5.45 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.86 ,Pays 100% Medicare OPPS,$4.37 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$5.24 ,120.37% of custom fee schedule,$4.86 ,Pays 100% Medicare OPPS,$6.31 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.86 ,Pays 100% Medicare OPPS,$4.37 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,84305,IGF-1,301,$420.00 ,$357.00 ,85% of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$21.26 ,Pays 100% Medicare OPPS,$21.26 ,Pays 100% Medicare OPPS,$27.63 ,Pays 130% Medicare OPPS,$32.17 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$21.68 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$33.46 ,125.18% of custom fee schedule,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$19.13 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$32.17 ,120.37% of custom fee schedule,$21.26 ,Pays 100% Medicare OPPS,$27.63 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$19.13 ,$378.00 ,$336.00 
Outpatient Medical Services,LAB,84307,SOMATOSTATIN,301,$865.00 ,$735.25 ,85% of total billed charges,$18.28 ,Pays 100% Medicare OPPS,$18.28 ,Pays 100% Medicare OPPS,$18.28 ,Pays 100% Medicare OPPS,$23.76 ,Pays 130% Medicare OPPS,$27.67 ,20.37% based on GA Medicaid OP CCR Rate,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$18.64 ,Pays 102% Medicare OPPS,$778.50 ,90% of total billed charges,$28.78 ,125.18% of custom fee schedule,$594.26 ,68.7% of total billed charges,$692.00 ,80 percent of total billed charges,$18.28 ,Pays 100% Medicare OPPS,$16.45 ,Pays 90% Medicare OPPS,$501.70 ,58% of total billed charges,$27.67 ,120.37% of custom fee schedule,$18.28 ,Pays 100% Medicare OPPS,$23.76 ,Pays 130% Medicare OPPS,$735.25 ,85% of total billed charges,$18.28 ,Pays 100% Medicare OPPS,$16.45 ,$778.50 ,$692.00 
Outpatient Medical Services,LAB,84311,....PHENOLP,301,$760.00 ,$646.00 ,85% of total billed charges,$8.10 ,Pays 100% Medicare OPPS,$8.10 ,Pays 100% Medicare OPPS,$8.10 ,Pays 100% Medicare OPPS,$10.53 ,Pays 130% Medicare OPPS,$10.58 ,20.37% based on GA Medicaid OP CCR Rate,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$8.26 ,Pays 102% Medicare OPPS,$684.00 ,90% of total billed charges,$11.00 ,125.18% of custom fee schedule,$522.12 ,68.7% of total billed charges,$608.00 ,80 percent of total billed charges,$8.10 ,Pays 100% Medicare OPPS,$7.29 ,Pays 90% Medicare OPPS,$440.80 ,58% of total billed charges,$10.58 ,120.37% of custom fee schedule,$8.10 ,Pays 100% Medicare OPPS,$10.53 ,Pays 130% Medicare OPPS,$646.00 ,85% of total billed charges,$8.10 ,Pays 100% Medicare OPPS,$7.29 ,$684.00 ,$608.00 
Outpatient Medical Services,LAB,80307,Testing for presence of drug,301,$545.00 ,$463.25 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$73.62 ,20.37% based on GA Medicaid OP CCR Rate,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$63.38 ,Pays 102% Medicare OPPS,$490.50 ,90% of total billed charges,$76.56 ,125.18% of custom fee schedule,$374.42 ,68.7% of total billed charges,$436.00 ,80 percent of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,Pays 90% Medicare OPPS,$316.10 ,58% of total billed charges,$73.62 ,120.37% of custom fee schedule,$62.14 ,Pays 100% Medicare OPPS,$80.78 ,Pays 130% Medicare OPPS,$463.25 ,85% of total billed charges,$62.14 ,Pays 100% Medicare OPPS,$55.92 ,$490.50 ,$436.00 
Outpatient Medical Services,LAB,84403,TESTOSTERONE LEVEL,301,$320.00 ,$272.00 ,85% of total billed charges,$25.81 ,Pays 100% Medicare OPPS,$25.81 ,Pays 100% Medicare OPPS,$25.81 ,Pays 100% Medicare OPPS,$33.55 ,Pays 130% Medicare OPPS,$39.08 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$26.32 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$40.65 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$25.81 ,Pays 100% Medicare OPPS,$23.22 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$39.08 ,120.37% of custom fee schedule,$25.81 ,Pays 100% Medicare OPPS,$33.55 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$25.81 ,Pays 100% Medicare OPPS,$23.22 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,84425,THIAMINE LEVEL,301,$320.00 ,$272.00 ,85% of total billed charges,$21.23 ,Pays 100% Medicare OPPS,$21.23 ,Pays 100% Medicare OPPS,$21.23 ,Pays 100% Medicare OPPS,$27.59 ,Pays 130% Medicare OPPS,$32.14 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$21.65 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$33.42 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$21.23 ,Pays 100% Medicare OPPS,$19.10 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$32.14 ,120.37% of custom fee schedule,$21.23 ,Pays 100% Medicare OPPS,$27.59 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$21.23 ,Pays 100% Medicare OPPS,$19.10 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,84432,THYROGLOBULIN PANEL,302,$215.00 ,$182.75 ,85% of total billed charges,$16.05 ,Pays 100% Medicare OPPS,$16.05 ,Pays 100% Medicare OPPS,$16.05 ,Pays 100% Medicare OPPS,$20.87 ,Pays 130% Medicare OPPS,$24.31 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$16.38 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$25.29 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$16.05 ,Pays 100% Medicare OPPS,$14.45 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$24.31 ,120.37% of custom fee schedule,$16.05 ,Pays 100% Medicare OPPS,$20.87 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$16.05 ,Pays 100% Medicare OPPS,$14.45 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,84436,Blood test to measure a type of thyroid hormone,301,$125.00 ,$106.25 ,85% of total billed charges,$6.87 ,Pays 100% Medicare OPPS,$6.87 ,Pays 100% Medicare OPPS,$6.87 ,Pays 100% Medicare OPPS,$8.93 ,Pays 130% Medicare OPPS,$10.41 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$7.00 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$10.83 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$6.87 ,Pays 100% Medicare OPPS,$6.18 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$10.41 ,120.37% of custom fee schedule,$6.87 ,Pays 100% Medicare OPPS,$8.93 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$6.87 ,Pays 100% Medicare OPPS,$6.18 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,84439,Blood test to evaluate thyroid function,301,$215.00 ,$182.75 ,85% of total billed charges,$9.02 ,Pays 100% Medicare OPPS,$9.02 ,Pays 100% Medicare OPPS,$9.02 ,Pays 100% Medicare OPPS,$11.72 ,Pays 130% Medicare OPPS,$13.65 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$9.20 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$14.20 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$9.02 ,Pays 100% Medicare OPPS,$8.11 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$13.65 ,120.37% of custom fee schedule,$9.02 ,Pays 100% Medicare OPPS,$11.72 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$9.02 ,Pays 100% Medicare OPPS,$8.11 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,84443,"Blood test, thyroid stimulating hormone (TSH)",301,$260.00 ,$221.00 ,85% of total billed charges,$16.80 ,Pays 100% Medicare OPPS,$16.80 ,Pays 100% Medicare OPPS,$16.80 ,Pays 100% Medicare OPPS,$21.84 ,Pays 130% Medicare OPPS,$25.42 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$17.13 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$26.44 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$16.80 ,Pays 100% Medicare OPPS,$15.12 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$25.42 ,120.37% of custom fee schedule,$16.80 ,Pays 100% Medicare OPPS,$21.84 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$16.80 ,Pays 100% Medicare OPPS,$15.12 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,84445,3RD TSH RECEPTOR ANTIBODY,300,$395.00 ,$335.75 ,85% of total billed charges,$50.86 ,Pays 100% Medicare OPPS,$50.86 ,Pays 100% Medicare OPPS,$50.86 ,Pays 100% Medicare OPPS,$66.11 ,Pays 130% Medicare OPPS,$12.82 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$51.87 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$13.33 ,125.18% of custom fee schedule,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$50.86 ,Pays 100% Medicare OPPS,$45.77 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$12.82 ,120.37% of custom fee schedule,$50.86 ,Pays 100% Medicare OPPS,$66.11 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$50.86 ,Pays 100% Medicare OPPS,$12.82 ,$355.50 ,$316.00 
Outpatient Medical Services,LAB,84446,VITAMIN E LEVEL,301,$275.00 ,$233.75 ,85% of total billed charges,$14.18 ,Pays 100% Medicare OPPS,$14.18 ,Pays 100% Medicare OPPS,$14.18 ,Pays 100% Medicare OPPS,$18.43 ,Pays 130% Medicare OPPS,$21.46 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$14.46 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$22.32 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$14.18 ,Pays 100% Medicare OPPS,$12.76 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$21.46 ,120.37% of custom fee schedule,$14.18 ,Pays 100% Medicare OPPS,$18.43 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$14.18 ,Pays 100% Medicare OPPS,$12.76 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,84466,TRANSFERRIN LEVEL,301,$210.00 ,$178.50 ,85% of total billed charges,$12.76 ,Pays 100% Medicare OPPS,$12.76 ,Pays 100% Medicare OPPS,$12.76 ,Pays 100% Medicare OPPS,$16.58 ,Pays 130% Medicare OPPS,$19.33 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$13.01 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$20.10 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$12.76 ,Pays 100% Medicare OPPS,$11.48 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$19.33 ,120.37% of custom fee schedule,$12.76 ,Pays 100% Medicare OPPS,$16.58 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$12.76 ,Pays 100% Medicare OPPS,$11.48 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,84478,TRIGLYCERIDES LEVEL,301,$175.00 ,$148.75 ,85% of total billed charges,$5.74 ,Pays 100% Medicare OPPS,$5.74 ,Pays 100% Medicare OPPS,$5.74 ,Pays 100% Medicare OPPS,$7.46 ,Pays 130% Medicare OPPS,$7.64 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$5.85 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$7.95 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$5.74 ,Pays 100% Medicare OPPS,$5.16 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$7.64 ,120.37% of custom fee schedule,$5.74 ,Pays 100% Medicare OPPS,$7.46 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$5.74 ,Pays 100% Medicare OPPS,$5.16 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,84479,T 3 UPTAKE OR T UPTAKE,301,$150.00 ,$127.50 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$9.80 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$6.59 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$10.19 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$9.80 ,120.37% of custom fee schedule,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,84480,Blood test to evaluate thyroid function,301,$240.00 ,$204.00 ,85% of total billed charges,$14.18 ,Pays 100% Medicare OPPS,$14.18 ,Pays 100% Medicare OPPS,$14.18 ,Pays 100% Medicare OPPS,$18.43 ,Pays 130% Medicare OPPS,$19.30 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$14.46 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$20.07 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$14.18 ,Pays 100% Medicare OPPS,$12.76 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$19.30 ,120.37% of custom fee schedule,$14.18 ,Pays 100% Medicare OPPS,$18.43 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$14.18 ,Pays 100% Medicare OPPS,$12.76 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,84481,FREE T3,301,$245.00 ,$208.25 ,85% of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$16.94 ,Pays 100% Medicare OPPS,$16.94 ,Pays 100% Medicare OPPS,$22.02 ,Pays 130% Medicare OPPS,$25.64 ,20.37% based on GA Medicaid OP CCR Rate,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$17.27 ,Pays 102% Medicare OPPS,$220.50 ,90% of total billed charges,$26.66 ,125.18% of custom fee schedule,$168.32 ,68.7% of total billed charges,$196.00 ,80 percent of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$15.24 ,Pays 90% Medicare OPPS,$142.10 ,58% of total billed charges,$25.64 ,120.37% of custom fee schedule,$16.94 ,Pays 100% Medicare OPPS,$22.02 ,Pays 130% Medicare OPPS,$208.25 ,85% of total billed charges,$16.94 ,Pays 100% Medicare OPPS,$15.24 ,$220.50 ,$196.00 
Outpatient Medical Services,LAB,84482,REVERSE T3,301,$120.00 ,$102.00 ,85% of total billed charges,$15.76 ,Pays 100% Medicare OPPS,$15.76 ,Pays 100% Medicare OPPS,$15.76 ,Pays 100% Medicare OPPS,$20.48 ,Pays 130% Medicare OPPS,$23.86 ,20.37% based on GA Medicaid OP CCR Rate,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$16.07 ,Pays 102% Medicare OPPS,$108.00 ,90% of total billed charges,$24.81 ,125.18% of custom fee schedule,$82.44 ,68.7% of total billed charges,$96.00 ,80 percent of total billed charges,$15.76 ,Pays 100% Medicare OPPS,$14.18 ,Pays 90% Medicare OPPS,$69.60 ,58% of total billed charges,$23.86 ,120.37% of custom fee schedule,$15.76 ,Pays 100% Medicare OPPS,$20.48 ,Pays 130% Medicare OPPS,$102.00 ,85% of total billed charges,$15.76 ,Pays 100% Medicare OPPS,$14.18 ,$108.00 ,$96.00 
Outpatient Medical Services,LAB,84484,Blood test to measure a certain protein in the blood to determine heart muscle damage,301,$295.00 ,$250.75 ,85% of total billed charges,$12.47 ,Pays 100% Medicare OPPS,$12.47 ,Pays 100% Medicare OPPS,$12.47 ,Pays 100% Medicare OPPS,$16.21 ,Pays 130% Medicare OPPS,$14.90 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$12.71 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$15.50 ,125.18% of custom fee schedule,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$12.47 ,Pays 100% Medicare OPPS,$11.22 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$14.90 ,120.37% of custom fee schedule,$12.47 ,Pays 100% Medicare OPPS,$16.21 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$12.47 ,Pays 100% Medicare OPPS,$11.22 ,$265.50 ,$236.00 
Outpatient Medical Services,LAB,84520,BUN SERUM,301,$150.00 ,$127.50 ,85% of total billed charges,$3.95 ,Pays 100% Medicare OPPS,$3.95 ,Pays 100% Medicare OPPS,$3.95 ,Pays 100% Medicare OPPS,$5.13 ,Pays 130% Medicare OPPS,$5.97 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$4.02 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$6.21 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$3.95 ,Pays 100% Medicare OPPS,$3.55 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$5.97 ,120.37% of custom fee schedule,$3.95 ,Pays 100% Medicare OPPS,$5.13 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$3.95 ,Pays 100% Medicare OPPS,$3.55 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,84540,BUN URINE,301,$150.00 ,$127.50 ,85% of total billed charges,$5.56 ,Pays 100% Medicare OPPS,$5.56 ,Pays 100% Medicare OPPS,$5.56 ,Pays 100% Medicare OPPS,$7.22 ,Pays 130% Medicare OPPS,$7.20 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.67 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$7.49 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.56 ,Pays 100% Medicare OPPS,$5.00 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.20 ,120.37% of custom fee schedule,$5.56 ,Pays 100% Medicare OPPS,$7.22 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.56 ,Pays 100% Medicare OPPS,$5.00 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,84545,UREA CLEARANCE,301,$215.00 ,$182.75 ,85% of total billed charges,$7.20 ,Pays 100% Medicare OPPS,$7.20 ,Pays 100% Medicare OPPS,$7.20 ,Pays 100% Medicare OPPS,$9.36 ,Pays 130% Medicare OPPS,$10.00 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$7.34 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$10.40 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$7.20 ,Pays 100% Medicare OPPS,$6.48 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$10.00 ,120.37% of custom fee schedule,$7.20 ,Pays 100% Medicare OPPS,$9.36 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$7.20 ,Pays 100% Medicare OPPS,$6.48 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,84550,URIC ACID SERUM,301,$195.00 ,$165.75 ,85% of total billed charges,$4.51 ,Pays 100% Medicare OPPS,$4.51 ,Pays 100% Medicare OPPS,$4.51 ,Pays 100% Medicare OPPS,$5.87 ,Pays 130% Medicare OPPS,$6.84 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$4.61 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$7.11 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$4.51 ,Pays 100% Medicare OPPS,$4.06 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$6.84 ,120.37% of custom fee schedule,$4.51 ,Pays 100% Medicare OPPS,$5.87 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$4.51 ,Pays 100% Medicare OPPS,$4.06 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,84560,URIC ACID URINE,301,$150.00 ,$127.50 ,85% of total billed charges,$5.08 ,Pays 100% Medicare OPPS,$5.08 ,Pays 100% Medicare OPPS,$5.08 ,Pays 100% Medicare OPPS,$6.60 ,Pays 130% Medicare OPPS,$7.20 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.18 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$7.49 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.08 ,Pays 100% Medicare OPPS,$4.57 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.20 ,120.37% of custom fee schedule,$5.08 ,Pays 100% Medicare OPPS,$6.60 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.08 ,Pays 100% Medicare OPPS,$4.57 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,84585,VMA RANDOM URINE,301,$320.00 ,$272.00 ,85% of total billed charges,$15.50 ,Pays 100% Medicare OPPS,$15.50 ,Pays 100% Medicare OPPS,$15.50 ,Pays 100% Medicare OPPS,$20.15 ,Pays 130% Medicare OPPS,$23.46 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$15.81 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$24.40 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$15.50 ,Pays 100% Medicare OPPS,$13.95 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$23.46 ,120.37% of custom fee schedule,$15.50 ,Pays 100% Medicare OPPS,$20.15 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$15.50 ,Pays 100% Medicare OPPS,$13.95 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,84586,VASOACTIVE INTESTINAL PREP,301,$465.00 ,$395.25 ,85% of total billed charges,$35.33 ,Pays 100% Medicare OPPS,$35.33 ,Pays 100% Medicare OPPS,$35.33 ,Pays 100% Medicare OPPS,$45.92 ,Pays 130% Medicare OPPS,$53.48 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$36.03 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$55.62 ,125.18% of custom fee schedule,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$35.33 ,Pays 100% Medicare OPPS,$31.79 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$53.48 ,120.37% of custom fee schedule,$35.33 ,Pays 100% Medicare OPPS,$45.92 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$35.33 ,Pays 100% Medicare OPPS,$31.79 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,84588,ANTI DIURETIC HORMONE,302,$225.00 ,$191.25 ,85% of total billed charges,$33.94 ,Pays 100% Medicare OPPS,$33.94 ,Pays 100% Medicare OPPS,$33.94 ,Pays 100% Medicare OPPS,$44.12 ,Pays 130% Medicare OPPS,$51.39 ,20.37% based on GA Medicaid OP CCR Rate,$127.13 ,56.5 percent of total billed charges,$127.13 ,56.5 percent of total billed charges,$127.13 ,56.5 percent of total billed charges,$127.13 ,56.5 percent of total billed charges,$34.61 ,Pays 102% Medicare OPPS,$202.50 ,90% of total billed charges,$53.44 ,125.18% of custom fee schedule,$154.58 ,68.7% of total billed charges,$180.00 ,80 percent of total billed charges,$33.94 ,Pays 100% Medicare OPPS,$30.54 ,Pays 90% Medicare OPPS,$130.50 ,58% of total billed charges,$51.39 ,120.37% of custom fee schedule,$33.94 ,Pays 100% Medicare OPPS,$44.12 ,Pays 130% Medicare OPPS,$191.25 ,85% of total billed charges,$33.94 ,Pays 100% Medicare OPPS,$30.54 ,$202.50 ,$180.00 
Outpatient Medical Services,LAB,84590,VITAMIN A  LEVEL,301,$395.00 ,$335.75 ,85% of total billed charges,$11.61 ,Pays 100% Medicare OPPS,$11.61 ,Pays 100% Medicare OPPS,$11.61 ,Pays 100% Medicare OPPS,$15.09 ,Pays 130% Medicare OPPS,$17.55 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$11.84 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$18.25 ,125.18% of custom fee schedule,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$11.61 ,Pays 100% Medicare OPPS,$10.44 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$17.55 ,120.37% of custom fee schedule,$11.61 ,Pays 100% Medicare OPPS,$15.09 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$11.61 ,Pays 100% Medicare OPPS,$10.44 ,$355.50 ,$316.00 
Outpatient Medical Services,LAB,80320,METHANOL  BLOOD LEVEL,301,$310.00 ,$263.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$16.36 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$17.01 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$16.36 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$16.36 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,84630,ZINC LEVEL,301,$215.00 ,$182.75 ,85% of total billed charges,$11.39 ,Pays 100% Medicare OPPS,$11.39 ,Pays 100% Medicare OPPS,$11.39 ,Pays 100% Medicare OPPS,$14.80 ,Pays 130% Medicare OPPS,$17.24 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$11.61 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$17.93 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$11.39 ,Pays 100% Medicare OPPS,$10.25 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$17.24 ,120.37% of custom fee schedule,$11.39 ,Pays 100% Medicare OPPS,$14.80 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$11.39 ,Pays 100% Medicare OPPS,$10.25 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,84681,C PEPTIDE,301,$415.00 ,$352.75 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$24.05 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$21.22 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$25.01 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$24.05 ,120.37% of custom fee schedule,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,84702,3RD PREGNANCY BETA (QUANT),301,$320.00 ,$272.00 ,85% of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$15.05 ,Pays 100% Medicare OPPS,$15.05 ,Pays 100% Medicare OPPS,$19.56 ,Pays 130% Medicare OPPS,$9.71 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$15.35 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$10.10 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$13.54 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$9.71 ,120.37% of custom fee schedule,$15.05 ,Pays 100% Medicare OPPS,$19.56 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$9.71 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,81025,Urine pregnancy test,301,$190.00 ,$161.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.19 ,Pays 130% Medicare OPPS,$9.58 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$8.78 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$9.96 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.74 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$9.58 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.19 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.74 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,84999,OSMOLALITY STOOL,301,$375.00 ,$318.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$131.25 ,35% based on GA Medicaid OP CCR Rate,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$76.39 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,85002,BLEEDING TIME,305,$195.00 ,$165.75 ,85% of total billed charges,$4.82 ,Pays 100% Medicare OPPS,$4.82 ,Pays 100% Medicare OPPS,$4.82 ,Pays 100% Medicare OPPS,$6.26 ,Pays 130% Medicare OPPS,$6.81 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$4.91 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$7.09 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$4.82 ,Pays 100% Medicare OPPS,$4.33 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$6.81 ,120.37% of custom fee schedule,$4.82 ,Pays 100% Medicare OPPS,$6.26 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$4.82 ,Pays 100% Medicare OPPS,$4.33 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,85007,Blood test to assess for infection,305,$85.00 ,$72.25 ,85% of total billed charges,$3.80 ,Pays 100% Medicare OPPS,$3.80 ,Pays 100% Medicare OPPS,$3.80 ,Pays 100% Medicare OPPS,$4.94 ,Pays 130% Medicare OPPS,$5.21 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$3.87 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$5.42 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$3.80 ,Pays 100% Medicare OPPS,$3.42 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$5.21 ,120.37% of custom fee schedule,$3.80 ,Pays 100% Medicare OPPS,$4.94 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$3.80 ,Pays 100% Medicare OPPS,$3.42 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,85004,EOSIN COUNT BLOOD,305,$150.00 ,$127.50 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$9.80 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$6.59 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$10.19 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$9.80 ,120.37% of custom fee schedule,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,85014,HEMATOCRIT,305,$95.00 ,$80.75 ,85% of total billed charges,$2.37 ,Pays 100% Medicare OPPS,$2.37 ,Pays 100% Medicare OPPS,$2.37 ,Pays 100% Medicare OPPS,$3.08 ,Pays 130% Medicare OPPS,$3.59 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$2.41 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$3.73 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$2.37 ,Pays 100% Medicare OPPS,$2.13 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$3.59 ,120.37% of custom fee schedule,$2.37 ,Pays 100% Medicare OPPS,$3.08 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$2.37 ,Pays 100% Medicare OPPS,$2.13 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,85018,Blood test to measure levels of hemoglobin,305,$95.00 ,$80.75 ,85% of total billed charges,$2.37 ,Pays 100% Medicare OPPS,$2.37 ,Pays 100% Medicare OPPS,$2.37 ,Pays 100% Medicare OPPS,$3.08 ,Pays 130% Medicare OPPS,$3.59 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$2.41 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$3.73 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$2.37 ,Pays 100% Medicare OPPS,$2.13 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$3.59 ,120.37% of custom fee schedule,$2.37 ,Pays 100% Medicare OPPS,$3.08 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$2.37 ,Pays 100% Medicare OPPS,$2.13 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,85025,"Complete blood cell count, with differential white blood cells, automated",305,$265.00 ,$225.25 ,85% of total billed charges,$7.77 ,Pays 100% Medicare OPPS,$7.77 ,Pays 100% Medicare OPPS,$7.77 ,Pays 100% Medicare OPPS,$10.10 ,Pays 130% Medicare OPPS,$11.76 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$7.92 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$12.23 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$7.77 ,Pays 100% Medicare OPPS,$6.99 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$11.76 ,120.37% of custom fee schedule,$7.77 ,Pays 100% Medicare OPPS,$10.10 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$7.77 ,Pays 100% Medicare OPPS,$6.99 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,85027,"Complete blood count, automated",305,$190.00 ,$161.50 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$9.80 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$6.59 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$10.19 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$9.80 ,120.37% of custom fee schedule,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,85027,"Complete blood count, automated",300,$190.00 ,$161.50 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$9.80 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$6.59 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$10.19 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$9.80 ,120.37% of custom fee schedule,$6.47 ,Pays 100% Medicare OPPS,$8.41 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$6.47 ,Pays 100% Medicare OPPS,$5.82 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,85041,RBC(AUTOMATED),305,$95.00 ,$80.75 ,85% of total billed charges,$3.02 ,Pays 100% Medicare OPPS,$3.02 ,Pays 100% Medicare OPPS,$3.02 ,Pays 100% Medicare OPPS,$3.92 ,Pays 130% Medicare OPPS,$4.55 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$3.08 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$4.73 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$3.02 ,Pays 100% Medicare OPPS,$2.71 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$4.55 ,120.37% of custom fee schedule,$3.02 ,Pays 100% Medicare OPPS,$3.92 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$3.02 ,Pays 100% Medicare OPPS,$2.71 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,85045,RETIC COUNT,305,$150.00 ,$127.50 ,85% of total billed charges,$3.99 ,Pays 100% Medicare OPPS,$3.99 ,Pays 100% Medicare OPPS,$3.99 ,Pays 100% Medicare OPPS,$5.18 ,Pays 130% Medicare OPPS,$6.05 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$4.06 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$6.30 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$3.99 ,Pays 100% Medicare OPPS,$3.59 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$6.05 ,120.37% of custom fee schedule,$3.99 ,Pays 100% Medicare OPPS,$5.18 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$3.99 ,Pays 100% Medicare OPPS,$3.59 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,85048,WBC (AUTOMATED),305,$95.00 ,$80.75 ,85% of total billed charges,$2.54 ,Pays 100% Medicare OPPS,$2.54 ,Pays 100% Medicare OPPS,$2.54 ,Pays 100% Medicare OPPS,$3.30 ,Pays 130% Medicare OPPS,$3.85 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$2.59 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$4.01 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$2.54 ,Pays 100% Medicare OPPS,$2.28 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$3.85 ,120.37% of custom fee schedule,$2.54 ,Pays 100% Medicare OPPS,$3.30 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$2.54 ,Pays 100% Medicare OPPS,$2.28 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,85049,PLATELET COUNT(AUTOMATED),305,$110.00 ,$93.50 ,85% of total billed charges,$4.48 ,Pays 100% Medicare OPPS,$4.48 ,Pays 100% Medicare OPPS,$4.48 ,Pays 100% Medicare OPPS,$5.82 ,Pays 130% Medicare OPPS,$6.78 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$4.56 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$7.05 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$4.48 ,Pays 100% Medicare OPPS,$4.03 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$6.78 ,120.37% of custom fee schedule,$4.48 ,Pays 100% Medicare OPPS,$5.82 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$4.48 ,Pays 100% Medicare OPPS,$4.03 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,85060,UNUSUAL SLIDE/PATH READ,305,$110.00 ,$93.50 ,85% of total billed charges,$27.50 ,Pays 100% Medicare OPPS,$27.50 ,Pays 100% Medicare OPPS,$27.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$31.26 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$32.51 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$99.00 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$31.26 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$27.50 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,85220,FACTOR V ACTIVITY,305,$410.00 ,$348.50 ,85% of total billed charges,$17.64 ,Pays 100% Medicare OPPS,$17.64 ,Pays 100% Medicare OPPS,$17.64 ,Pays 100% Medicare OPPS,$22.94 ,Pays 130% Medicare OPPS,$26.71 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$18.00 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$27.78 ,125.18% of custom fee schedule,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$17.64 ,Pays 100% Medicare OPPS,$15.88 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$26.71 ,120.37% of custom fee schedule,$17.64 ,Pays 100% Medicare OPPS,$22.94 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$17.64 ,Pays 100% Medicare OPPS,$15.88 ,$369.00 ,$328.00 
Outpatient Medical Services,LAB,85240,.FACTOR VIII ONE STAGE,305,$215.00 ,$182.75 ,85% of total billed charges,$17.89 ,Pays 100% Medicare OPPS,$17.89 ,Pays 100% Medicare OPPS,$17.89 ,Pays 100% Medicare OPPS,$23.27 ,Pays 130% Medicare OPPS,$27.11 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$18.25 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$28.19 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$17.89 ,Pays 100% Medicare OPPS,$16.10 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$27.11 ,120.37% of custom fee schedule,$17.89 ,Pays 100% Medicare OPPS,$23.27 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$17.89 ,Pays 100% Medicare OPPS,$16.10 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,85245,".FACTOR VIII, VW FACTOR",305,$215.00 ,$182.75 ,85% of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$22.94 ,Pays 100% Medicare OPPS,$22.94 ,Pays 100% Medicare OPPS,$29.82 ,Pays 130% Medicare OPPS,$34.73 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$23.39 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$36.11 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$20.64 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$34.73 ,120.37% of custom fee schedule,$22.94 ,Pays 100% Medicare OPPS,$29.82 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$20.64 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,85246,3RD VON WILLENBRAND ANTIGEN,301,$245.00 ,$208.25 ,85% of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$22.94 ,Pays 100% Medicare OPPS,$22.94 ,Pays 100% Medicare OPPS,$29.82 ,Pays 130% Medicare OPPS,$34.73 ,20.37% based on GA Medicaid OP CCR Rate,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$23.39 ,Pays 102% Medicare OPPS,$220.50 ,90% of total billed charges,$36.11 ,125.18% of custom fee schedule,$168.32 ,68.7% of total billed charges,$196.00 ,80 percent of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$20.64 ,Pays 90% Medicare OPPS,$142.10 ,58% of total billed charges,$34.73 ,120.37% of custom fee schedule,$22.94 ,Pays 100% Medicare OPPS,$29.82 ,Pays 130% Medicare OPPS,$208.25 ,85% of total billed charges,$22.94 ,Pays 100% Medicare OPPS,$20.64 ,$220.50 ,$196.00 
Outpatient Medical Services,LAB,85300,ANTITHROMBIN III ACTIVITY,305,$375.00 ,$318.75 ,85% of total billed charges,$11.85 ,Pays 100% Medicare OPPS,$11.85 ,Pays 100% Medicare OPPS,$11.85 ,Pays 100% Medicare OPPS,$15.40 ,Pays 130% Medicare OPPS,$17.94 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$12.08 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$18.65 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$11.85 ,Pays 100% Medicare OPPS,$10.66 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$17.94 ,120.37% of custom fee schedule,$11.85 ,Pays 100% Medicare OPPS,$15.40 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$11.85 ,Pays 100% Medicare OPPS,$10.66 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,85301,ANTITHROMBIN III ANTIGEN,305,$300.00 ,$255.00 ,85% of total billed charges,$10.81 ,Pays 100% Medicare OPPS,$10.81 ,Pays 100% Medicare OPPS,$10.81 ,Pays 100% Medicare OPPS,$14.05 ,Pays 130% Medicare OPPS,$16.37 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$11.02 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$17.02 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$10.81 ,Pays 100% Medicare OPPS,$9.72 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$16.37 ,120.37% of custom fee schedule,$10.81 ,Pays 100% Medicare OPPS,$14.05 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$10.81 ,Pays 100% Medicare OPPS,$9.72 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,85302,3RD PROTEIN C (ANTIGEN) LEVEL,305,$345.00 ,$293.25 ,85% of total billed charges,$12.01 ,Pays 100% Medicare OPPS,$12.01 ,Pays 100% Medicare OPPS,$12.01 ,Pays 100% Medicare OPPS,$15.61 ,Pays 130% Medicare OPPS,$18.20 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$12.25 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$18.93 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$12.01 ,Pays 100% Medicare OPPS,$10.80 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$18.20 ,120.37% of custom fee schedule,$12.01 ,Pays 100% Medicare OPPS,$15.61 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$12.01 ,Pays 100% Medicare OPPS,$10.80 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,85303,3RD PROTEIN C (ACTIVITY) LEVEL,305,$345.00 ,$293.25 ,85% of total billed charges,$13.84 ,Pays 100% Medicare OPPS,$13.84 ,Pays 100% Medicare OPPS,$13.84 ,Pays 100% Medicare OPPS,$17.99 ,Pays 130% Medicare OPPS,$20.93 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$14.11 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$21.77 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$13.84 ,Pays 100% Medicare OPPS,$12.45 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$20.93 ,120.37% of custom fee schedule,$13.84 ,Pays 100% Medicare OPPS,$17.99 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$13.84 ,Pays 100% Medicare OPPS,$12.45 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,85305,PROTEIN S (ANTIGEN) LEVEL,305,$345.00 ,$293.25 ,85% of total billed charges,$11.61 ,Pays 100% Medicare OPPS,$11.61 ,Pays 100% Medicare OPPS,$11.61 ,Pays 100% Medicare OPPS,$15.09 ,Pays 130% Medicare OPPS,$17.55 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$11.84 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$18.25 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$11.61 ,Pays 100% Medicare OPPS,$10.44 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$17.55 ,120.37% of custom fee schedule,$11.61 ,Pays 100% Medicare OPPS,$15.09 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$11.61 ,Pays 100% Medicare OPPS,$10.44 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,85306,3RD PROTEIN S (ACTIVITY) LEVEL,305,$345.00 ,$293.25 ,85% of total billed charges,$15.32 ,Pays 100% Medicare OPPS,$15.32 ,Pays 100% Medicare OPPS,$15.32 ,Pays 100% Medicare OPPS,$19.91 ,Pays 130% Medicare OPPS,$23.20 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$15.62 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$24.12 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$15.32 ,Pays 100% Medicare OPPS,$13.78 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$23.20 ,120.37% of custom fee schedule,$15.32 ,Pays 100% Medicare OPPS,$19.91 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$15.32 ,Pays 100% Medicare OPPS,$13.78 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,85335,PROTEIN C ACT RESISTANCE LEVEL,305,$540.00 ,$459.00 ,85% of total billed charges,$12.87 ,Pays 100% Medicare OPPS,$12.87 ,Pays 100% Medicare OPPS,$12.87 ,Pays 100% Medicare OPPS,$16.73 ,Pays 130% Medicare OPPS,$19.49 ,20.37% based on GA Medicaid OP CCR Rate,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$13.12 ,Pays 102% Medicare OPPS,$486.00 ,90% of total billed charges,$20.27 ,125.18% of custom fee schedule,$370.98 ,68.7% of total billed charges,$432.00 ,80 percent of total billed charges,$12.87 ,Pays 100% Medicare OPPS,$11.58 ,Pays 90% Medicare OPPS,$313.20 ,58% of total billed charges,$19.49 ,120.37% of custom fee schedule,$12.87 ,Pays 100% Medicare OPPS,$16.73 ,Pays 130% Medicare OPPS,$459.00 ,85% of total billed charges,$12.87 ,Pays 100% Medicare OPPS,$11.58 ,$486.00 ,$432.00 
Outpatient Medical Services,LAB,85345,CLOT TIME LEE WHITE,305,$195.00 ,$165.75 ,85% of total billed charges,$4.69 ,Pays 100% Medicare OPPS,$4.69 ,Pays 100% Medicare OPPS,$4.69 ,Pays 100% Medicare OPPS,$6.09 ,Pays 130% Medicare OPPS,$5.24 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$4.78 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$5.45 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$4.69 ,Pays 100% Medicare OPPS,$4.22 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$5.24 ,120.37% of custom fee schedule,$4.69 ,Pays 100% Medicare OPPS,$6.09 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$4.69 ,Pays 100% Medicare OPPS,$4.22 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,85362,FIBRIN DEGRADATION PRODUC,305,$240.00 ,$204.00 ,85% of total billed charges,$6.89 ,Pays 100% Medicare OPPS,$6.89 ,Pays 100% Medicare OPPS,$6.89 ,Pays 100% Medicare OPPS,$8.95 ,Pays 130% Medicare OPPS,$10.42 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$7.02 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$10.84 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$6.89 ,Pays 100% Medicare OPPS,$6.20 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$10.42 ,120.37% of custom fee schedule,$6.89 ,Pays 100% Medicare OPPS,$8.95 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$6.89 ,Pays 100% Medicare OPPS,$6.20 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,85379,.D DIMER,305,$345.00 ,$293.25 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$15.41 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$10.38 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$16.02 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$15.41 ,120.37% of custom fee schedule,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,85384,FIBRINOGEN ACTIVITY,305,$215.00 ,$182.75 ,85% of total billed charges,$9.72 ,Pays 100% Medicare OPPS,$9.72 ,Pays 100% Medicare OPPS,$9.72 ,Pays 100% Medicare OPPS,$12.63 ,Pays 130% Medicare OPPS,$12.86 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$9.91 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$13.37 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$9.72 ,Pays 100% Medicare OPPS,$8.74 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$12.86 ,120.37% of custom fee schedule,$9.72 ,Pays 100% Medicare OPPS,$12.63 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$9.72 ,Pays 100% Medicare OPPS,$8.74 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,85400,3RD LUPUS TYPE ANTICOAG,305,$320.00 ,$272.00 ,85% of total billed charges,$7.71 ,Pays 100% Medicare OPPS,$7.71 ,Pays 100% Medicare OPPS,$7.71 ,Pays 100% Medicare OPPS,$10.02 ,Pays 130% Medicare OPPS,$13.39 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$7.86 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$13.92 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$7.71 ,Pays 100% Medicare OPPS,$6.93 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$13.39 ,120.37% of custom fee schedule,$7.71 ,Pays 100% Medicare OPPS,$10.02 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$7.71 ,Pays 100% Medicare OPPS,$6.93 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,85420,PLASMINOGEN ACTIVITY,305,$435.00 ,$369.75 ,85% of total billed charges,$6.53 ,Pays 100% Medicare OPPS,$6.53 ,Pays 100% Medicare OPPS,$6.53 ,Pays 100% Medicare OPPS,$8.48 ,Pays 130% Medicare OPPS,$9.89 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$6.66 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$10.29 ,125.18% of custom fee schedule,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$6.53 ,Pays 100% Medicare OPPS,$5.87 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$9.89 ,120.37% of custom fee schedule,$6.53 ,Pays 100% Medicare OPPS,$8.48 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$6.53 ,Pays 100% Medicare OPPS,$5.87 ,$391.50 ,$348.00 
Outpatient Medical Services,LAB,85460,KLEIHAUER BETKE,305,$735.00 ,$624.75 ,85% of total billed charges,$7.73 ,Pays 100% Medicare OPPS,$7.73 ,Pays 100% Medicare OPPS,$7.73 ,Pays 100% Medicare OPPS,$10.04 ,Pays 130% Medicare OPPS,$3.66 ,20.37% based on GA Medicaid OP CCR Rate,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$7.88 ,Pays 102% Medicare OPPS,$661.50 ,90% of total billed charges,$3.81 ,125.18% of custom fee schedule,$504.95 ,68.7% of total billed charges,$588.00 ,80 percent of total billed charges,$7.73 ,Pays 100% Medicare OPPS,$6.95 ,Pays 90% Medicare OPPS,$426.30 ,58% of total billed charges,$3.66 ,120.37% of custom fee schedule,$7.73 ,Pays 100% Medicare OPPS,$10.04 ,Pays 130% Medicare OPPS,$624.75 ,85% of total billed charges,$7.73 ,Pays 100% Medicare OPPS,$3.66 ,$661.50 ,$588.00 
Outpatient Medical Services,LAB,85461,FETAL SCREEN,305,$135.00 ,$114.75 ,85% of total billed charges,$9.36 ,Pays 100% Medicare OPPS,$9.36 ,Pays 100% Medicare OPPS,$9.36 ,Pays 100% Medicare OPPS,$12.16 ,Pays 130% Medicare OPPS,$10.03 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$9.54 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$10.43 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$9.36 ,Pays 100% Medicare OPPS,$8.42 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$10.03 ,120.37% of custom fee schedule,$9.36 ,Pays 100% Medicare OPPS,$12.16 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$9.36 ,Pays 100% Medicare OPPS,$8.42 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,85520,ANTI FACTOR XA (LOVENOX),300,$395.00 ,$335.75 ,85% of total billed charges,$13.09 ,Pays 100% Medicare OPPS,$13.09 ,Pays 100% Medicare OPPS,$13.09 ,Pays 100% Medicare OPPS,$17.01 ,Pays 130% Medicare OPPS,$19.81 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$13.35 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$20.60 ,125.18% of custom fee schedule,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$13.09 ,Pays 100% Medicare OPPS,$11.78 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$19.81 ,120.37% of custom fee schedule,$13.09 ,Pays 100% Medicare OPPS,$17.01 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$13.09 ,Pays 100% Medicare OPPS,$11.78 ,$355.50 ,$316.00 
Outpatient Medical Services,LAB,85540,LAP STAIN,305,$260.00 ,$221.00 ,85% of total billed charges,$8.60 ,Pays 100% Medicare OPPS,$8.60 ,Pays 100% Medicare OPPS,$8.60 ,Pays 100% Medicare OPPS,$11.18 ,Pays 130% Medicare OPPS,$9.15 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$8.77 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$9.51 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$8.60 ,Pays 100% Medicare OPPS,$7.74 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$9.15 ,120.37% of custom fee schedule,$8.60 ,Pays 100% Medicare OPPS,$11.18 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$8.60 ,Pays 100% Medicare OPPS,$7.74 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,85549,LYSOZYME,305,$260.00 ,$221.00 ,85% of total billed charges,$18.75 ,Pays 100% Medicare OPPS,$18.75 ,Pays 100% Medicare OPPS,$18.75 ,Pays 100% Medicare OPPS,$24.37 ,Pays 130% Medicare OPPS,$28.40 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$19.12 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$29.53 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$18.75 ,Pays 100% Medicare OPPS,$16.87 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$28.40 ,120.37% of custom fee schedule,$18.75 ,Pays 100% Medicare OPPS,$24.37 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$18.75 ,Pays 100% Medicare OPPS,$16.87 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,85576,.PLATELET AGGREGATION,305,$215.00 ,$182.75 ,85% of total billed charges,$24.91 ,Pays 100% Medicare OPPS,$24.91 ,Pays 100% Medicare OPPS,$24.91 ,Pays 100% Medicare OPPS,$32.38 ,Pays 130% Medicare OPPS,$32.51 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$25.40 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$33.81 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$24.91 ,Pays 100% Medicare OPPS,$22.41 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$32.51 ,120.37% of custom fee schedule,$24.91 ,Pays 100% Medicare OPPS,$32.38 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$24.91 ,Pays 100% Medicare OPPS,$22.41 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,85610,"Blood test, clotting time",305,$120.00 ,$102.00 ,85% of total billed charges,$4.29 ,Pays 100% Medicare OPPS,$4.29 ,Pays 100% Medicare OPPS,$4.29 ,Pays 100% Medicare OPPS,$5.57 ,Pays 130% Medicare OPPS,$5.95 ,20.37% based on GA Medicaid OP CCR Rate,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$4.37 ,Pays 102% Medicare OPPS,$108.00 ,90% of total billed charges,$6.18 ,125.18% of custom fee schedule,$82.44 ,68.7% of total billed charges,$96.00 ,80 percent of total billed charges,$4.29 ,Pays 100% Medicare OPPS,$3.86 ,Pays 90% Medicare OPPS,$69.60 ,58% of total billed charges,$5.95 ,120.37% of custom fee schedule,$4.29 ,Pays 100% Medicare OPPS,$5.57 ,Pays 130% Medicare OPPS,$102.00 ,85% of total billed charges,$4.29 ,Pays 100% Medicare OPPS,$3.86 ,$108.00 ,$96.00 
Outpatient Medical Services,LAB,85651,SEDIMENTATION RATE,305,$165.00 ,$140.25 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$5.37 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$4.35 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$5.58 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.84 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$5.37 ,120.37% of custom fee schedule,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.84 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,85660,SICKLE CELL PREP,305,$210.00 ,$178.50 ,85% of total billed charges,$5.51 ,Pays 100% Medicare OPPS,$5.51 ,Pays 100% Medicare OPPS,$5.51 ,Pays 100% Medicare OPPS,$7.16 ,Pays 130% Medicare OPPS,$8.35 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$5.62 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$8.69 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$5.51 ,Pays 100% Medicare OPPS,$4.95 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$8.35 ,120.37% of custom fee schedule,$5.51 ,Pays 100% Medicare OPPS,$7.16 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$5.51 ,Pays 100% Medicare OPPS,$4.95 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,85670,THROMBIN TIME,305,$345.00 ,$293.25 ,85% of total billed charges,$5.77 ,Pays 100% Medicare OPPS,$5.77 ,Pays 100% Medicare OPPS,$5.77 ,Pays 100% Medicare OPPS,$7.50 ,Pays 130% Medicare OPPS,$8.74 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$5.88 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$9.09 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$5.77 ,Pays 100% Medicare OPPS,$5.19 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$8.74 ,120.37% of custom fee schedule,$5.77 ,Pays 100% Medicare OPPS,$7.50 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$5.77 ,Pays 100% Medicare OPPS,$5.19 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,85730,Coagulation assessment blood test,305,$195.00 ,$165.75 ,85% of total billed charges,$6.01 ,Pays 100% Medicare OPPS,$6.01 ,Pays 100% Medicare OPPS,$6.01 ,Pays 100% Medicare OPPS,$7.81 ,Pays 130% Medicare OPPS,$9.08 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$6.13 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$9.44 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$6.01 ,Pays 100% Medicare OPPS,$5.40 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$9.08 ,120.37% of custom fee schedule,$6.01 ,Pays 100% Medicare OPPS,$7.81 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$6.01 ,Pays 100% Medicare OPPS,$5.40 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,86003,.ALLERGEN (RAST PROFILE),301,$135.00 ,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$7.91 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.32 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.22 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.91 ,120.37% of custom fee schedule,$5.22 ,Pays 100% Medicare OPPS,$6.78 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.22 ,Pays 100% Medicare OPPS,$4.69 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86038,ANCA,302,$420.00 ,$357.00 ,85% of total billed charges,$12.09 ,Pays 100% Medicare OPPS,$12.09 ,Pays 100% Medicare OPPS,$12.09 ,Pays 100% Medicare OPPS,$15.71 ,Pays 130% Medicare OPPS,$18.30 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$12.33 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$19.03 ,125.18% of custom fee schedule,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$12.09 ,Pays 100% Medicare OPPS,$10.88 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$18.30 ,120.37% of custom fee schedule,$12.09 ,Pays 100% Medicare OPPS,$15.71 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$12.09 ,Pays 100% Medicare OPPS,$10.88 ,$378.00 ,$336.00 
Outpatient Medical Services,LAB,86022,PLATELET ANTIBODIES,302,$365.00 ,$310.25 ,85% of total billed charges,$18.37 ,Pays 100% Medicare OPPS,$18.37 ,Pays 100% Medicare OPPS,$18.37 ,Pays 100% Medicare OPPS,$23.88 ,Pays 130% Medicare OPPS,$27.79 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$18.73 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$28.90 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$18.37 ,Pays 100% Medicare OPPS,$16.53 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$27.79 ,120.37% of custom fee schedule,$18.37 ,Pays 100% Medicare OPPS,$23.88 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$18.37 ,Pays 100% Medicare OPPS,$16.53 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86038,ANA  W/TITER,302,$260.00 ,$221.00 ,85% of total billed charges,$12.09 ,Pays 100% Medicare OPPS,$12.09 ,Pays 100% Medicare OPPS,$12.09 ,Pays 100% Medicare OPPS,$15.71 ,Pays 130% Medicare OPPS,$18.30 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$12.33 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$19.03 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$12.09 ,Pays 100% Medicare OPPS,$10.88 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$18.30 ,120.37% of custom fee schedule,$12.09 ,Pays 100% Medicare OPPS,$15.71 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$12.09 ,Pays 100% Medicare OPPS,$10.88 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86060,ASO (STREPTOZYME),302,$175.00 ,$148.75 ,85% of total billed charges,$7.30 ,Pays 100% Medicare OPPS,$7.30 ,Pays 100% Medicare OPPS,$7.30 ,Pays 100% Medicare OPPS,$9.49 ,Pays 130% Medicare OPPS,$10.58 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$7.44 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$11.00 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$7.30 ,Pays 100% Medicare OPPS,$6.57 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$10.58 ,120.37% of custom fee schedule,$7.30 ,Pays 100% Medicare OPPS,$9.49 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$7.30 ,Pays 100% Medicare OPPS,$6.57 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,86140,C REACTIVE PROTEIN (CRP),302,$150.00 ,$127.50 ,85% of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$5.18 ,Pays 100% Medicare OPPS,$5.18 ,Pays 100% Medicare OPPS,$6.73 ,Pays 130% Medicare OPPS,$7.84 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.28 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$8.15 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$4.66 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.84 ,120.37% of custom fee schedule,$5.18 ,Pays 100% Medicare OPPS,$6.73 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$4.66 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,86141,C REACTIVE PRTN(ULTR SENS,302,$465.00 ,$395.25 ,85% of total billed charges,$12.95 ,Pays 100% Medicare OPPS,$12.95 ,Pays 100% Medicare OPPS,$12.95 ,Pays 100% Medicare OPPS,$16.83 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$13.20 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$12.95 ,Pays 100% Medicare OPPS,$11.65 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$12.95 ,Pays 100% Medicare OPPS,$16.83 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$12.95 ,Pays 100% Medicare OPPS,$11.65 ,$418.50 ,$372.00 
Outpatient Medical Services,LAB,86147,Blood test to determine cause of inappropriate blood clot formation,302,$165.00 ,$140.25 ,85% of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$25.45 ,Pays 100% Medicare OPPS,$25.45 ,Pays 100% Medicare OPPS,$33.08 ,Pays 130% Medicare OPPS,$38.51 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$25.95 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$40.05 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$22.90 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$38.51 ,120.37% of custom fee schedule,$25.45 ,Pays 100% Medicare OPPS,$33.08 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$25.45 ,Pays 100% Medicare OPPS,$22.90 ,$148.50 ,$132.00 
Outpatient Medical Services,LAB,86157,COLD AGGLUTININS,302,$215.00 ,$182.75 ,85% of total billed charges,$8.06 ,Pays 100% Medicare OPPS,$8.06 ,Pays 100% Medicare OPPS,$8.06 ,Pays 100% Medicare OPPS,$10.47 ,Pays 130% Medicare OPPS,$12.21 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$8.22 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$12.69 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$8.06 ,Pays 100% Medicare OPPS,$7.25 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$12.21 ,120.37% of custom fee schedule,$8.06 ,Pays 100% Medicare OPPS,$10.47 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$8.06 ,Pays 100% Medicare OPPS,$7.25 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,86160,C3 COMPLEMENT,302,$320.00 ,$272.00 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$18.18 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$12.24 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$18.90 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$18.18 ,120.37% of custom fee schedule,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,86161,3RD C1-ESTERASE INHIBITOR,302,$320.00 ,$272.00 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$18.18 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$12.24 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$18.90 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$18.18 ,120.37% of custom fee schedule,$12.00 ,Pays 100% Medicare OPPS,$15.60 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.00 ,Pays 100% Medicare OPPS,$10.80 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,86162,CH 50 COMPLEMENT,302,$320.00 ,$272.00 ,85% of total billed charges,$20.32 ,Pays 100% Medicare OPPS,$20.32 ,Pays 100% Medicare OPPS,$20.32 ,Pays 100% Medicare OPPS,$26.41 ,Pays 130% Medicare OPPS,$30.75 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$20.72 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$31.98 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$20.32 ,Pays 100% Medicare OPPS,$18.28 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$30.75 ,120.37% of custom fee schedule,$20.32 ,Pays 100% Medicare OPPS,$26.41 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$20.32 ,Pays 100% Medicare OPPS,$18.28 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,86200,Blood test to diagnose rheumatoid arthritis,300,$475.00 ,$403.75 ,85% of total billed charges,$12.95 ,Pays 100% Medicare OPPS,$12.95 ,Pays 100% Medicare OPPS,$12.95 ,Pays 100% Medicare OPPS,$16.83 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$13.20 ,Pays 102% Medicare OPPS,$427.50 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$326.33 ,68.7% of total billed charges,$380.00 ,80 percent of total billed charges,$12.95 ,Pays 100% Medicare OPPS,$11.65 ,Pays 90% Medicare OPPS,$275.50 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$12.95 ,Pays 100% Medicare OPPS,$16.83 ,Pays 130% Medicare OPPS,$403.75 ,85% of total billed charges,$12.95 ,Pays 100% Medicare OPPS,$11.65 ,$427.50 ,$380.00 
Outpatient Medical Services,LAB,86215,ANTI DNASE B,302,$260.00 ,$221.00 ,85% of total billed charges,$13.25 ,Pays 100% Medicare OPPS,$13.25 ,Pays 100% Medicare OPPS,$13.25 ,Pays 100% Medicare OPPS,$17.22 ,Pays 130% Medicare OPPS,$20.05 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$13.51 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$20.85 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$13.25 ,Pays 100% Medicare OPPS,$11.92 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$20.05 ,120.37% of custom fee schedule,$13.25 ,Pays 100% Medicare OPPS,$17.22 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$13.25 ,Pays 100% Medicare OPPS,$11.92 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86225,ANTI DNA DOUBLE STRANDED AB,302,$275.00 ,$233.75 ,85% of total billed charges,$13.74 ,Pays 100% Medicare OPPS,$13.74 ,Pays 100% Medicare OPPS,$13.74 ,Pays 100% Medicare OPPS,$17.86 ,Pays 130% Medicare OPPS,$20.80 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$14.01 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$21.63 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$13.74 ,Pays 100% Medicare OPPS,$12.36 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$20.80 ,120.37% of custom fee schedule,$13.74 ,Pays 100% Medicare OPPS,$17.86 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$13.74 ,Pays 100% Medicare OPPS,$12.36 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,86226,ANTI DNA SINGLE STRANDED,302,$275.00 ,$233.75 ,85% of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$12.11 ,Pays 100% Medicare OPPS,$12.11 ,Pays 100% Medicare OPPS,$15.74 ,Pays 130% Medicare OPPS,$18.33 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$12.35 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$19.06 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$10.89 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$18.33 ,120.37% of custom fee schedule,$12.11 ,Pays 100% Medicare OPPS,$15.74 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$10.89 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,86255,3RD MYLELIN ANTIBODY IGG,301,$190.00 ,$161.50 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,86255,3RD RETICULIN IgA AB,300,$320.00 ,$272.00 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,86300,Blood test to monitor breast cancer,302,$345.00 ,$293.25 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$31.49 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$21.22 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$32.75 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$31.49 ,120.37% of custom fee schedule,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,86301,CA 19-9 (COLON),302,$365.00 ,$310.25 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$31.49 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$21.22 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$32.75 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$31.49 ,120.37% of custom fee schedule,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86304,Blood test to monitor for cancer,302,$365.00 ,$310.25 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$31.49 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$21.22 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$32.75 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$31.49 ,120.37% of custom fee schedule,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86308,MONO TEST,302,$175.00 ,$148.75 ,85% of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$5.18 ,Pays 100% Medicare OPPS,$5.18 ,Pays 100% Medicare OPPS,$6.73 ,Pays 130% Medicare OPPS,$7.84 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$5.28 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$8.15 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$4.66 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$7.84 ,120.37% of custom fee schedule,$5.18 ,Pays 100% Medicare OPPS,$6.73 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$5.18 ,Pays 100% Medicare OPPS,$4.66 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,86316,SQUAMOUS CA ANTIGEN (SCA),302,$615.00 ,$522.75 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$31.49 ,20.37% based on GA Medicaid OP CCR Rate,$347.48 ,56.5 percent of total billed charges,$347.48 ,56.5 percent of total billed charges,$347.48 ,56.5 percent of total billed charges,$347.48 ,56.5 percent of total billed charges,$21.22 ,Pays 102% Medicare OPPS,$553.50 ,90% of total billed charges,$32.75 ,125.18% of custom fee schedule,$422.51 ,68.7% of total billed charges,$492.00 ,80 percent of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,Pays 90% Medicare OPPS,$356.70 ,58% of total billed charges,$31.49 ,120.37% of custom fee schedule,$20.81 ,Pays 100% Medicare OPPS,$27.05 ,Pays 130% Medicare OPPS,$522.75 ,85% of total billed charges,$20.81 ,Pays 100% Medicare OPPS,$18.72 ,$553.50 ,$492.00 
Outpatient Medical Services,LAB,83520,3RD ANTI GBM (GLOMERULAR B),302,$485.00 ,$412.25 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$436.50 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$333.20 ,68.7% of total billed charges,$388.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$281.30 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$412.25 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$436.50 ,$388.00 
Outpatient Medical Services,LAB,86328,COVID-19 RAPID IgM  IgG,300,$195.00 ,$165.75 ,85% of total billed charges,$45.28 ,Pays 100% Medicare OPPS,$45.28 ,Pays 100% Medicare OPPS,$45.28 ,Pays 100% Medicare OPPS,$58.86 ,Pays 130% Medicare OPPS,$61.76 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$46.18 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$64.23 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$45.28 ,Pays 100% Medicare OPPS,$40.75 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$61.76 ,120.37% of custom fee schedule,$45.28 ,Pays 100% Medicare OPPS,$58.86 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$45.28 ,Pays 100% Medicare OPPS,$40.75 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,86331,".GEL DIFFUSION, EACH",302,$190.00 ,$161.50 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$12.21 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,86332,C1Q BINDING ASSAY,302,$525.00 ,$446.25 ,85% of total billed charges,$24.37 ,Pays 100% Medicare OPPS,$24.37 ,Pays 100% Medicare OPPS,$24.37 ,Pays 100% Medicare OPPS,$31.68 ,Pays 130% Medicare OPPS,$36.89 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$24.85 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$38.37 ,125.18% of custom fee schedule,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$24.37 ,Pays 100% Medicare OPPS,$21.93 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$36.89 ,120.37% of custom fee schedule,$24.37 ,Pays 100% Medicare OPPS,$31.68 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$24.37 ,Pays 100% Medicare OPPS,$21.93 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,84155,IMMUNOFIXATION SERUM,302,$375.00 ,$318.75 ,85% of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.67 ,Pays 100% Medicare OPPS,$3.67 ,Pays 100% Medicare OPPS,$4.77 ,Pays 130% Medicare OPPS,$5.55 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$3.74 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$5.77 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.30 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$5.55 ,120.37% of custom fee schedule,$3.67 ,Pays 100% Medicare OPPS,$4.77 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$3.67 ,Pays 100% Medicare OPPS,$3.30 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,86336,Blood test to monitor for cancer in the ovaries or testis,302,$240.00 ,$204.00 ,85% of total billed charges,$15.59 ,Pays 100% Medicare OPPS,$15.59 ,Pays 100% Medicare OPPS,$15.59 ,Pays 100% Medicare OPPS,$20.26 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$15.90 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$15.59 ,Pays 100% Medicare OPPS,$14.03 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$15.59 ,Pays 100% Medicare OPPS,$20.26 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$15.59 ,Pays 100% Medicare OPPS,$14.03 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,86337,3RD INSULIN ANTIBODIES,302,$415.00 ,$352.75 ,85% of total billed charges,$21.41 ,Pays 100% Medicare OPPS,$21.41 ,Pays 100% Medicare OPPS,$21.41 ,Pays 100% Medicare OPPS,$27.83 ,Pays 130% Medicare OPPS,$32.42 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$21.83 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$33.71 ,125.18% of custom fee schedule,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$21.41 ,Pays 100% Medicare OPPS,$19.26 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$32.42 ,120.37% of custom fee schedule,$21.41 ,Pays 100% Medicare OPPS,$27.83 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$21.41 ,Pays 100% Medicare OPPS,$19.26 ,$373.50 ,$332.00 
Outpatient Medical Services,LAB,86340,INTRINSIC FACTOR BLK AB,300,$265.00 ,$225.25 ,85% of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$15.08 ,Pays 100% Medicare OPPS,$15.08 ,Pays 100% Medicare OPPS,$19.60 ,Pays 130% Medicare OPPS,$22.81 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$15.38 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$23.72 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$13.57 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$22.81 ,120.37% of custom fee schedule,$15.08 ,Pays 100% Medicare OPPS,$19.60 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$15.08 ,Pays 100% Medicare OPPS,$13.57 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,86341,3RD ISLET CELL IgG AUTOAB,302,$375.00 ,$318.75 ,85% of total billed charges,$23.57 ,Pays 100% Medicare OPPS,$23.57 ,Pays 100% Medicare OPPS,$23.57 ,Pays 100% Medicare OPPS,$30.64 ,Pays 130% Medicare OPPS,$29.96 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$24.04 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$31.16 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$23.57 ,Pays 100% Medicare OPPS,$21.21 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$29.96 ,120.37% of custom fee schedule,$23.57 ,Pays 100% Medicare OPPS,$30.64 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$23.57 ,Pays 100% Medicare OPPS,$21.21 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,86341,3RD IA-2 ANTIBODY,301,"$1,075.00 ",$913.75 ,85% of total billed charges,$23.57 ,Pays 100% Medicare OPPS,$23.57 ,Pays 100% Medicare OPPS,$23.57 ,Pays 100% Medicare OPPS,$30.64 ,Pays 130% Medicare OPPS,$29.96 ,20.37% based on GA Medicaid OP CCR Rate,$607.38 ,56.5 percent of total billed charges,$607.38 ,56.5 percent of total billed charges,$607.38 ,56.5 percent of total billed charges,$607.38 ,56.5 percent of total billed charges,$24.04 ,Pays 102% Medicare OPPS,$967.50 ,90% of total billed charges,$31.16 ,125.18% of custom fee schedule,$738.53 ,68.7% of total billed charges,$860.00 ,80 percent of total billed charges,$23.57 ,Pays 100% Medicare OPPS,$21.21 ,Pays 90% Medicare OPPS,$623.50 ,58% of total billed charges,$29.96 ,120.37% of custom fee schedule,$23.57 ,Pays 100% Medicare OPPS,$30.64 ,Pays 130% Medicare OPPS,$913.75 ,85% of total billed charges,$23.57 ,Pays 100% Medicare OPPS,$21.21 ,$967.50 ,$860.00 
Outpatient Medical Services,LAB,86356,RITUXAN LEVEL,301,$375.00 ,$318.75 ,85% of total billed charges,$26.78 ,Pays 100% Medicare OPPS,$26.78 ,Pays 100% Medicare OPPS,$26.78 ,Pays 100% Medicare OPPS,$34.81 ,Pays 130% Medicare OPPS,$39.52 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$27.31 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$41.10 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$26.78 ,Pays 100% Medicare OPPS,$24.10 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$39.52 ,120.37% of custom fee schedule,$26.78 ,Pays 100% Medicare OPPS,$34.81 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$26.78 ,Pays 100% Medicare OPPS,$24.10 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,86359,CD3/C19,300,$320.00 ,$272.00 ,85% of total billed charges,$37.72 ,Pays 100% Medicare OPPS,$37.72 ,Pays 100% Medicare OPPS,$37.72 ,Pays 100% Medicare OPPS,$49.04 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$38.48 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$37.08 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$37.72 ,Pays 100% Medicare OPPS,$33.95 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$35.65 ,120.37% of custom fee schedule,$37.72 ,Pays 100% Medicare OPPS,$49.04 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$37.72 ,Pays 100% Medicare OPPS,$33.95 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,86360,"ABSOLUTE CD4,CD8&CD19",302,$485.00 ,$412.25 ,85% of total billed charges,$46.98 ,Pays 100% Medicare OPPS,$46.98 ,Pays 100% Medicare OPPS,$46.98 ,Pays 100% Medicare OPPS,$61.07 ,Pays 130% Medicare OPPS,$71.13 ,20.37% based on GA Medicaid OP CCR Rate,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$47.91 ,Pays 102% Medicare OPPS,$436.50 ,90% of total billed charges,$73.97 ,125.18% of custom fee schedule,$333.20 ,68.7% of total billed charges,$388.00 ,80 percent of total billed charges,$46.98 ,Pays 100% Medicare OPPS,$42.28 ,Pays 90% Medicare OPPS,$281.30 ,58% of total billed charges,$71.13 ,120.37% of custom fee schedule,$46.98 ,Pays 100% Medicare OPPS,$61.07 ,Pays 130% Medicare OPPS,$412.25 ,85% of total billed charges,$46.98 ,Pays 100% Medicare OPPS,$42.28 ,$436.50 ,$388.00 
Outpatient Medical Services,LAB,86361,CD4 COUNT,311,$485.00 ,$412.25 ,85% of total billed charges,$26.78 ,Pays 100% Medicare OPPS,$26.78 ,Pays 100% Medicare OPPS,$26.78 ,Pays 100% Medicare OPPS,$34.81 ,Pays 130% Medicare OPPS,$39.51 ,20.37% based on GA Medicaid OP CCR Rate,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$27.31 ,Pays 102% Medicare OPPS,$436.50 ,90% of total billed charges,$41.08 ,125.18% of custom fee schedule,$333.20 ,68.7% of total billed charges,$388.00 ,80 percent of total billed charges,$26.78 ,Pays 100% Medicare OPPS,$24.10 ,Pays 90% Medicare OPPS,$281.30 ,58% of total billed charges,$39.51 ,120.37% of custom fee schedule,$26.78 ,Pays 100% Medicare OPPS,$34.81 ,Pays 130% Medicare OPPS,$412.25 ,85% of total billed charges,$26.78 ,Pays 100% Medicare OPPS,$24.10 ,$436.50 ,$388.00 
Outpatient Medical Services,LAB,86376,ANTI LKM,302,$345.00 ,$293.25 ,85% of total billed charges,$14.55 ,Pays 100% Medicare OPPS,$14.55 ,Pays 100% Medicare OPPS,$14.55 ,Pays 100% Medicare OPPS,$18.91 ,Pays 130% Medicare OPPS,$22.03 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$14.84 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$22.91 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$14.55 ,Pays 100% Medicare OPPS,$13.09 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$22.03 ,120.37% of custom fee schedule,$14.55 ,Pays 100% Medicare OPPS,$18.91 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$14.55 ,Pays 100% Medicare OPPS,$13.09 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,86431,RA TEST,302,$190.00 ,$161.50 ,85% of total billed charges,$5.67 ,Pays 100% Medicare OPPS,$5.67 ,Pays 100% Medicare OPPS,$5.67 ,Pays 100% Medicare OPPS,$7.37 ,Pays 130% Medicare OPPS,$8.59 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$5.78 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$8.94 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$5.67 ,Pays 100% Medicare OPPS,$5.10 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$8.59 ,120.37% of custom fee schedule,$5.67 ,Pays 100% Medicare OPPS,$7.37 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$5.67 ,Pays 100% Medicare OPPS,$5.10 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,86430,3RD RA TEST BODY FLUID,302,$190.00 ,$161.50 ,85% of total billed charges,$6.14 ,Pays 100% Medicare OPPS,$6.14 ,Pays 100% Medicare OPPS,$6.14 ,Pays 100% Medicare OPPS,$7.98 ,Pays 130% Medicare OPPS,$8.59 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$6.26 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$8.94 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$6.14 ,Pays 100% Medicare OPPS,$5.52 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$8.59 ,120.37% of custom fee schedule,$6.14 ,Pays 100% Medicare OPPS,$7.98 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$6.14 ,Pays 100% Medicare OPPS,$5.52 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,86480,QUANTIFERON TB GOLD,301,$365.00 ,$310.25 ,85% of total billed charges,$61.98 ,Pays 100% Medicare OPPS,$61.98 ,Pays 100% Medicare OPPS,$61.98 ,Pays 100% Medicare OPPS,$80.57 ,Pays 130% Medicare OPPS,$93.80 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$63.21 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$97.55 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$61.98 ,Pays 100% Medicare OPPS,$55.78 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$93.80 ,120.37% of custom fee schedule,$61.98 ,Pays 100% Medicare OPPS,$80.57 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$61.98 ,Pays 100% Medicare OPPS,$55.78 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86592,Blood test to screen for syphilis,302,$145.00 ,$123.25 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$5.60 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.35 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$5.82 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.84 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$5.60 ,120.37% of custom fee schedule,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.84 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,86606,ASPERGILLUS ANTIBODY SCREEN,302,$210.00 ,$178.50 ,85% of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$15.05 ,Pays 100% Medicare OPPS,$15.05 ,Pays 100% Medicare OPPS,$19.56 ,Pays 130% Medicare OPPS,$22.79 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$15.35 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$23.70 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$13.54 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$22.79 ,120.37% of custom fee schedule,$15.05 ,Pays 100% Medicare OPPS,$19.56 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$15.05 ,Pays 100% Medicare OPPS,$13.54 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,86609,3RD STREP PNEUMOCOCCAL 14 PANEL,300,$590.00 ,$501.50 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$333.35 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$531.00 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$405.33 ,68.7% of total billed charges,$472.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$342.20 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$501.50 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$531.00 ,$472.00 
Outpatient Medical Services,LAB,86611,.BARTONELLA HENSELAE IgG,302,$370.00 ,$314.50 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$15.41 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$10.38 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$16.02 ,125.18% of custom fee schedule,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$15.41 ,120.37% of custom fee schedule,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,$333.00 ,$296.00 
Outpatient Medical Services,LAB,86612,BLASTOMYCES ANTIBODIES,302,$210.00 ,$178.50 ,85% of total billed charges,$12.90 ,Pays 100% Medicare OPPS,$12.90 ,Pays 100% Medicare OPPS,$12.90 ,Pays 100% Medicare OPPS,$16.77 ,Pays 130% Medicare OPPS,$19.54 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$13.15 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$20.32 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$12.90 ,Pays 100% Medicare OPPS,$11.61 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$19.54 ,120.37% of custom fee schedule,$12.90 ,Pays 100% Medicare OPPS,$16.77 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$12.90 ,Pays 100% Medicare OPPS,$11.61 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,83520,3RD BORDETELLA PERTUSSIN IGG &IGA ABS,301,$620.00 ,$527.00 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$19.60 ,20.37% based on GA Medicaid OP CCR Rate,$350.30 ,56.5 percent of total billed charges,$350.30 ,56.5 percent of total billed charges,$350.30 ,56.5 percent of total billed charges,$350.30 ,56.5 percent of total billed charges,$17.61 ,Pays 102% Medicare OPPS,$558.00 ,90% of total billed charges,$20.38 ,125.18% of custom fee schedule,$425.94 ,68.7% of total billed charges,$496.00 ,80 percent of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,Pays 90% Medicare OPPS,$359.60 ,58% of total billed charges,$19.60 ,120.37% of custom fee schedule,$17.27 ,Pays 100% Medicare OPPS,$22.45 ,Pays 130% Medicare OPPS,$527.00 ,85% of total billed charges,$17.27 ,Pays 100% Medicare OPPS,$15.54 ,$558.00 ,$496.00 
Outpatient Medical Services,LAB,86617,"LYME DISEASE IgG, IgM CSF",302,$540.00 ,$459.00 ,85% of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$15.49 ,Pays 100% Medicare OPPS,$15.49 ,Pays 100% Medicare OPPS,$20.13 ,Pays 130% Medicare OPPS,$23.45 ,20.37% based on GA Medicaid OP CCR Rate,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$15.79 ,Pays 102% Medicare OPPS,$486.00 ,90% of total billed charges,$24.39 ,125.18% of custom fee schedule,$370.98 ,68.7% of total billed charges,$432.00 ,80 percent of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$13.94 ,Pays 90% Medicare OPPS,$313.20 ,58% of total billed charges,$23.45 ,120.37% of custom fee schedule,$15.49 ,Pays 100% Medicare OPPS,$20.13 ,Pays 130% Medicare OPPS,$459.00 ,85% of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$13.94 ,$486.00 ,$432.00 
Outpatient Medical Services,LAB,86617,3RD LYME DISEASE,300,$260.00 ,$221.00 ,85% of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$15.49 ,Pays 100% Medicare OPPS,$15.49 ,Pays 100% Medicare OPPS,$20.13 ,Pays 130% Medicare OPPS,$23.45 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$15.79 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$24.39 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$13.94 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$23.45 ,120.37% of custom fee schedule,$15.49 ,Pays 100% Medicare OPPS,$20.13 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$15.49 ,Pays 100% Medicare OPPS,$13.94 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86622,BRUCELLA ABORTUS AB,302,$195.00 ,$165.75 ,85% of total billed charges,$8.93 ,Pays 100% Medicare OPPS,$8.93 ,Pays 100% Medicare OPPS,$8.93 ,Pays 100% Medicare OPPS,$11.60 ,Pays 130% Medicare OPPS,$13.52 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$9.10 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$14.06 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$8.93 ,Pays 100% Medicare OPPS,$8.03 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$13.52 ,120.37% of custom fee schedule,$8.93 ,Pays 100% Medicare OPPS,$11.60 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$8.93 ,Pays 100% Medicare OPPS,$8.03 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,86628,CANDIDA ANTIBODIES,300,$135.00 ,$114.75 ,85% of total billed charges,$12.01 ,Pays 100% Medicare OPPS,$12.01 ,Pays 100% Medicare OPPS,$12.01 ,Pays 100% Medicare OPPS,$15.61 ,Pays 130% Medicare OPPS,$18.18 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$12.25 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$18.90 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$12.01 ,Pays 100% Medicare OPPS,$10.80 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$18.18 ,120.37% of custom fee schedule,$12.01 ,Pays 100% Medicare OPPS,$15.61 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$12.01 ,Pays 100% Medicare OPPS,$10.80 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86635,COCCIDIOIDES ANTIBODIES,302,$210.00 ,$178.50 ,85% of total billed charges,$11.47 ,Pays 100% Medicare OPPS,$11.47 ,Pays 100% Medicare OPPS,$11.47 ,Pays 100% Medicare OPPS,$14.91 ,Pays 130% Medicare OPPS,$17.37 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$11.69 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$18.06 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$11.47 ,Pays 100% Medicare OPPS,$10.32 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$17.37 ,120.37% of custom fee schedule,$11.47 ,Pays 100% Medicare OPPS,$14.91 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$11.47 ,Pays 100% Medicare OPPS,$10.32 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,86638,COXIELLA BURNETII IGM ABS,302,$525.00 ,$446.25 ,85% of total billed charges,$12.12 ,Pays 100% Medicare OPPS,$12.12 ,Pays 100% Medicare OPPS,$12.12 ,Pays 100% Medicare OPPS,$15.75 ,Pays 130% Medicare OPPS,$18.36 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$12.36 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$19.09 ,125.18% of custom fee schedule,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$12.12 ,Pays 100% Medicare OPPS,$10.90 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$18.36 ,120.37% of custom fee schedule,$12.12 ,Pays 100% Medicare OPPS,$15.75 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$12.12 ,Pays 100% Medicare OPPS,$10.90 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,86641,CRYPTOCOCCUS AB,301,$85.00 ,$72.25 ,85% of total billed charges,$14.41 ,Pays 100% Medicare OPPS,$14.41 ,Pays 100% Medicare OPPS,$14.41 ,Pays 100% Medicare OPPS,$18.73 ,Pays 130% Medicare OPPS,$21.82 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$14.69 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$22.70 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$14.41 ,Pays 100% Medicare OPPS,$12.96 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$21.82 ,120.37% of custom fee schedule,$14.41 ,Pays 100% Medicare OPPS,$18.73 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$14.41 ,Pays 100% Medicare OPPS,$12.96 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,86644,Blood test to monitor for cytomegalovirus,302,$275.00 ,$233.75 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$17.61 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$14.67 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$18.31 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$17.61 ,120.37% of custom fee schedule,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,86648,DIPHTHERIA ANTIBODIES,302,$345.00 ,$293.25 ,85% of total billed charges,$15.21 ,Pays 100% Medicare OPPS,$15.21 ,Pays 100% Medicare OPPS,$15.21 ,Pays 100% Medicare OPPS,$19.77 ,Pays 130% Medicare OPPS,$23.03 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$15.51 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$23.95 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$15.21 ,Pays 100% Medicare OPPS,$13.68 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$23.03 ,120.37% of custom fee schedule,$15.21 ,Pays 100% Medicare OPPS,$19.77 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$15.21 ,Pays 100% Medicare OPPS,$13.68 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,86651,"ENCEPH,CALIFORNIA IgG",302,$170.00 ,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$19.97 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$13.45 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$20.77 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$19.97 ,120.37% of custom fee schedule,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86652,"ENCEPH,E.EQUINE IgG",302,$170.00 ,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$19.97 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$13.45 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$20.77 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$19.97 ,120.37% of custom fee schedule,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86653,"ENCEPH,ST. LOUIS IgG",302,$170.00 ,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$19.97 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$13.45 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$20.77 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$19.97 ,120.37% of custom fee schedule,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86654,WESTERN EQUINE IgG,302,$170.00 ,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$19.97 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$13.45 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$20.77 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$19.97 ,120.37% of custom fee schedule,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86658,.ENTEROVIRUS(COXSACKIE A),302,$135.00 ,$114.75 ,85% of total billed charges,$13.03 ,Pays 100% Medicare OPPS,$13.03 ,Pays 100% Medicare OPPS,$13.03 ,Pays 100% Medicare OPPS,$16.93 ,Pays 130% Medicare OPPS,$19.72 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$13.29 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$20.50 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$13.03 ,Pays 100% Medicare OPPS,$11.72 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$19.72 ,120.37% of custom fee schedule,$13.03 ,Pays 100% Medicare OPPS,$16.93 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$13.03 ,Pays 100% Medicare OPPS,$11.72 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86664,EBV NUCLEAR AG IGG,302,$100.00 ,$85.00 ,85% of total billed charges,$15.29 ,Pays 100% Medicare OPPS,$15.29 ,Pays 100% Medicare OPPS,$15.29 ,Pays 100% Medicare OPPS,$19.87 ,Pays 130% Medicare OPPS,$23.16 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$15.59 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$24.08 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$15.29 ,Pays 100% Medicare OPPS,$13.76 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$23.16 ,120.37% of custom fee schedule,$15.29 ,Pays 100% Medicare OPPS,$19.87 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$15.29 ,Pays 100% Medicare OPPS,$13.76 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,86663,EBV EARLY AG IGG(EB VIRUS),302,$145.00 ,$123.25 ,85% of total billed charges,$13.12 ,Pays 100% Medicare OPPS,$13.12 ,Pays 100% Medicare OPPS,$13.12 ,Pays 100% Medicare OPPS,$17.05 ,Pays 130% Medicare OPPS,$19.86 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$13.38 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$20.65 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$13.12 ,Pays 100% Medicare OPPS,$11.80 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$19.86 ,120.37% of custom fee schedule,$13.12 ,Pays 100% Medicare OPPS,$17.05 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$13.12 ,Pays 100% Medicare OPPS,$11.80 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,86664,.EBV (EB VIRUS),302,$175.00 ,$148.75 ,85% of total billed charges,$15.29 ,Pays 100% Medicare OPPS,$15.29 ,Pays 100% Medicare OPPS,$15.29 ,Pays 100% Medicare OPPS,$19.87 ,Pays 130% Medicare OPPS,$23.16 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$15.59 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$24.08 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$15.29 ,Pays 100% Medicare OPPS,$13.76 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$23.16 ,120.37% of custom fee schedule,$15.29 ,Pays 100% Medicare OPPS,$19.87 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$15.29 ,Pays 100% Medicare OPPS,$13.76 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,86665,Blood test to diagnose mononucleosis,302,$215.00 ,$182.75 ,85% of total billed charges,$18.14 ,Pays 100% Medicare OPPS,$18.14 ,Pays 100% Medicare OPPS,$18.14 ,Pays 100% Medicare OPPS,$23.58 ,Pays 130% Medicare OPPS,$27.47 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$18.50 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$28.57 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$18.14 ,Pays 100% Medicare OPPS,$16.32 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$27.47 ,120.37% of custom fee schedule,$18.14 ,Pays 100% Medicare OPPS,$23.58 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$18.14 ,Pays 100% Medicare OPPS,$16.32 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,86666,.EHRLICH.TIT IgG(CHAFF/EQU,302,$300.00 ,$255.00 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$15.41 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$10.38 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$16.02 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$15.41 ,120.37% of custom fee schedule,$10.18 ,Pays 100% Medicare OPPS,$13.23 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$10.18 ,Pays 100% Medicare OPPS,$9.16 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,87081,Medical test to find an infection,302,$135.00 ,$114.75 ,85% of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$6.63 ,Pays 100% Medicare OPPS,$6.63 ,Pays 100% Medicare OPPS,$8.61 ,Pays 130% Medicare OPPS,$10.03 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$6.76 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$10.43 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$5.96 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$10.03 ,120.37% of custom fee schedule,$6.63 ,Pays 100% Medicare OPPS,$8.61 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$5.96 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86671,SACCHAROMYCES CEREVIS IgA,300,$365.00 ,$310.25 ,85% of total billed charges,$12.25 ,Pays 100% Medicare OPPS,$12.25 ,Pays 100% Medicare OPPS,$12.25 ,Pays 100% Medicare OPPS,$15.92 ,Pays 130% Medicare OPPS,$18.56 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$12.49 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$19.30 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$12.25 ,Pays 100% Medicare OPPS,$11.02 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$18.56 ,120.37% of custom fee schedule,$12.25 ,Pays 100% Medicare OPPS,$15.92 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$12.25 ,Pays 100% Medicare OPPS,$11.02 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,87329,GIARDIA ANTIGEN STOOL,302,$135.00 ,$114.75 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$12.21 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86677,Blood test to if peptic ulcers are caused by a certain bacterium,302,$260.00 ,$221.00 ,85% of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$16.85 ,Pays 100% Medicare OPPS,$16.85 ,Pays 100% Medicare OPPS,$21.90 ,Pays 130% Medicare OPPS,$21.97 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$17.18 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$22.85 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$15.16 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$21.97 ,120.37% of custom fee schedule,$16.85 ,Pays 100% Medicare OPPS,$21.90 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$16.85 ,Pays 100% Medicare OPPS,$15.16 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86682,TOXOCARA TITER,302,$800.00 ,$680.00 ,85% of total billed charges,$13.01 ,Pays 100% Medicare OPPS,$13.01 ,Pays 100% Medicare OPPS,$13.01 ,Pays 100% Medicare OPPS,$16.91 ,Pays 130% Medicare OPPS,$19.68 ,20.37% based on GA Medicaid OP CCR Rate,$452.00 ,56.5 percent of total billed charges,$452.00 ,56.5 percent of total billed charges,$452.00 ,56.5 percent of total billed charges,$452.00 ,56.5 percent of total billed charges,$13.27 ,Pays 102% Medicare OPPS,$720.00 ,90% of total billed charges,$20.47 ,125.18% of custom fee schedule,$549.60 ,68.7% of total billed charges,$640.00 ,80 percent of total billed charges,$13.01 ,Pays 100% Medicare OPPS,$11.70 ,Pays 90% Medicare OPPS,$464.00 ,58% of total billed charges,$19.68 ,120.37% of custom fee schedule,$13.01 ,Pays 100% Medicare OPPS,$16.91 ,Pays 130% Medicare OPPS,$680.00 ,85% of total billed charges,$13.01 ,Pays 100% Medicare OPPS,$11.70 ,$720.00 ,$640.00 
Outpatient Medical Services,LAB,86684,H FLU b ANTIBODIES IgG,300,$345.00 ,$293.25 ,85% of total billed charges,$15.84 ,Pays 100% Medicare OPPS,$15.84 ,Pays 100% Medicare OPPS,$15.84 ,Pays 100% Medicare OPPS,$20.59 ,Pays 130% Medicare OPPS,$23.99 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$16.15 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$24.95 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$15.84 ,Pays 100% Medicare OPPS,$14.25 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$23.99 ,120.37% of custom fee schedule,$15.84 ,Pays 100% Medicare OPPS,$20.59 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$15.84 ,Pays 100% Medicare OPPS,$14.25 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,86689,HIV BY WESTERN BLOT,300,$135.00 ,$114.75 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$25.42 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$19.73 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$26.44 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$25.42 ,120.37% of custom fee schedule,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,87799,3RD HEPATITIS DELTA VIRSUS AB,302,"$1,120.00 ",$952.00 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$228.14 ,20.37% based on GA Medicaid OP CCR Rate,$632.80 ,56.5 percent of total billed charges,$632.80 ,56.5 percent of total billed charges,$632.80 ,56.5 percent of total billed charges,$632.80 ,56.5 percent of total billed charges,$43.69 ,Pays 102% Medicare OPPS,"$1,008.00 ",90% of total billed charges,$392.00 ,35% based on GA Medicaid OP CCR Rate,$769.44 ,68.7% of total billed charges,$896.00 ,80 percent of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,Pays 90% Medicare OPPS,$649.60 ,58% of total billed charges,$228.14 ,20.37% based on GA Medicaid OP CCR Rate,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$952.00 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,"$1,008.00 ",$896.00 
Outpatient Medical Services,LAB,86695,HERPES AB TYP I IgG,302,$195.00 ,$165.75 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$19.97 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$13.45 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$20.77 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$19.97 ,120.37% of custom fee schedule,$13.19 ,Pays 100% Medicare OPPS,$17.14 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$13.19 ,Pays 100% Medicare OPPS,$11.87 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,86696,HERPES AB TY II IgG,302,$195.00 ,$165.75 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$29.31 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$19.73 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$30.48 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$29.31 ,120.37% of custom fee schedule,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,$175.50 ,$156.00 
Outpatient Medical Services,LAB,86698,HISTOPLASMA ANTIBODIES,302,$210.00 ,$178.50 ,85% of total billed charges,$13.79 ,Pays 100% Medicare OPPS,$13.79 ,Pays 100% Medicare OPPS,$13.79 ,Pays 100% Medicare OPPS,$17.92 ,Pays 130% Medicare OPPS,$18.91 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$14.06 ,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$19.67 ,125.18% of custom fee schedule,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,$13.79 ,Pays 100% Medicare OPPS,$12.41 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$18.91 ,120.37% of custom fee schedule,$13.79 ,Pays 100% Medicare OPPS,$17.92 ,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,$13.79 ,Pays 100% Medicare OPPS,$12.41 ,$189.00 ,$168.00 
Outpatient Medical Services,LAB,86704,Blood test indicating infection with Hepatitis B,302,$240.00 ,$204.00 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$18.25 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$18.98 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$18.25 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,86705,HEP B CORE IgM AB,302,$110.00 ,$93.50 ,85% of total billed charges,$11.77 ,Pays 100% Medicare OPPS,$11.77 ,Pays 100% Medicare OPPS,$11.77 ,Pays 100% Medicare OPPS,$15.30 ,Pays 130% Medicare OPPS,$17.81 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$12.00 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$18.53 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$11.77 ,Pays 100% Medicare OPPS,$10.59 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$17.81 ,120.37% of custom fee schedule,$11.77 ,Pays 100% Medicare OPPS,$15.30 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$11.77 ,Pays 100% Medicare OPPS,$10.59 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,86706,HEP B SURFACE ANTIBODY,302,$240.00 ,$204.00 ,85% of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$10.74 ,Pays 100% Medicare OPPS,$10.74 ,Pays 100% Medicare OPPS,$13.96 ,Pays 130% Medicare OPPS,$16.26 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$10.95 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$16.91 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$9.66 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$16.26 ,120.37% of custom fee schedule,$10.74 ,Pays 100% Medicare OPPS,$13.96 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$10.74 ,Pays 100% Medicare OPPS,$9.66 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,86707,HEPATITIS BE ANTIBODY,302,$240.00 ,$204.00 ,85% of total billed charges,$11.57 ,Pays 100% Medicare OPPS,$11.57 ,Pays 100% Medicare OPPS,$11.57 ,Pays 100% Medicare OPPS,$15.04 ,Pays 130% Medicare OPPS,$17.50 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$11.80 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$18.20 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$11.57 ,Pays 100% Medicare OPPS,$10.41 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$17.50 ,120.37% of custom fee schedule,$11.57 ,Pays 100% Medicare OPPS,$15.04 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$11.57 ,Pays 100% Medicare OPPS,$10.41 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,86708,Blood test indicating infection with Hepatitis A,302,$365.00 ,$310.25 ,85% of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$12.39 ,Pays 100% Medicare OPPS,$12.39 ,Pays 100% Medicare OPPS,$16.10 ,Pays 130% Medicare OPPS,$18.75 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$12.63 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$19.50 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$11.15 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$18.75 ,120.37% of custom fee schedule,$12.39 ,Pays 100% Medicare OPPS,$16.10 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$11.15 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86709,HEP A IgM AB,302,$100.00 ,$85.00 ,85% of total billed charges,$11.26 ,Pays 100% Medicare OPPS,$11.26 ,Pays 100% Medicare OPPS,$11.26 ,Pays 100% Medicare OPPS,$14.63 ,Pays 130% Medicare OPPS,$17.04 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$11.48 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$17.73 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$11.26 ,Pays 100% Medicare OPPS,$10.13 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$17.04 ,120.37% of custom fee schedule,$11.26 ,Pays 100% Medicare OPPS,$14.63 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$11.26 ,Pays 100% Medicare OPPS,$10.13 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,86710,INFLUENZA A VIRUS AB,302,$345.00 ,$293.25 ,85% of total billed charges,$13.55 ,Pays 100% Medicare OPPS,$13.55 ,Pays 100% Medicare OPPS,$13.55 ,Pays 100% Medicare OPPS,$17.61 ,Pays 130% Medicare OPPS,$20.52 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$13.82 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$21.34 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$13.55 ,Pays 100% Medicare OPPS,$12.19 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$20.52 ,120.37% of custom fee schedule,$13.55 ,Pays 100% Medicare OPPS,$17.61 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$13.55 ,Pays 100% Medicare OPPS,$12.19 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,86713,LEGIONELLA ANTIBODIES IgG,302,$510.00 ,$433.50 ,85% of total billed charges,$15.30 ,Pays 100% Medicare OPPS,$15.30 ,Pays 100% Medicare OPPS,$15.30 ,Pays 100% Medicare OPPS,$19.89 ,Pays 130% Medicare OPPS,$23.17 ,20.37% based on GA Medicaid OP CCR Rate,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$15.60 ,Pays 102% Medicare OPPS,$459.00 ,90% of total billed charges,$24.10 ,125.18% of custom fee schedule,$350.37 ,68.7% of total billed charges,$408.00 ,80 percent of total billed charges,$15.30 ,Pays 100% Medicare OPPS,$13.77 ,Pays 90% Medicare OPPS,$295.80 ,58% of total billed charges,$23.17 ,120.37% of custom fee schedule,$15.30 ,Pays 100% Medicare OPPS,$19.89 ,Pays 130% Medicare OPPS,$433.50 ,85% of total billed charges,$15.30 ,Pays 100% Medicare OPPS,$13.77 ,$459.00 ,$408.00 
Outpatient Medical Services,LAB,87798,LEPTOSPIRA URINE PCR,302,$300.00 ,$255.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$29.70 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$30.88 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$29.70 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$29.70 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,86735,MUMPS VIRUS IGG AB,302,$365.00 ,$310.25 ,85% of total billed charges,$13.05 ,Pays 100% Medicare OPPS,$13.05 ,Pays 100% Medicare OPPS,$13.05 ,Pays 100% Medicare OPPS,$16.96 ,Pays 130% Medicare OPPS,$19.75 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$13.31 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$20.54 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$13.05 ,Pays 100% Medicare OPPS,$11.74 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$19.75 ,120.37% of custom fee schedule,$13.05 ,Pays 100% Medicare OPPS,$16.96 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$13.05 ,Pays 100% Medicare OPPS,$11.74 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86738,MYCOPLASMA PNEUMONIAE/IgG,302,$240.00 ,$204.00 ,85% of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$13.24 ,Pays 100% Medicare OPPS,$13.24 ,Pays 100% Medicare OPPS,$17.21 ,Pays 130% Medicare OPPS,$20.05 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$13.50 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$20.85 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$11.91 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$20.05 ,120.37% of custom fee schedule,$13.24 ,Pays 100% Medicare OPPS,$17.21 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$11.91 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,86744,NOCARDIA ANTIBODY,302,$265.00 ,$225.25 ,85% of total billed charges,$15.99 ,Pays 100% Medicare OPPS,$15.99 ,Pays 100% Medicare OPPS,$15.99 ,Pays 100% Medicare OPPS,$20.78 ,Pays 130% Medicare OPPS,$19.97 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$16.30 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$20.77 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$15.99 ,Pays 100% Medicare OPPS,$14.39 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$19.97 ,120.37% of custom fee schedule,$15.99 ,Pays 100% Medicare OPPS,$20.78 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$15.99 ,Pays 100% Medicare OPPS,$14.39 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,86747,PARVOVIRUS B19 IGG & IGM ABS,302,$240.00 ,$204.00 ,85% of total billed charges,$15.03 ,Pays 100% Medicare OPPS,$15.03 ,Pays 100% Medicare OPPS,$15.03 ,Pays 100% Medicare OPPS,$19.53 ,Pays 130% Medicare OPPS,$22.75 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$15.33 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$23.66 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$15.03 ,Pays 100% Medicare OPPS,$13.52 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$22.75 ,120.37% of custom fee schedule,$15.03 ,Pays 100% Medicare OPPS,$19.53 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$15.03 ,Pays 100% Medicare OPPS,$13.52 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,86753,AMOEBIC ANTIBODIES,302,$300.00 ,$255.00 ,85% of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$12.39 ,Pays 100% Medicare OPPS,$12.39 ,Pays 100% Medicare OPPS,$16.10 ,Pays 130% Medicare OPPS,$18.77 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$12.63 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$19.52 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$11.15 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$18.77 ,120.37% of custom fee schedule,$12.39 ,Pays 100% Medicare OPPS,$16.10 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$11.15 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,86756,RSV ANTIBODY IgG,302,$170.00 ,$144.50 ,85% of total billed charges,$15.89 ,Pays 100% Medicare OPPS,$15.89 ,Pays 100% Medicare OPPS,$15.89 ,Pays 100% Medicare OPPS,$20.65 ,Pays 130% Medicare OPPS,$19.51 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$16.20 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$20.29 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$15.89 ,Pays 100% Medicare OPPS,$14.30 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$19.51 ,120.37% of custom fee schedule,$15.89 ,Pays 100% Medicare OPPS,$20.65 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$15.89 ,Pays 100% Medicare OPPS,$14.30 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86757,RICKETTSIA IgG,302,$170.00 ,$144.50 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$29.31 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$19.73 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$30.48 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$29.31 ,120.37% of custom fee schedule,$19.35 ,Pays 100% Medicare OPPS,$25.15 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$19.35 ,Pays 100% Medicare OPPS,$17.41 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,86765,Blood test to determine if antibodies exist for measles,302,$260.00 ,$221.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86774,3RD TETANUS ANTIBODIES,302,$320.00 ,$272.00 ,85% of total billed charges,$14.80 ,Pays 100% Medicare OPPS,$14.80 ,Pays 100% Medicare OPPS,$14.80 ,Pays 100% Medicare OPPS,$19.24 ,Pays 130% Medicare OPPS,$22.40 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$15.09 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$23.30 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$14.80 ,Pays 100% Medicare OPPS,$13.32 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$22.40 ,120.37% of custom fee schedule,$14.80 ,Pays 100% Medicare OPPS,$19.24 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$14.80 ,Pays 100% Medicare OPPS,$13.32 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,86777,3RD TOXOPLASMOSIS IgG,302,$260.00 ,$221.00 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$17.61 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$14.67 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$18.31 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$17.61 ,120.37% of custom fee schedule,$14.39 ,Pays 100% Medicare OPPS,$18.70 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$14.39 ,Pays 100% Medicare OPPS,$12.95 ,$234.00 ,$208.00 
Outpatient Medical Services,LAB,86778,3RD TOXOPLASMOSIS IgM,302,$345.00 ,$293.25 ,85% of total billed charges,$14.41 ,Pays 100% Medicare OPPS,$14.41 ,Pays 100% Medicare OPPS,$14.41 ,Pays 100% Medicare OPPS,$18.73 ,Pays 130% Medicare OPPS,$21.80 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$14.69 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$22.67 ,125.18% of custom fee schedule,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$14.41 ,Pays 100% Medicare OPPS,$12.96 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$21.80 ,120.37% of custom fee schedule,$14.41 ,Pays 100% Medicare OPPS,$18.73 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$14.41 ,Pays 100% Medicare OPPS,$12.96 ,$310.50 ,$276.00 
Outpatient Medical Services,LAB,86780,Blood test to determine existence of certain bacterium that causes syphilis,302,$215.00 ,$182.75 ,85% of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$13.24 ,Pays 100% Medicare OPPS,$13.24 ,Pays 100% Medicare OPPS,$17.21 ,Pays 130% Medicare OPPS,$43.80 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$13.50 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$75.25 ,35% based on GA Medicaid OP CCR Rate,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$11.91 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$43.80 ,20.37% based on GA Medicaid OP CCR Rate,$13.24 ,Pays 100% Medicare OPPS,$17.21 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$13.24 ,Pays 100% Medicare OPPS,$11.91 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,86787,VARICELLA IgG,302,$275.00 ,$233.75 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,86790,DENGUE VIRUS IgG ANTIBODY,300,$450.00 ,$382.50 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$19.50 ,20.37% based on GA Medicaid OP CCR Rate,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$13.13 ,Pays 102% Medicare OPPS,$405.00 ,90% of total billed charges,$20.28 ,125.18% of custom fee schedule,$309.15 ,68.7% of total billed charges,$360.00 ,80 percent of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,Pays 90% Medicare OPPS,$261.00 ,58% of total billed charges,$19.50 ,120.37% of custom fee schedule,$12.88 ,Pays 100% Medicare OPPS,$16.74 ,Pays 130% Medicare OPPS,$382.50 ,85% of total billed charges,$12.88 ,Pays 100% Medicare OPPS,$11.59 ,$405.00 ,$360.00 
Outpatient Medical Services,LAB,86800,THYROGLOBULIN AB,302,$215.00 ,$182.75 ,85% of total billed charges,$15.91 ,Pays 100% Medicare OPPS,$15.91 ,Pays 100% Medicare OPPS,$15.91 ,Pays 100% Medicare OPPS,$20.68 ,Pays 130% Medicare OPPS,$24.07 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$16.22 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$25.04 ,125.18% of custom fee schedule,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$15.91 ,Pays 100% Medicare OPPS,$14.31 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$24.07 ,120.37% of custom fee schedule,$15.91 ,Pays 100% Medicare OPPS,$20.68 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$15.91 ,Pays 100% Medicare OPPS,$14.31 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,86803,Blood test to determine infection with Hepatitis C,302,$275.00 ,$233.75 ,85% of total billed charges,$14.27 ,Pays 100% Medicare OPPS,$14.27 ,Pays 100% Medicare OPPS,$14.27 ,Pays 100% Medicare OPPS,$18.55 ,Pays 130% Medicare OPPS,$12.04 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$14.55 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$12.52 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$14.27 ,Pays 100% Medicare OPPS,$12.84 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$12.04 ,120.37% of custom fee schedule,$14.27 ,Pays 100% Medicare OPPS,$18.55 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$14.27 ,Pays 100% Medicare OPPS,$12.04 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,87522,3RD HEPATITIS C BY RNA,302,$365.00 ,$310.25 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$64.84 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$43.69 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$67.43 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$64.84 ,120.37% of custom fee schedule,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,86812,HLA B-27 ANTIGEN,302,$420.00 ,$357.00 ,85% of total billed charges,$25.81 ,Pays 100% Medicare OPPS,$25.81 ,Pays 100% Medicare OPPS,$25.81 ,Pays 100% Medicare OPPS,$33.55 ,Pays 130% Medicare OPPS,$39.06 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$26.32 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$40.62 ,125.18% of custom fee schedule,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$25.81 ,Pays 100% Medicare OPPS,$23.22 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$39.06 ,120.37% of custom fee schedule,$25.81 ,Pays 100% Medicare OPPS,$33.55 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$25.81 ,Pays 100% Medicare OPPS,$23.22 ,$378.00 ,$336.00 
Outpatient Medical Services,LAB,86850,Blood test to screen for antibodies that could harm red blood cells,300,$220.00 ,$187.00 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$18.33 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$45.53 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$19.06 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$18.33 ,120.37% of custom fee schedule,$44.10 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$18.33 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,86860,RC ANTIBODY ELUTION REF LAB,300,$195.00 ,$165.75 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$7.37 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$136.65 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$7.66 ,125.18% of custom fee schedule,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$120.57 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$7.37 ,120.37% of custom fee schedule,$138.31 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$7.37 ,$179.80 ,$156.00 
Outpatient Medical Services,LAB,86870,RC ANTIBODY/EACH PANEL & MEDIA,300,$165.00 ,$140.25 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$7.37 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$266.86 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$7.66 ,125.18% of custom fee schedule,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$235.46 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$7.37 ,120.37% of custom fee schedule,$285.08 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$7.37 ,$370.60 ,$132.00 
Outpatient Medical Services,LAB,86880,"COOMBS, DIRECT (CRD)",300,$175.00 ,$148.75 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$8.12 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$51.00 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$8.45 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$8.12 ,120.37% of custom fee schedule,$50.55 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$8.12 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,86885,RC AB ID/EACH SELECTED REAGENT CELL,300,$40.00 ,$34.00 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$8.65 ,20.37% based on GA Medicaid OP CCR Rate,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$136.65 ,Pays 102% Medicare OPPS,$36.00 ,90% of total billed charges,$9.00 ,125.18% of custom fee schedule,$27.48 ,68.7% of total billed charges,$32.00 ,80 percent of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$120.57 ,Pays 90% Medicare OPPS,$23.20 ,58% of total billed charges,$8.65 ,120.37% of custom fee schedule,$138.31 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$34.00 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$8.65 ,$179.80 ,$32.00 
Outpatient Medical Services,LAB,86886,INDIRECT COOMBS,300,$220.00 ,$187.00 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$7.04 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$136.65 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$7.32 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$120.57 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$7.04 ,120.37% of custom fee schedule,$138.31 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$7.04 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,86900,"BB BLOOD TYPE, ABO",300,$60.00 ,$51.00 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$4.51 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$4.69 ,125.18% of custom fee schedule,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$4.51 ,120.37% of custom fee schedule,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$4.51 ,$132.76 ,$48.00 
Outpatient Medical Services,LAB,86901,BB RH BLOOD TYPE,300,$85.00 ,$72.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$17.47 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$31.01 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$18.16 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$17.47 ,120.37% of custom fee schedule,$29.87 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$17.47 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,86902,BLOOD TYPE ANTIGEN DONOR,300,$725.00 ,$616.25 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$5.18 ,20.37% based on GA Medicaid OP CCR Rate,$409.63 ,56.5 percent of total billed charges,$409.63 ,56.5 percent of total billed charges,$409.63 ,56.5 percent of total billed charges,$409.63 ,56.5 percent of total billed charges,$266.86 ,Pays 102% Medicare OPPS,$652.50 ,90% of total billed charges,$5.38 ,125.18% of custom fee schedule,$498.08 ,68.7% of total billed charges,$580.00 ,80 percent of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$235.46 ,Pays 90% Medicare OPPS,$420.50 ,58% of total billed charges,$5.18 ,120.37% of custom fee schedule,$285.08 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$616.25 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$5.18 ,$652.50 ,$580.00 
Outpatient Medical Services,LAB,86904,RC AG SCREEN WITH PT SERUM PER UNIT,300,$110.00 ,$93.50 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$14.38 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$31.01 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$14.96 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$14.38 ,120.37% of custom fee schedule,$29.87 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$14.38 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,86905,RC RBC ANTIGENS OTHER THAN ABO/RH(D) (RC,300,$70.00 ,$59.50 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$5.79 ,20.37% based on GA Medicaid OP CCR Rate,$39.55 ,56.5 percent of total billed charges,$39.55 ,56.5 percent of total billed charges,$39.55 ,56.5 percent of total billed charges,$39.55 ,56.5 percent of total billed charges,$266.86 ,Pays 102% Medicare OPPS,$63.00 ,90% of total billed charges,$6.02 ,125.18% of custom fee schedule,$48.09 ,68.7% of total billed charges,$56.00 ,80 percent of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$235.46 ,Pays 90% Medicare OPPS,$40.60 ,58% of total billed charges,$5.79 ,120.37% of custom fee schedule,$285.08 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$59.50 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$5.79 ,$370.60 ,$56.00 
Outpatient Medical Services,LAB,86906,RC RH PHENOTYPING COMPLETE,300,$150.00 ,$127.50 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$11.74 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$31.01 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$12.21 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$11.74 ,120.37% of custom fee schedule,$29.87 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$11.74 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,86920,.IMMEDIATE SPIN (X-M),300,$265.00 ,$225.25 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$53.98 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$136.65 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$92.75 ,35% based on GA Medicaid OP CCR Rate,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$120.57 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$53.98 ,20.37% based on GA Medicaid OP CCR Rate,$138.31 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$53.98 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,86921,.INCUBATION (X-M),300,$215.00 ,$182.75 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$43.80 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$136.65 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$75.25 ,35% based on GA Medicaid OP CCR Rate,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$120.57 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$43.80 ,20.37% based on GA Medicaid OP CCR Rate,$138.31 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$43.80 ,$193.50 ,$172.00 
Outpatient Medical Services,LAB,86922,.ANTIGLOBULIN (X-M),300,$150.00 ,$127.50 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$30.56 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$136.65 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$52.50 ,35% based on GA Medicaid OP CCR Rate,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$120.57 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$30.56 ,20.37% based on GA Medicaid OP CCR Rate,$138.31 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$30.56 ,$179.80 ,$120.00 
Outpatient Medical Services,LAB,86941,.DONATH-LANDSTEINER Ab,300,$375.00 ,$318.75 ,85% of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$12.11 ,Pays 100% Medicare OPPS,$12.11 ,Pays 100% Medicare OPPS,$15.74 ,Pays 130% Medicare OPPS,$18.33 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$12.35 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$19.06 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$10.89 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$18.33 ,120.37% of custom fee schedule,$12.11 ,Pays 100% Medicare OPPS,$15.74 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$12.11 ,Pays 100% Medicare OPPS,$10.89 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,86970,"RC PRETREATMENT OF RBC,INCUBATION",300,$160.00 ,$136.00 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$32.59 ,20.37% based on GA Medicaid OP CCR Rate,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$90.40 ,56.5 percent of total billed charges,$31.01 ,Pays 102% Medicare OPPS,$144.00 ,90% of total billed charges,$56.00 ,35% based on GA Medicaid OP CCR Rate,$109.92 ,68.7% of total billed charges,$128.00 ,80 percent of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,Pays 90% Medicare OPPS,$92.80 ,58% of total billed charges,$32.59 ,20.37% based on GA Medicaid OP CCR Rate,$29.87 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$136.00 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,$144.00 ,$128.00 
Outpatient Medical Services,LAB,86971,RC PRETREATMENT W/ENZYMES PER CELL (RC),300,$40.00 ,$34.00 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$266.86 ,Pays 102% Medicare OPPS,$36.00 ,90% of total billed charges,$14.00 ,35% based on GA Medicaid OP CCR Rate,$27.48 ,68.7% of total billed charges,$32.00 ,80 percent of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$235.46 ,Pays 90% Medicare OPPS,$23.20 ,58% of total billed charges,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,$285.08 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$34.00 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$8.15 ,$370.60 ,$32.00 
Outpatient Medical Services,LAB,86972,.DENSITY GRADIENT SEPARATION,300,$835.00 ,$709.75 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$170.09 ,20.37% based on GA Medicaid OP CCR Rate,$471.78 ,56.5 percent of total billed charges,$471.78 ,56.5 percent of total billed charges,$471.78 ,56.5 percent of total billed charges,$471.78 ,56.5 percent of total billed charges,$136.65 ,Pays 102% Medicare OPPS,$751.50 ,90% of total billed charges,$292.25 ,35% based on GA Medicaid OP CCR Rate,$573.65 ,68.7% of total billed charges,$668.00 ,80 percent of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$120.57 ,Pays 90% Medicare OPPS,$484.30 ,58% of total billed charges,$170.09 ,20.37% based on GA Medicaid OP CCR Rate,$138.31 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$709.75 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$120.57 ,$751.50 ,$668.00 
Outpatient Medical Services,LAB,86978,RC DIFFERENTIAL/AUTO ADS OF SERUM,300,$125.00 ,$106.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$25.46 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$31.01 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$43.75 ,35% based on GA Medicaid OP CCR Rate,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$25.46 ,20.37% based on GA Medicaid OP CCR Rate,$29.87 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$25.46 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,87015,.AFB CULTURE (AFB S&C),306,$240.00 ,$204.00 ,85% of total billed charges,$6.68 ,Pays 100% Medicare OPPS,$6.68 ,Pays 100% Medicare OPPS,$6.68 ,Pays 100% Medicare OPPS,$8.68 ,Pays 130% Medicare OPPS,$10.11 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$6.81 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$10.52 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$6.68 ,Pays 100% Medicare OPPS,$6.01 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$10.11 ,120.37% of custom fee schedule,$6.68 ,Pays 100% Medicare OPPS,$8.68 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$6.68 ,Pays 100% Medicare OPPS,$6.01 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,87040,Blood test to screen for bacteria in the blood,306,$300.00 ,$255.00 ,85% of total billed charges,$10.32 ,Pays 100% Medicare OPPS,$10.32 ,Pays 100% Medicare OPPS,$10.32 ,Pays 100% Medicare OPPS,$13.41 ,Pays 130% Medicare OPPS,$15.62 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$10.52 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$16.25 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$10.32 ,Pays 100% Medicare OPPS,$9.28 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$15.62 ,120.37% of custom fee schedule,$10.32 ,Pays 100% Medicare OPPS,$13.41 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$10.32 ,Pays 100% Medicare OPPS,$9.28 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,87046,Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,306,$135.00 ,$114.75 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$3.57 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$9.62 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$3.72 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$8.49 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$3.57 ,120.37% of custom fee schedule,$9.44 ,Pays 100% Medicare OPPS,$12.27 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$9.44 ,Pays 100% Medicare OPPS,$3.57 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,87070,Test of body fluid other than blood to assess for bacteria,300,$310.00 ,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$13.04 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$8.79 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$13.56 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$13.04 ,120.37% of custom fee schedule,$8.61 ,Pays 100% Medicare OPPS,$11.20 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$8.61 ,Pays 100% Medicare OPPS,$7.75 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,87075,CULTURE ANAEROBIC,306,$310.00 ,$263.50 ,85% of total billed charges,$9.47 ,Pays 100% Medicare OPPS,$9.47 ,Pays 100% Medicare OPPS,$9.47 ,Pays 100% Medicare OPPS,$12.31 ,Pays 130% Medicare OPPS,$14.32 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$9.65 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$14.90 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$9.47 ,Pays 100% Medicare OPPS,$8.52 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$14.32 ,120.37% of custom fee schedule,$9.47 ,Pays 100% Medicare OPPS,$12.31 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$9.47 ,Pays 100% Medicare OPPS,$8.52 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,87076,ANAEROBIC IDENTIFICATION,306,$65.00 ,$55.25 ,85% of total billed charges,$8.08 ,Pays 100% Medicare OPPS,$8.08 ,Pays 100% Medicare OPPS,$8.08 ,Pays 100% Medicare OPPS,$10.50 ,Pays 130% Medicare OPPS,$12.23 ,20.37% based on GA Medicaid OP CCR Rate,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$36.73 ,56.5 percent of total billed charges,$8.24 ,Pays 102% Medicare OPPS,$58.50 ,90% of total billed charges,$12.72 ,125.18% of custom fee schedule,$44.66 ,68.7% of total billed charges,$52.00 ,80 percent of total billed charges,$8.08 ,Pays 100% Medicare OPPS,$7.27 ,Pays 90% Medicare OPPS,$37.70 ,58% of total billed charges,$12.23 ,120.37% of custom fee schedule,$8.08 ,Pays 100% Medicare OPPS,$10.50 ,Pays 130% Medicare OPPS,$55.25 ,85% of total billed charges,$8.08 ,Pays 100% Medicare OPPS,$7.27 ,$58.50 ,$52.00 
Outpatient Medical Services,LAB,87339,CLOTEST,306,$240.00 ,$204.00 ,85% of total billed charges,$16.00 ,Pays 100% Medicare OPPS,$16.00 ,Pays 100% Medicare OPPS,$16.00 ,Pays 100% Medicare OPPS,$20.80 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$16.32 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$16.00 ,Pays 100% Medicare OPPS,$14.40 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$16.00 ,Pays 100% Medicare OPPS,$20.80 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$16.00 ,Pays 100% Medicare OPPS,$14.40 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,87081,Medical test to find an infection,306,$220.00 ,$187.00 ,85% of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$6.63 ,Pays 100% Medicare OPPS,$6.63 ,Pays 100% Medicare OPPS,$8.61 ,Pays 130% Medicare OPPS,$10.03 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$6.76 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$10.43 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$5.96 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$10.03 ,120.37% of custom fee schedule,$6.63 ,Pays 100% Medicare OPPS,$8.61 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$6.63 ,Pays 100% Medicare OPPS,$5.96 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,87086,Culture of the urine to determine number of bacteria,306,$220.00 ,$187.00 ,85% of total billed charges,$8.07 ,Pays 100% Medicare OPPS,$8.07 ,Pays 100% Medicare OPPS,$8.07 ,Pays 100% Medicare OPPS,$10.49 ,Pays 130% Medicare OPPS,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$8.23 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$12.71 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$8.07 ,Pays 100% Medicare OPPS,$7.26 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$12.22 ,120.37% of custom fee schedule,$8.07 ,Pays 100% Medicare OPPS,$10.49 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$8.07 ,Pays 100% Medicare OPPS,$7.26 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,87088,Culture of the urine to determine bacterial infection,306,$275.00 ,$233.75 ,85% of total billed charges,$8.09 ,Pays 100% Medicare OPPS,$8.09 ,Pays 100% Medicare OPPS,$8.09 ,Pays 100% Medicare OPPS,$10.51 ,Pays 130% Medicare OPPS,$12.25 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$8.25 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$12.74 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$8.09 ,Pays 100% Medicare OPPS,$7.28 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$12.25 ,120.37% of custom fee schedule,$8.09 ,Pays 100% Medicare OPPS,$10.51 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$8.09 ,Pays 100% Medicare OPPS,$7.28 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,87101,A procedure used to determine if fungi are present in an area of the body,306,$310.00 ,$263.50 ,85% of total billed charges,$7.71 ,Pays 100% Medicare OPPS,$7.71 ,Pays 100% Medicare OPPS,$7.71 ,Pays 100% Medicare OPPS,$10.02 ,Pays 130% Medicare OPPS,$11.66 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$7.86 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$12.13 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$7.71 ,Pays 100% Medicare OPPS,$6.93 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$11.66 ,120.37% of custom fee schedule,$7.71 ,Pays 100% Medicare OPPS,$10.02 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$7.71 ,Pays 100% Medicare OPPS,$6.93 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,87102,CULTURE FUNGUS/OTHER,306,$310.00 ,$263.50 ,85% of total billed charges,$8.41 ,Pays 100% Medicare OPPS,$8.41 ,Pays 100% Medicare OPPS,$8.41 ,Pays 100% Medicare OPPS,$10.93 ,Pays 130% Medicare OPPS,$12.72 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$8.57 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$13.23 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$8.41 ,Pays 100% Medicare OPPS,$7.56 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$12.72 ,120.37% of custom fee schedule,$8.41 ,Pays 100% Medicare OPPS,$10.93 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$8.41 ,Pays 100% Medicare OPPS,$7.56 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,87103,.CULTURE FUNGUS/BLOOD,306,$310.00 ,$263.50 ,85% of total billed charges,$20.46 ,Pays 100% Medicare OPPS,$20.46 ,Pays 100% Medicare OPPS,$20.46 ,Pays 100% Medicare OPPS,$26.59 ,Pays 130% Medicare OPPS,$13.65 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$20.86 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$14.20 ,125.18% of custom fee schedule,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$20.46 ,Pays 100% Medicare OPPS,$18.41 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$13.65 ,120.37% of custom fee schedule,$20.46 ,Pays 100% Medicare OPPS,$26.59 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$20.46 ,Pays 100% Medicare OPPS,$13.65 ,$279.00 ,$248.00 
Outpatient Medical Services,LAB,87116,.CULTURE MYCOBACTERIA,306,$240.00 ,$204.00 ,85% of total billed charges,$10.80 ,Pays 100% Medicare OPPS,$10.80 ,Pays 100% Medicare OPPS,$10.80 ,Pays 100% Medicare OPPS,$14.04 ,Pays 130% Medicare OPPS,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$11.01 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$84.00 ,35% based on GA Medicaid OP CCR Rate,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$10.80 ,Pays 100% Medicare OPPS,$9.72 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$10.80 ,Pays 100% Medicare OPPS,$14.04 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$10.80 ,Pays 100% Medicare OPPS,$9.72 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,87158,GROUP B STREP ID,306,$50.00 ,$42.50 ,85% of total billed charges,$7.74 ,Pays 100% Medicare OPPS,$7.74 ,Pays 100% Medicare OPPS,$7.74 ,Pays 100% Medicare OPPS,$10.06 ,Pays 130% Medicare OPPS,$7.92 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$7.89 ,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$8.24 ,125.18% of custom fee schedule,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,$7.74 ,Pays 100% Medicare OPPS,$6.96 ,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$7.92 ,120.37% of custom fee schedule,$7.74 ,Pays 100% Medicare OPPS,$10.06 ,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,$7.74 ,Pays 100% Medicare OPPS,$6.96 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,87172,PIN WORM PREP,306,$135.00 ,$114.75 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$6.45 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.35 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$6.71 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.84 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$6.45 ,120.37% of custom fee schedule,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.84 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,87186,A test used to determine which medications work on bacteria for fungi,306,$125.00 ,$106.25 ,85% of total billed charges,$8.65 ,Pays 100% Medicare OPPS,$8.65 ,Pays 100% Medicare OPPS,$8.65 ,Pays 100% Medicare OPPS,$11.24 ,Pays 130% Medicare OPPS,$13.08 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$8.82 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$13.61 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$8.65 ,Pays 100% Medicare OPPS,$7.78 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$13.08 ,120.37% of custom fee schedule,$8.65 ,Pays 100% Medicare OPPS,$11.24 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$8.65 ,Pays 100% Medicare OPPS,$7.78 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,87186,A test used to determine which medications work on bacteria for fungi,306,$190.00 ,$161.50 ,85% of total billed charges,$8.65 ,Pays 100% Medicare OPPS,$8.65 ,Pays 100% Medicare OPPS,$8.65 ,Pays 100% Medicare OPPS,$11.24 ,Pays 130% Medicare OPPS,$13.08 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$8.82 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$13.61 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$8.65 ,Pays 100% Medicare OPPS,$7.78 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$13.08 ,120.37% of custom fee schedule,$8.65 ,Pays 100% Medicare OPPS,$11.24 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$8.65 ,Pays 100% Medicare OPPS,$7.78 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,87205,A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,306,$145.00 ,$123.25 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$3.55 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$4.35 ,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$3.69 ,125.18% of custom fee schedule,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.84 ,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$3.55 ,120.37% of custom fee schedule,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.55 ,$130.50 ,$116.00 
Outpatient Medical Services,LAB,87206,.AFB SMEAR (AFB S&C),306,$135.00 ,$114.75 ,85% of total billed charges,$5.39 ,Pays 100% Medicare OPPS,$5.39 ,Pays 100% Medicare OPPS,$5.39 ,Pays 100% Medicare OPPS,$7.00 ,Pays 130% Medicare OPPS,$8.12 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.49 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$8.45 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.39 ,Pays 100% Medicare OPPS,$4.85 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$8.12 ,120.37% of custom fee schedule,$5.39 ,Pays 100% Medicare OPPS,$7.00 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.39 ,Pays 100% Medicare OPPS,$4.85 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,87207,.CYCLOSPORA STAIN,300,$150.00 ,$127.50 ,85% of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.99 ,Pays 100% Medicare OPPS,$5.99 ,Pays 100% Medicare OPPS,$7.78 ,Pays 130% Medicare OPPS,$9.06 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$6.10 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$9.43 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.39 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$9.06 ,120.37% of custom fee schedule,$5.99 ,Pays 100% Medicare OPPS,$7.78 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.39 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,87209,O & P STAIN,306,$175.00 ,$148.75 ,85% of total billed charges,$17.98 ,Pays 100% Medicare OPPS,$17.98 ,Pays 100% Medicare OPPS,$17.98 ,Pays 100% Medicare OPPS,$23.37 ,Pays 130% Medicare OPPS,$27.20 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$18.33 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$28.29 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$17.98 ,Pays 100% Medicare OPPS,$16.18 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$27.20 ,120.37% of custom fee schedule,$17.98 ,Pays 100% Medicare OPPS,$23.37 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$17.98 ,Pays 100% Medicare OPPS,$16.18 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,87210,A lab test to screen for evidence of vaginal infection,306,$135.00 ,$114.75 ,85% of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.82 ,Pays 100% Medicare OPPS,$5.82 ,Pays 100% Medicare OPPS,$7.56 ,Pays 130% Medicare OPPS,$6.45 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.93 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$6.71 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.23 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$6.45 ,120.37% of custom fee schedule,$5.82 ,Pays 100% Medicare OPPS,$7.56 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$5.82 ,Pays 100% Medicare OPPS,$5.23 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,87220,KOH PREP,306,$100.00 ,$85.00 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$6.45 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$4.35 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$6.71 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.84 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$6.45 ,120.37% of custom fee schedule,$4.26 ,Pays 100% Medicare OPPS,$5.55 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$4.26 ,Pays 100% Medicare OPPS,$3.84 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,87252,CULTURE CYTOMEGALOVIRUS,306,$300.00 ,$255.00 ,85% of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$26.07 ,Pays 100% Medicare OPPS,$26.07 ,Pays 100% Medicare OPPS,$33.89 ,Pays 130% Medicare OPPS,$33.46 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$26.59 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$34.80 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$23.46 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$33.46 ,120.37% of custom fee schedule,$26.07 ,Pays 100% Medicare OPPS,$33.89 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$23.46 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,87493,..CLOSTRIDIUM DIFFICILE,306,$275.00 ,$233.75 ,85% of total billed charges,$37.27 ,Pays 100% Medicare OPPS,$37.27 ,Pays 100% Medicare OPPS,$37.27 ,Pays 100% Medicare OPPS,$48.45 ,Pays 130% Medicare OPPS,$56.02 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$38.01 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$96.25 ,35% based on GA Medicaid OP CCR Rate,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$37.27 ,Pays 100% Medicare OPPS,$33.54 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$56.02 ,20.37% based on GA Medicaid OP CCR Rate,$37.27 ,Pays 100% Medicare OPPS,$48.45 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$37.27 ,Pays 100% Medicare OPPS,$33.54 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,87328,"3RD CRYPTOSPORIDIUM, STOOL",306,$135.00 ,$114.75 ,85% of total billed charges,$13.82 ,Pays 100% Medicare OPPS,$13.82 ,Pays 100% Medicare OPPS,$13.82 ,Pays 100% Medicare OPPS,$17.96 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$14.09 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$13.82 ,Pays 100% Medicare OPPS,$12.43 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$13.82 ,Pays 100% Medicare OPPS,$17.96 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$13.82 ,Pays 100% Medicare OPPS,$12.43 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,87177,O&P SMEAR,306,$135.00 ,$114.75 ,85% of total billed charges,$8.90 ,Pays 100% Medicare OPPS,$8.90 ,Pays 100% Medicare OPPS,$8.90 ,Pays 100% Medicare OPPS,$11.57 ,Pays 130% Medicare OPPS,$13.47 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$9.07 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$14.01 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$8.90 ,Pays 100% Medicare OPPS,$8.01 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$13.47 ,120.37% of custom fee schedule,$8.90 ,Pays 100% Medicare OPPS,$11.57 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$8.90 ,Pays 100% Medicare OPPS,$8.01 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,86753,ENTAMOEBA HISTOLYTICA ANTIBODY IGG,302,$275.00 ,$233.75 ,85% of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$12.39 ,Pays 100% Medicare OPPS,$12.39 ,Pays 100% Medicare OPPS,$16.10 ,Pays 130% Medicare OPPS,$18.77 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$12.63 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$19.52 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$11.15 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$18.77 ,120.37% of custom fee schedule,$12.39 ,Pays 100% Medicare OPPS,$16.10 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$12.39 ,Pays 100% Medicare OPPS,$11.15 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,87337,ENTAMOEBA HISTOLYTICA  ANTIGEN,306,$85.00 ,$72.25 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$12.21 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,87338,H PYLORI STOOL ANTIGEN,302,$565.00 ,$480.25 ,85% of total billed charges,$14.38 ,Pays 100% Medicare OPPS,$14.38 ,Pays 100% Medicare OPPS,$14.38 ,Pays 100% Medicare OPPS,$18.69 ,Pays 130% Medicare OPPS,$21.77 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$14.66 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$22.65 ,125.18% of custom fee schedule,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$14.38 ,Pays 100% Medicare OPPS,$12.94 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$21.77 ,120.37% of custom fee schedule,$14.38 ,Pays 100% Medicare OPPS,$18.69 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$14.38 ,Pays 100% Medicare OPPS,$12.94 ,$508.50 ,$452.00 
Outpatient Medical Services,LAB,87340,HEP B SURFACE ANTIGEN,300,$240.00 ,$204.00 ,85% of total billed charges,$10.33 ,Pays 100% Medicare OPPS,$10.33 ,Pays 100% Medicare OPPS,$10.33 ,Pays 100% Medicare OPPS,$13.42 ,Pays 130% Medicare OPPS,$15.64 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$10.53 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$16.26 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$10.33 ,Pays 100% Medicare OPPS,$9.29 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$15.64 ,120.37% of custom fee schedule,$10.33 ,Pays 100% Medicare OPPS,$13.42 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$10.33 ,Pays 100% Medicare OPPS,$9.29 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,87350,HEPATITIS BE ANTIGEN,300,$240.00 ,$204.00 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$17.44 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$11.76 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$18.14 ,125.18% of custom fee schedule,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$17.44 ,120.37% of custom fee schedule,$11.53 ,Pays 100% Medicare OPPS,$14.98 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$11.53 ,Pays 100% Medicare OPPS,$10.37 ,$216.00 ,$192.00 
Outpatient Medical Services,LAB,87400,.INFLUENZA A RAPID TEST,300,$135.00 ,$114.75 ,85% of total billed charges,$14.13 ,Pays 100% Medicare OPPS,$14.13 ,Pays 100% Medicare OPPS,$14.13 ,Pays 100% Medicare OPPS,$18.36 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$14.41 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$14.13 ,Pays 100% Medicare OPPS,$12.71 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$14.13 ,Pays 100% Medicare OPPS,$18.36 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$14.13 ,Pays 100% Medicare OPPS,$12.71 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,87420,RSV (SWAB),306,$325.00 ,$276.25 ,85% of total billed charges,$13.91 ,Pays 100% Medicare OPPS,$13.91 ,Pays 100% Medicare OPPS,$13.91 ,Pays 100% Medicare OPPS,$18.08 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$14.18 ,Pays 102% Medicare OPPS,$292.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$223.28 ,68.7% of total billed charges,$260.00 ,80 percent of total billed charges,$13.91 ,Pays 100% Medicare OPPS,$12.51 ,Pays 90% Medicare OPPS,$188.50 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$13.91 ,Pays 100% Medicare OPPS,$18.08 ,Pays 130% Medicare OPPS,$276.25 ,85% of total billed charges,$13.91 ,Pays 100% Medicare OPPS,$12.51 ,$292.50 ,$260.00 
Outpatient Medical Services,LAB,87425,ROTA VIRUS STOOL,306,$365.00 ,$310.25 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$12.21 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,$328.50 ,$292.00 
Outpatient Medical Services,LAB,87426,CoV-2 SARS ANTIGEN SWAB,300,$250.00 ,$212.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,$45.92 ,Pays 130% Medicare OPPS,$43.55 ,20.37% based on GA Medicaid OP CCR Rate,$141.25 ,56.5 percent of total billed charges,$141.25 ,56.5 percent of total billed charges,$141.25 ,56.5 percent of total billed charges,$141.25 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$225.00 ,90% of total billed charges,$45.29 ,125.18% of custom fee schedule,$171.75 ,68.7% of total billed charges,$200.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$145.00 ,58% of total billed charges,$43.55 ,120.37% of custom fee schedule,$35.33 ,Pays 100% Medicare OPPS,$45.92 ,Pays 130% Medicare OPPS,$212.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$35.33 ,$225.00 ,$200.00 
Outpatient Medical Services,LAB,87430,RAPID STREP Gp A TEST,306,$95.00 ,$80.75 ,85% of total billed charges,$16.80 ,Pays 100% Medicare OPPS,$16.80 ,Pays 100% Medicare OPPS,$16.80 ,Pays 100% Medicare OPPS,$21.85 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$17.14 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$16.80 ,Pays 100% Medicare OPPS,$15.12 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$16.80 ,Pays 100% Medicare OPPS,$21.85 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$16.80 ,Pays 100% Medicare OPPS,$15.12 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,87449,NOROVIRUS STOOL LEVEL,306,$275.00 ,$233.75 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$155.38 ,56.5 percent of total billed charges,$12.21 ,Pays 102% Medicare OPPS,$247.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$188.93 ,68.7% of total billed charges,$220.00 ,80 percent of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,Pays 90% Medicare OPPS,$159.50 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$233.75 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,$247.50 ,$220.00 
Outpatient Medical Services,LAB,87481,.CANDIDA DNA AMP PROBE,302,$100.00 ,$85.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$29.70 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$30.88 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$29.70 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$29.70 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,87490,.CHLAMYDIA (DNA PROBE),306,$190.00 ,$161.50 ,85% of total billed charges,$22.75 ,Pays 100% Medicare OPPS,$22.75 ,Pays 100% Medicare OPPS,$22.75 ,Pays 100% Medicare OPPS,$29.57 ,Pays 130% Medicare OPPS,$29.85 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$23.20 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$31.04 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$22.75 ,Pays 100% Medicare OPPS,$20.47 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$29.85 ,120.37% of custom fee schedule,$22.75 ,Pays 100% Medicare OPPS,$29.57 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$22.75 ,Pays 100% Medicare OPPS,$20.47 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,87491,Test that detects Chlamydia,300,$375.00 ,$318.75 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$29.70 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$30.88 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$29.70 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$29.70 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,87493,3RD CLOSTRIDIUM DIFFICILE PCR,306,$525.00 ,$446.25 ,85% of total billed charges,$37.27 ,Pays 100% Medicare OPPS,$37.27 ,Pays 100% Medicare OPPS,$37.27 ,Pays 100% Medicare OPPS,$48.45 ,Pays 130% Medicare OPPS,$106.94 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$38.01 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$183.75 ,35% based on GA Medicaid OP CCR Rate,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$37.27 ,Pays 100% Medicare OPPS,$33.54 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$106.94 ,20.37% based on GA Medicaid OP CCR Rate,$37.27 ,Pays 100% Medicare OPPS,$48.45 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$37.27 ,Pays 100% Medicare OPPS,$33.54 ,$472.50 ,$420.00 
Outpatient Medical Services,LAB,87497,3RD CMV QUANTATIVE BY PCR,302,$635.00 ,$539.75 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$64.84 ,20.37% based on GA Medicaid OP CCR Rate,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$43.69 ,Pays 102% Medicare OPPS,$571.50 ,90% of total billed charges,$67.43 ,125.18% of custom fee schedule,$436.25 ,68.7% of total billed charges,$508.00 ,80 percent of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,Pays 90% Medicare OPPS,$368.30 ,58% of total billed charges,$64.84 ,120.37% of custom fee schedule,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$539.75 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,$571.50 ,$508.00 
Outpatient Medical Services,LAB,87517,3RD HEPATITIS B VIRAL LOAD  DNA,306,"$1,510.00 ","$1,283.50 ",85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$64.84 ,20.37% based on GA Medicaid OP CCR Rate,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$43.69 ,Pays 102% Medicare OPPS,"$1,359.00 ",90% of total billed charges,$67.43 ,125.18% of custom fee schedule,"$1,037.37 ",68.7% of total billed charges,"$1,208.00 ",80 percent of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,Pays 90% Medicare OPPS,$875.80 ,58% of total billed charges,$64.84 ,120.37% of custom fee schedule,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,"$1,283.50 ",85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,"$1,359.00 ","$1,208.00 "
Outpatient Medical Services,LAB,87522,3RD HEP C RNA QUANTITATIVE,306,$940.00 ,$799.00 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$64.84 ,20.37% based on GA Medicaid OP CCR Rate,$531.10 ,56.5 percent of total billed charges,$531.10 ,56.5 percent of total billed charges,$531.10 ,56.5 percent of total billed charges,$531.10 ,56.5 percent of total billed charges,$43.69 ,Pays 102% Medicare OPPS,$846.00 ,90% of total billed charges,$67.43 ,125.18% of custom fee schedule,$645.78 ,68.7% of total billed charges,$752.00 ,80 percent of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,Pays 90% Medicare OPPS,$545.20 ,58% of total billed charges,$64.84 ,120.37% of custom fee schedule,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$799.00 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,$846.00 ,$752.00 
Outpatient Medical Services,LAB,87530,"3RD HERPES SIMPLEX VIRUS,QUAN",300,$485.00 ,$412.25 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$98.79 ,20.37% based on GA Medicaid OP CCR Rate,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$274.03 ,56.5 percent of total billed charges,$43.69 ,Pays 102% Medicare OPPS,$436.50 ,90% of total billed charges,$169.75 ,35% based on GA Medicaid OP CCR Rate,$333.20 ,68.7% of total billed charges,$388.00 ,80 percent of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,Pays 90% Medicare OPPS,$281.30 ,58% of total billed charges,$98.79 ,20.37% based on GA Medicaid OP CCR Rate,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$412.25 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,$436.50 ,$388.00 
Outpatient Medical Services,LAB,87535,HIV DNA BY PRC,300,$820.00 ,$697.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$29.70 ,20.37% based on GA Medicaid OP CCR Rate,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$738.00 ,90% of total billed charges,$30.88 ,125.18% of custom fee schedule,$563.34 ,68.7% of total billed charges,$656.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$475.60 ,58% of total billed charges,$29.70 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$697.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$29.70 ,$738.00 ,$656.00 
Outpatient Medical Services,LAB,87536,3RD HIV RNA BY PCR,306,$820.00 ,$697.00 ,85% of total billed charges,$85.10 ,Pays 100% Medicare OPPS,$85.10 ,Pays 100% Medicare OPPS,$85.10 ,Pays 100% Medicare OPPS,$110.63 ,Pays 130% Medicare OPPS,$68.01 ,20.37% based on GA Medicaid OP CCR Rate,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$86.80 ,Pays 102% Medicare OPPS,$738.00 ,90% of total billed charges,$70.73 ,125.18% of custom fee schedule,$563.34 ,68.7% of total billed charges,$656.00 ,80 percent of total billed charges,$85.10 ,Pays 100% Medicare OPPS,$76.58 ,Pays 90% Medicare OPPS,$475.60 ,58% of total billed charges,$68.01 ,120.37% of custom fee schedule,$85.10 ,Pays 100% Medicare OPPS,$110.63 ,Pays 130% Medicare OPPS,$697.00 ,85% of total billed charges,$85.10 ,Pays 100% Medicare OPPS,$68.01 ,$738.00 ,$656.00 
Outpatient Medical Services,LAB,87591,Blood test for an STD,300,$375.00 ,$318.75 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$25.78 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$26.81 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$25.78 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$25.78 ,$337.50 ,$300.00 
Outpatient Medical Services,LAB,87640,.STAPH A DNA AMP PROBE,302,$100.00 ,$85.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$29.70 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$30.88 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$29.70 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$29.70 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,87653,Blood test for strep infection,302,$100.00 ,$85.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$29.70 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$30.88 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$29.70 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$29.70 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,87661,Blood test for an STD,300,$220.00 ,$187.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$25.78 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$26.81 ,125.18% of custom fee schedule,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$25.78 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$25.78 ,$198.00 ,$176.00 
Outpatient Medical Services,LAB,87798,.DETECT AGENT DNA PROBE,302,$100.00 ,$85.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$29.70 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$30.88 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$29.70 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$29.70 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,87498,ENTEROVIRUS PCR,300,"$1,145.00 ",$973.25 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$29.70 ,20.37% based on GA Medicaid OP CCR Rate,$646.93 ,56.5 percent of total billed charges,$646.93 ,56.5 percent of total billed charges,$646.93 ,56.5 percent of total billed charges,$646.93 ,56.5 percent of total billed charges,$35.79 ,Pays 102% Medicare OPPS,"$1,030.50 ",90% of total billed charges,$30.88 ,125.18% of custom fee schedule,$786.62 ,68.7% of total billed charges,$916.00 ,80 percent of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$31.58 ,Pays 90% Medicare OPPS,$664.10 ,58% of total billed charges,$29.70 ,120.37% of custom fee schedule,$35.09 ,Pays 100% Medicare OPPS,$45.61 ,Pays 130% Medicare OPPS,$973.25 ,85% of total billed charges,$35.09 ,Pays 100% Medicare OPPS,$29.70 ,"$1,030.50 ",$916.00 
Outpatient Medical Services,LAB,87799,3RD BK VIRUS QUANT PCR URINE,301,$720.00 ,$612.00 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$146.66 ,20.37% based on GA Medicaid OP CCR Rate,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$406.80 ,56.5 percent of total billed charges,$43.69 ,Pays 102% Medicare OPPS,$648.00 ,90% of total billed charges,$252.00 ,35% based on GA Medicaid OP CCR Rate,$494.64 ,68.7% of total billed charges,$576.00 ,80 percent of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,Pays 90% Medicare OPPS,$417.60 ,58% of total billed charges,$146.66 ,20.37% based on GA Medicaid OP CCR Rate,$42.84 ,Pays 100% Medicare OPPS,$55.69 ,Pays 130% Medicare OPPS,$612.00 ,85% of total billed charges,$42.84 ,Pays 100% Medicare OPPS,$38.55 ,$648.00 ,$576.00 
Outpatient Medical Services,LAB,87449,.CAMPYLOBACTER ANTIGEN,306,$75.00 ,$63.75 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$18.15 ,20.37% based on GA Medicaid OP CCR Rate,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$12.21 ,Pays 102% Medicare OPPS,$67.50 ,90% of total billed charges,$18.88 ,125.18% of custom fee schedule,$51.53 ,68.7% of total billed charges,$60.00 ,80 percent of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,Pays 90% Medicare OPPS,$43.50 ,58% of total billed charges,$18.15 ,120.37% of custom fee schedule,$11.98 ,Pays 100% Medicare OPPS,$15.57 ,Pays 130% Medicare OPPS,$63.75 ,85% of total billed charges,$11.98 ,Pays 100% Medicare OPPS,$10.78 ,$67.50 ,$60.00 
Outpatient Medical Services,LAB,88142,PAP smear,300,$100.00 ,$85.00 ,85% of total billed charges,$20.26 ,Pays 100% Medicare OPPS,$20.26 ,Pays 100% Medicare OPPS,$20.26 ,Pays 100% Medicare OPPS,$26.33 ,Pays 130% Medicare OPPS,$30.67 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$20.66 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$31.90 ,125.18% of custom fee schedule,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$20.26 ,Pays 100% Medicare OPPS,$18.23 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$30.67 ,120.37% of custom fee schedule,$20.26 ,Pays 100% Medicare OPPS,$26.33 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$20.26 ,Pays 100% Medicare OPPS,$18.23 ,$90.00 ,$80.00 
Outpatient Medical Services,LAB,88182,3RD FLOW CYTOMETRY,311,$900.00 ,$765.00 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$80.60 ,20.37% based on GA Medicaid OP CCR Rate,$508.50 ,56.5 percent of total billed charges,$508.50 ,56.5 percent of total billed charges,$508.50 ,56.5 percent of total billed charges,$508.50 ,56.5 percent of total billed charges,$45.53 ,Pays 102% Medicare OPPS,$810.00 ,90% of total billed charges,$83.82 ,125.18% of custom fee schedule,$618.30 ,68.7% of total billed charges,$720.00 ,80 percent of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,Pays 90% Medicare OPPS,$522.00 ,58% of total billed charges,$80.60 ,120.37% of custom fee schedule,$44.10 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$765.00 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,$810.00 ,$720.00 
Outpatient Medical Services,LAB,88184,CD 19/CD 3,300,$375.00 ,$318.75 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$55.49 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$266.86 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$57.71 ,125.18% of custom fee schedule,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$235.46 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$55.49 ,120.37% of custom fee schedule,$285.08 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$55.49 ,$370.60 ,$300.00 
Outpatient Medical Services,LAB,88230,.PRADER-WILLI BY FISH-A,311,"$1,045.00 ",$888.25 ,85% of total billed charges,$116.49 ,Pays 100% Medicare OPPS,$116.49 ,Pays 100% Medicare OPPS,$116.49 ,Pays 100% Medicare OPPS,$151.43 ,Pays 130% Medicare OPPS,$176.33 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$118.81 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$183.38 ,125.18% of custom fee schedule,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$116.49 ,Pays 100% Medicare OPPS,$104.84 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$176.33 ,120.37% of custom fee schedule,$116.49 ,Pays 100% Medicare OPPS,$151.43 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$116.49 ,Pays 100% Medicare OPPS,$104.84 ,$940.50 ,$836.00 
Outpatient Medical Services,LAB,88237,.TISSUE CULT(CHROM 7 & 11),311,$840.00 ,$714.00 ,85% of total billed charges,$143.75 ,Pays 100% Medicare OPPS,$143.75 ,Pays 100% Medicare OPPS,$143.75 ,Pays 100% Medicare OPPS,$186.87 ,Pays 130% Medicare OPPS,$133.63 ,20.37% based on GA Medicaid OP CCR Rate,$474.60 ,56.5 percent of total billed charges,$474.60 ,56.5 percent of total billed charges,$474.60 ,56.5 percent of total billed charges,$474.60 ,56.5 percent of total billed charges,$146.62 ,Pays 102% Medicare OPPS,$756.00 ,90% of total billed charges,$138.97 ,125.18% of custom fee schedule,$577.08 ,68.7% of total billed charges,$672.00 ,80 percent of total billed charges,$143.75 ,Pays 100% Medicare OPPS,$129.37 ,Pays 90% Medicare OPPS,$487.20 ,58% of total billed charges,$133.63 ,120.37% of custom fee schedule,$143.75 ,Pays 100% Medicare OPPS,$186.87 ,Pays 130% Medicare OPPS,$714.00 ,85% of total billed charges,$143.75 ,Pays 100% Medicare OPPS,$129.37 ,$756.00 ,$672.00 
Outpatient Medical Services,LAB,88248,.CHROMOSOME BASE (C FG X),311,"$1,510.00 ","$1,283.50 ",85% of total billed charges,$173.17 ,Pays 100% Medicare OPPS,$173.17 ,Pays 100% Medicare OPPS,$173.17 ,Pays 100% Medicare OPPS,$225.12 ,Pays 130% Medicare OPPS,$262.12 ,20.37% based on GA Medicaid OP CCR Rate,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$176.63 ,Pays 102% Medicare OPPS,"$1,359.00 ",90% of total billed charges,$272.59 ,125.18% of custom fee schedule,"$1,037.37 ",68.7% of total billed charges,"$1,208.00 ",80 percent of total billed charges,$173.17 ,Pays 100% Medicare OPPS,$155.85 ,Pays 90% Medicare OPPS,$875.80 ,58% of total billed charges,$262.12 ,120.37% of custom fee schedule,$173.17 ,Pays 100% Medicare OPPS,$225.12 ,Pays 130% Medicare OPPS,"$1,283.50 ",85% of total billed charges,$173.17 ,Pays 100% Medicare OPPS,$155.85 ,"$1,359.00 ","$1,208.00 "
Outpatient Medical Services,LAB,88262,.30 CELL COUNT(CHROMOSOME,311,$675.00 ,$573.75 ,85% of total billed charges,$125.49 ,Pays 100% Medicare OPPS,$125.49 ,Pays 100% Medicare OPPS,$125.49 ,Pays 100% Medicare OPPS,$163.13 ,Pays 130% Medicare OPPS,$188.66 ,20.37% based on GA Medicaid OP CCR Rate,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$127.99 ,Pays 102% Medicare OPPS,$607.50 ,90% of total billed charges,$196.19 ,125.18% of custom fee schedule,$463.73 ,68.7% of total billed charges,$540.00 ,80 percent of total billed charges,$125.49 ,Pays 100% Medicare OPPS,$112.94 ,Pays 90% Medicare OPPS,$391.50 ,58% of total billed charges,$188.66 ,120.37% of custom fee schedule,$125.49 ,Pays 100% Medicare OPPS,$163.13 ,Pays 130% Medicare OPPS,$573.75 ,85% of total billed charges,$125.49 ,Pays 100% Medicare OPPS,$112.94 ,$607.50 ,$540.00 
Outpatient Medical Services,LAB,88264,.CHROM ANAL20-25(CHROM7&11,311,"$1,045.00 ",$888.25 ,85% of total billed charges,$144.61 ,Pays 100% Medicare OPPS,$144.61 ,Pays 100% Medicare OPPS,$144.61 ,Pays 100% Medicare OPPS,$187.99 ,Pays 130% Medicare OPPS,$188.66 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$147.50 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$196.19 ,125.18% of custom fee schedule,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$144.61 ,Pays 100% Medicare OPPS,$130.14 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$188.66 ,120.37% of custom fee schedule,$144.61 ,Pays 100% Medicare OPPS,$187.99 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$144.61 ,Pays 100% Medicare OPPS,$130.14 ,$940.50 ,$836.00 
Outpatient Medical Services,LAB,88271,.MOLECULAR CYTO DNA PROBE,311,$335.00 ,$284.75 ,85% of total billed charges,$21.42 ,Pays 100% Medicare OPPS,$21.42 ,Pays 100% Medicare OPPS,$21.42 ,Pays 100% Medicare OPPS,$27.84 ,Pays 130% Medicare OPPS,$32.43 ,20.37% based on GA Medicaid OP CCR Rate,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$21.84 ,Pays 102% Medicare OPPS,$301.50 ,90% of total billed charges,$33.72 ,125.18% of custom fee schedule,$230.15 ,68.7% of total billed charges,$268.00 ,80 percent of total billed charges,$21.42 ,Pays 100% Medicare OPPS,$19.27 ,Pays 90% Medicare OPPS,$194.30 ,58% of total billed charges,$32.43 ,120.37% of custom fee schedule,$21.42 ,Pays 100% Medicare OPPS,$27.84 ,Pays 130% Medicare OPPS,$284.75 ,85% of total billed charges,$21.42 ,Pays 100% Medicare OPPS,$19.27 ,$301.50 ,$268.00 
Outpatient Medical Services,LAB,88274,.MOLECULAR CYTO 25-99 CELL,311,$550.00 ,$467.50 ,85% of total billed charges,$42.38 ,Pays 100% Medicare OPPS,$42.38 ,Pays 100% Medicare OPPS,$42.38 ,Pays 100% Medicare OPPS,$55.09 ,Pays 130% Medicare OPPS,$52.69 ,20.37% based on GA Medicaid OP CCR Rate,$310.75 ,56.5 percent of total billed charges,$310.75 ,56.5 percent of total billed charges,$310.75 ,56.5 percent of total billed charges,$310.75 ,56.5 percent of total billed charges,$43.22 ,Pays 102% Medicare OPPS,$495.00 ,90% of total billed charges,$54.79 ,125.18% of custom fee schedule,$377.85 ,68.7% of total billed charges,$440.00 ,80 percent of total billed charges,$42.38 ,Pays 100% Medicare OPPS,$38.14 ,Pays 90% Medicare OPPS,$319.00 ,58% of total billed charges,$52.69 ,120.37% of custom fee schedule,$42.38 ,Pays 100% Medicare OPPS,$55.09 ,Pays 130% Medicare OPPS,$467.50 ,85% of total billed charges,$42.38 ,Pays 100% Medicare OPPS,$38.14 ,$495.00 ,$440.00 
Outpatient Medical Services,LAB,88280,.3 KARYOTYPES & BANDING,311,$675.00 ,$573.75 ,85% of total billed charges,$33.47 ,Pays 100% Medicare OPPS,$33.47 ,Pays 100% Medicare OPPS,$33.47 ,Pays 100% Medicare OPPS,$43.51 ,Pays 130% Medicare OPPS,$37.99 ,20.37% based on GA Medicaid OP CCR Rate,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$34.13 ,Pays 102% Medicare OPPS,$607.50 ,90% of total billed charges,$39.51 ,125.18% of custom fee schedule,$463.73 ,68.7% of total billed charges,$540.00 ,80 percent of total billed charges,$33.47 ,Pays 100% Medicare OPPS,$30.12 ,Pays 90% Medicare OPPS,$391.50 ,58% of total billed charges,$37.99 ,120.37% of custom fee schedule,$33.47 ,Pays 100% Medicare OPPS,$43.51 ,Pays 130% Medicare OPPS,$573.75 ,85% of total billed charges,$33.47 ,Pays 100% Medicare OPPS,$30.12 ,$607.50 ,$540.00 
Outpatient Medical Services,LAB,88275,.CYTOGENTETICS 100-300,306,$190.00 ,$161.50 ,85% of total billed charges,$51.19 ,Pays 100% Medicare OPPS,$51.19 ,Pays 100% Medicare OPPS,$51.19 ,Pays 100% Medicare OPPS,$66.54 ,Pays 130% Medicare OPPS,$60.79 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$52.21 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$63.22 ,125.18% of custom fee schedule,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$51.19 ,Pays 100% Medicare OPPS,$46.07 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$60.79 ,120.37% of custom fee schedule,$51.19 ,Pays 100% Medicare OPPS,$66.54 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$51.19 ,Pays 100% Medicare OPPS,$46.07 ,$171.00 ,$152.00 
Outpatient Medical Services,LAB,87207,GIEMSA STAIN,312,$300.00 ,$255.00 ,85% of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.99 ,Pays 100% Medicare OPPS,$5.99 ,Pays 100% Medicare OPPS,$7.78 ,Pays 130% Medicare OPPS,$9.06 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$6.10 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$9.43 ,125.18% of custom fee schedule,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.39 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$9.06 ,120.37% of custom fee schedule,$5.99 ,Pays 100% Medicare OPPS,$7.78 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$5.99 ,Pays 100% Medicare OPPS,$5.39 ,$270.00 ,$240.00 
Outpatient Medical Services,LAB,88365,.PRADER-WILLI BY FISH-B,312,$320.00 ,$272.00 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$106.14 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$136.65 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$110.38 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$120.57 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$106.14 ,120.37% of custom fee schedule,$138.31 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$106.14 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,89050,CELL CO JOINT FLUID/DIFF,309,$135.00 ,$114.75 ,85% of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,$7.16 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$4.81 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$7.45 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$7.16 ,120.37% of custom fee schedule,$4.72 ,Pays 100% Medicare OPPS,$6.13 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$4.72 ,Pays 100% Medicare OPPS,$4.24 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,89051,CELL CO BODY FLUID W DIF,309,$135.00 ,$114.75 ,85% of total billed charges,$5.60 ,Pays 100% Medicare OPPS,$5.60 ,Pays 100% Medicare OPPS,$5.60 ,Pays 100% Medicare OPPS,$7.28 ,Pays 130% Medicare OPPS,$2.66 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$5.71 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$2.77 ,125.18% of custom fee schedule,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$5.60 ,Pays 100% Medicare OPPS,$5.03 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$2.66 ,120.37% of custom fee schedule,$5.60 ,Pays 100% Medicare OPPS,$7.28 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$5.60 ,Pays 100% Medicare OPPS,$2.66 ,$121.50 ,$108.00 
Outpatient Medical Services,LAB,83630,3RD WBC COUNT STOOL/LACTOFERRIN,300,$110.00 ,$93.50 ,85% of total billed charges,$19.70 ,Pays 100% Medicare OPPS,$19.70 ,Pays 100% Medicare OPPS,$19.70 ,Pays 100% Medicare OPPS,$25.61 ,Pays 130% Medicare OPPS,$16.19 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$20.09 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$16.84 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$19.70 ,Pays 100% Medicare OPPS,$17.73 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$16.19 ,120.37% of custom fee schedule,$19.70 ,Pays 100% Medicare OPPS,$25.61 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$19.70 ,Pays 100% Medicare OPPS,$16.19 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,89060,CRYSTALS ANY BODY FLUID,309,$175.00 ,$148.75 ,85% of total billed charges,$7.33 ,Pays 100% Medicare OPPS,$7.33 ,Pays 100% Medicare OPPS,$7.33 ,Pays 100% Medicare OPPS,$9.52 ,Pays 130% Medicare OPPS,$10.82 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$7.47 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$11.25 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$7.33 ,Pays 100% Medicare OPPS,$6.59 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$10.82 ,120.37% of custom fee schedule,$7.33 ,Pays 100% Medicare OPPS,$9.52 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$7.33 ,Pays 100% Medicare OPPS,$6.59 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,82705,3RD FAT STOOL QUAL,309,$175.00 ,$148.75 ,85% of total billed charges,$5.09 ,Pays 100% Medicare OPPS,$5.09 ,Pays 100% Medicare OPPS,$5.09 ,Pays 100% Medicare OPPS,$6.63 ,Pays 130% Medicare OPPS,$7.70 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$5.20 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$8.01 ,125.18% of custom fee schedule,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$5.09 ,Pays 100% Medicare OPPS,$4.58 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$7.70 ,120.37% of custom fee schedule,$5.09 ,Pays 100% Medicare OPPS,$6.63 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$5.09 ,Pays 100% Medicare OPPS,$4.58 ,$157.50 ,$140.00 
Outpatient Medical Services,LAB,82930,GASTRIC ANALYSIS,309,$320.00 ,$272.00 ,85% of total billed charges,$6.71 ,Pays 100% Medicare OPPS,$6.71 ,Pays 100% Medicare OPPS,$6.71 ,Pays 100% Medicare OPPS,$8.72 ,Pays 130% Medicare OPPS,$26.78 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$6.84 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$27.85 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$6.71 ,Pays 100% Medicare OPPS,$6.03 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$26.78 ,120.37% of custom fee schedule,$6.71 ,Pays 100% Medicare OPPS,$8.72 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$6.71 ,Pays 100% Medicare OPPS,$6.03 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,89190,EOSIN SMEAR NASAL,309,$150.00 ,$127.50 ,85% of total billed charges,$5.79 ,Pays 100% Medicare OPPS,$5.79 ,Pays 100% Medicare OPPS,$5.79 ,Pays 100% Medicare OPPS,$7.52 ,Pays 130% Medicare OPPS,$7.20 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$5.90 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$7.49 ,125.18% of custom fee schedule,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$5.79 ,Pays 100% Medicare OPPS,$5.21 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$7.20 ,120.37% of custom fee schedule,$5.79 ,Pays 100% Medicare OPPS,$7.52 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$5.79 ,Pays 100% Medicare OPPS,$5.21 ,$135.00 ,$120.00 
Outpatient Medical Services,LAB,89320,SPERM COUNT,309,$320.00 ,$272.00 ,85% of total billed charges,$12.31 ,Pays 100% Medicare OPPS,$12.31 ,Pays 100% Medicare OPPS,$12.31 ,Pays 100% Medicare OPPS,$16.00 ,Pays 130% Medicare OPPS,$8.73 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$12.55 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$9.08 ,125.18% of custom fee schedule,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$12.31 ,Pays 100% Medicare OPPS,$11.07 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$8.73 ,120.37% of custom fee schedule,$12.31 ,Pays 100% Medicare OPPS,$16.00 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$12.31 ,Pays 100% Medicare OPPS,$8.73 ,$288.00 ,$256.00 
Outpatient Medical Services,LAB,89321,.SPERM COUNT-POST VAS,309,$110.00 ,$93.50 ,85% of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,$8.73 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$12.29 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$9.08 ,125.18% of custom fee schedule,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$12.05 ,Pays 100% Medicare OPPS,$10.84 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$8.73 ,120.37% of custom fee schedule,$12.05 ,Pays 100% Medicare OPPS,$15.66 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$12.05 ,Pays 100% Medicare OPPS,$8.73 ,$99.00 ,$88.00 
Outpatient Medical Services,LAB,83909,MOLECULAR DGN SEP & ID,301,$95.00 ,$80.75 ,85% of total billed charges,$23.75 ,Pays 100% Medicare OPPS,$23.75 ,Pays 100% Medicare OPPS,$23.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$19.35 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$33.25 ,35% based on GA Medicaid OP CCR Rate,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$85.50 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$19.35 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$19.35 ,$85.50 ,$76.00 
Outpatient Medical Services,LAB,80377,"DRUG SCREEN, HANDLING",300,$75.00 ,$63.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$15.28 ,20.37% based on GA Medicaid OP CCR Rate,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$67.50 ,90% of total billed charges,$26.25 ,35% based on GA Medicaid OP CCR Rate,$51.53 ,68.7% of total billed charges,$60.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$43.50 ,58% of total billed charges,$15.28 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$63.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$15.28 ,$67.50 ,$60.00 
Outpatient Medical Services,LAB,85025,"Complete blood cell count, with differential white blood cells, automated",300,$265.00 ,$225.25 ,85% of total billed charges,$7.77 ,Pays 100% Medicare OPPS,$7.77 ,Pays 100% Medicare OPPS,$7.77 ,Pays 100% Medicare OPPS,$10.10 ,Pays 130% Medicare OPPS,$11.76 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$7.92 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$12.23 ,125.18% of custom fee schedule,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$7.77 ,Pays 100% Medicare OPPS,$6.99 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$11.76 ,120.37% of custom fee schedule,$7.77 ,Pays 100% Medicare OPPS,$10.10 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$7.77 ,Pays 100% Medicare OPPS,$6.99 ,$238.50 ,$212.00 
Outpatient Medical Services,LAB,81003,Automated urinalysis test,300,$125.00 ,$106.25 ,85% of total billed charges,$2.25 ,Pays 100% Medicare OPPS,$2.25 ,Pays 100% Medicare OPPS,$2.25 ,Pays 100% Medicare OPPS,$2.92 ,Pays 130% Medicare OPPS,$3.41 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$2.29 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$3.54 ,125.18% of custom fee schedule,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$2.25 ,Pays 100% Medicare OPPS,$2.02 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$3.41 ,120.37% of custom fee schedule,$2.25 ,Pays 100% Medicare OPPS,$2.92 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$2.25 ,Pays 100% Medicare OPPS,$2.02 ,$112.50 ,$100.00 
Outpatient Medical Services,LAB,88104,88104 CYTOPATHOLOGY FL NONGYN SMEARS,311,$85.00 ,$72.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$51.37 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$31.01 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$53.43 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$51.37 ,120.37% of custom fee schedule,$29.87 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,88108,88108 CP CONCENTRATION TECH SMEAR,311,$85.00 ,$72.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$55.06 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$31.01 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$57.26 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$55.06 ,120.37% of custom fee schedule,$29.87 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,88173,88173 CP INTERPRETATION AND REPORT,311,$170.00 ,$144.50 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$110.23 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$45.53 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$114.64 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$110.23 ,120.37% of custom fee schedule,$44.10 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,88300,88300 SURGICAL PATHOLOGY LEVEL 1,310,$50.00 ,$42.50 ,85% of total billed charges,$22.19 ,Pays 100% Medicare OPPS,$22.19 ,Pays 100% Medicare OPPS,$22.19 ,Pays 100% Medicare OPPS,$28.54 ,Pays 130% Medicare OPPS,$17.21 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$22.63 ,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$17.90 ,125.18% of custom fee schedule,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,$22.19 ,Pays 100% Medicare OPPS,$19.97 ,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$17.21 ,120.37% of custom fee schedule,$21.95 ,Pays 100% Medicare OPPS,$28.54 ,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,$22.19 ,Pays 100% Medicare OPPS,$17.21 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,88304,88304 SURGICAL PATHOLOGY LEVEL III,310,$170.00 ,$144.50 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$36.33 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$45.53 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$37.78 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$36.33 ,120.37% of custom fee schedule,$44.10 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$36.33 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,88305,Test of tissues for diagnosis of abnormalities,310,$170.00 ,$144.50 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$79.30 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$45.53 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$82.47 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$79.30 ,120.37% of custom fee schedule,$44.10 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,$153.00 ,$136.00 
Outpatient Medical Services,LAB,88307,88307 SURGICAL PATHOLOGY LEVEL V,310,$260.00 ,$221.00 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$261.63 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$160.45 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$266.86 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$166.86 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$235.46 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$160.45 ,120.37% of custom fee schedule,$285.08 ,Pays 100% Medicare OPPS,$370.60 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$261.63 ,Pays 100% Medicare OPPS,$146.90 ,$370.60 ,$208.00 
Outpatient Medical Services,LAB,88309,88309 SURGICAL PATHOLOGY LEVEL VI,310,$260.00 ,$221.00 ,85% of total billed charges,$588.69 ,Pays 100% Medicare OPPS,$588.69 ,Pays 100% Medicare OPPS,$588.69 ,Pays 100% Medicare OPPS,$887.90 ,Pays 130% Medicare OPPS,$226.03 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$600.46 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$235.06 ,125.18% of custom fee schedule,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$588.69 ,Pays 100% Medicare OPPS,$529.82 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$226.03 ,120.37% of custom fee schedule,$683.00 ,Pays 100% Medicare OPPS,$887.90 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$588.69 ,Pays 100% Medicare OPPS,$146.90 ,$887.90 ,$208.00 
Outpatient Medical Services,LAB,88311,88311 DECALCIFICATION PROCEDURE,310,$50.00 ,$42.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$18.60 ,20.37% based on GA Medicaid OP CCR Rate,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,$28.25 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$45.00 ,90% of total billed charges,$19.34 ,125.18% of custom fee schedule,$34.35 ,68.7% of total billed charges,$40.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$29.00 ,58% of total billed charges,$18.60 ,120.37% of custom fee schedule,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$42.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$18.60 ,$45.00 ,$40.00 
Outpatient Medical Services,LAB,88312,Blood test to assist with diagnosis,310,$85.00 ,$72.25 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$44.63 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$52.23 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$45.53 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$54.32 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$52.23 ,120.37% of custom fee schedule,$44.10 ,Pays 100% Medicare OPPS,$57.33 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$44.63 ,Pays 100% Medicare OPPS,$40.17 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,88313,Blood test to assist with diagnosis,310,$85.00 ,$72.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$30.40 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$54.06 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$31.01 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$56.22 ,125.18% of custom fee schedule,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$54.06 ,120.37% of custom fee schedule,$29.87 ,Pays 100% Medicare OPPS,$38.83 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$30.40 ,Pays 100% Medicare OPPS,$27.36 ,$76.50 ,$68.00 
Outpatient Medical Services,LAB,88342,Pathology test,310,$170.00 ,$144.50 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$133.97 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$86.16 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$136.65 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$89.60 ,125.18% of custom fee schedule,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$120.57 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$86.16 ,120.37% of custom fee schedule,$138.31 ,Pays 100% Medicare OPPS,$179.80 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$133.97 ,Pays 100% Medicare OPPS,$86.16 ,$179.80 ,$136.00 
Outpatient Medical Services,LAB,82803,Test to measure arterial blood gases,301,$475.00 ,$403.75 ,85% of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$26.07 ,Pays 100% Medicare OPPS,$26.07 ,Pays 100% Medicare OPPS,$33.89 ,Pays 130% Medicare OPPS,$29.30 ,20.37% based on GA Medicaid OP CCR Rate,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$26.59 ,Pays 102% Medicare OPPS,$427.50 ,90% of total billed charges,$30.47 ,125.18% of custom fee schedule,$326.33 ,68.7% of total billed charges,$380.00 ,80 percent of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$23.46 ,Pays 90% Medicare OPPS,$275.50 ,58% of total billed charges,$29.30 ,120.37% of custom fee schedule,$26.07 ,Pays 100% Medicare OPPS,$33.89 ,Pays 130% Medicare OPPS,$403.75 ,85% of total billed charges,$26.07 ,Pays 100% Medicare OPPS,$23.46 ,$427.50 ,$380.00 
Outpatient Medical Services,RADIOLOGY,71045,Single view,324,$365.00 ,$310.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$74.35 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$205.13 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$127.75 ,35% based on GA Medicaid OP CCR Rate,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.38 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$74.35 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.38 ,$328.50 ,$292.00 
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,$370.00 ,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$207.94 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$129.50 ,35% based on GA Medicaid OP CCR Rate,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$333.00 ,$296.00 
Outpatient Medical Services,RADIOLOGY,73521,XR HIPS BIL WITH AP/PELVIS,320,$575.00 ,$488.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$323.15 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$201.25 ,35% based on GA Medicaid OP CCR Rate,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$517.50 ,$460.00 
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",320,$370.00 ,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$207.94 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$129.50 ,35% based on GA Medicaid OP CCR Rate,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$333.00 ,$296.00 
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73070,"Radiologic examination, elbow; 2 views",320,$370.00 ,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$207.94 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$129.50 ,35% based on GA Medicaid OP CCR Rate,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$333.00 ,$296.00 
Outpatient Medical Services,RADIOLOGY,20610,Draining or injecting medication into a major joint/bursa without ultrasound,320,$970.00 ,$824.50 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$197.59 ,20.37% based on GA Medicaid OP CCR Rate,$548.05 ,56.5 percent of total billed charges,$548.05 ,56.5 percent of total billed charges,$548.05 ,56.5 percent of total billed charges,$545.14 ,56.5 percent of total billed charges,$239.38 ,Pays 102% Medicare OPPS,$873.00 ,90% of total billed charges,$339.50 ,35% based on GA Medicaid OP CCR Rate,$666.39 ,68.7% of total billed charges,$776.00 ,80 percent of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$211.22 ,Pays 90% Medicare OPPS,$562.60 ,58% of total billed charges,$197.59 ,20.37% based on GA Medicaid OP CCR Rate,$239.14 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$824.50 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$197.59 ,$873.00 ,$776.00 
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,320,$565.00 ,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,71047,3 views,324,$465.00 ,$395.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$94.72 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$261.33 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$162.75 ,35% based on GA Medicaid OP CCR Rate,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$94.72 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$418.50 ,$372.00 
Outpatient Medical Services,RADIOLOGY,74022,Serial radiologic examination of the abdomen,320,$620.00 ,$527.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$126.29 ,20.37% based on GA Medicaid OP CCR Rate,$350.30 ,56.5 percent of total billed charges,$350.30 ,56.5 percent of total billed charges,$350.30 ,56.5 percent of total billed charges,$348.44 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$558.00 ,90% of total billed charges,$217.00 ,35% based on GA Medicaid OP CCR Rate,$425.94 ,68.7% of total billed charges,$496.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$359.60 ,58% of total billed charges,$126.29 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$527.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$558.00 ,$496.00 
Outpatient Medical Services,RADIOLOGY,74246,XR GI / AC,320,"$1,125.00 ",$956.25 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$229.16 ,20.37% based on GA Medicaid OP CCR Rate,$635.63 ,56.5 percent of total billed charges,$635.63 ,56.5 percent of total billed charges,$635.63 ,56.5 percent of total billed charges,$632.25 ,56.5 percent of total billed charges,$163.67 ,Pays 102% Medicare OPPS,"$1,012.50 ",90% of total billed charges,$393.75 ,35% based on GA Medicaid OP CCR Rate,$772.88 ,68.7% of total billed charges,$900.00 ,80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,$652.50 ,58% of total billed charges,$229.16 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$956.25 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$1,012.50 ",$900.00 
Outpatient Medical Services,RADIOLOGY,10021,Fine Needle Aspiration Biopsy without imaging,320,$710.00 ,$603.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$399.02 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$639.00 ,90% of total billed charges,$248.50 ,35% based on GA Medicaid OP CCR Rate,$487.77 ,68.7% of total billed charges,$568.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$411.80 ,58% of total billed charges,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$603.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$144.63 ,$639.00 ,$568.00 
Outpatient Medical Services,RADIOLOGY,10022,XR ASPIR FINE NDLE W IMAGE G,320,$750.00 ,$637.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$421.50 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$675.00 ,90% of total billed charges,$262.50 ,35% based on GA Medicaid OP CCR Rate,$515.25 ,68.7% of total billed charges,$600.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$435.00 ,58% of total billed charges,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$637.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$152.78 ,$675.00 ,$600.00 
Outpatient Medical Services,RADIOLOGY,19081,BREAST BIOPSY,320,$650.00 ,$552.50 ,85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$132.41 ,20.37% based on GA Medicaid OP CCR Rate,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$365.30 ,56.5 percent of total billed charges,"$1,289.21 ",Pays 102% Medicare OPPS,$585.00 ,90% of total billed charges,$227.50 ,35% based on GA Medicaid OP CCR Rate,$446.55 ,68.7% of total billed charges,$520.00 ,80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,$377.00 ,58% of total billed charges,$132.41 ,20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$552.50 ,85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,$132.41 ,"$1,714.66 ",$520.00 
Outpatient Medical Services,RADIOLOGY,20605,Draining or injecting medication into a large joint/bursa without ultrasound,320,$700.00 ,$595.00 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$142.59 ,20.37% based on GA Medicaid OP CCR Rate,$395.50 ,56.5 percent of total billed charges,$395.50 ,56.5 percent of total billed charges,$395.50 ,56.5 percent of total billed charges,$393.40 ,56.5 percent of total billed charges,$239.38 ,Pays 102% Medicare OPPS,$630.00 ,90% of total billed charges,$245.00 ,35% based on GA Medicaid OP CCR Rate,$480.90 ,68.7% of total billed charges,$560.00 ,80 percent of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$211.22 ,Pays 90% Medicare OPPS,$406.00 ,58% of total billed charges,$142.59 ,20.37% based on GA Medicaid OP CCR Rate,$239.14 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$595.00 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$142.59 ,$630.00 ,$560.00 
Outpatient Medical Services,RADIOLOGY,20610,Draining or injecting medication into a major joint/bursa without ultrasound,320,$970.00 ,$824.50 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$197.59 ,20.37% based on GA Medicaid OP CCR Rate,$548.05 ,56.5 percent of total billed charges,$548.05 ,56.5 percent of total billed charges,$548.05 ,56.5 percent of total billed charges,$545.14 ,56.5 percent of total billed charges,$239.38 ,Pays 102% Medicare OPPS,$873.00 ,90% of total billed charges,$339.50 ,35% based on GA Medicaid OP CCR Rate,$666.39 ,68.7% of total billed charges,$776.00 ,80 percent of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$211.22 ,Pays 90% Medicare OPPS,$562.60 ,58% of total billed charges,$197.59 ,20.37% based on GA Medicaid OP CCR Rate,$239.14 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$824.50 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$197.59 ,$873.00 ,$776.00 
Outpatient Medical Services,RADIOLOGY,23350,XR INJECTION SHOULDER ARTHROGRAM,322,$395.00 ,$335.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$221.99 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,RADIOLOGY,32555,THORACENTESIS FOR ASPIRATION,324,$700.00 ,$595.00 ,85% of total billed charges,$485.56 ,Pays 100% Medicare OPPS,$485.56 ,Pays 100% Medicare OPPS,$485.56 ,Pays 100% Medicare OPPS,$661.48 ,Pays 130% Medicare OPPS,$142.59 ,20.37% based on GA Medicaid OP CCR Rate,$395.50 ,56.5 percent of total billed charges,$395.50 ,56.5 percent of total billed charges,$395.50 ,56.5 percent of total billed charges,$393.40 ,56.5 percent of total billed charges,$495.27 ,Pays 102% Medicare OPPS,$630.00 ,90% of total billed charges,$245.00 ,35% based on GA Medicaid OP CCR Rate,$480.90 ,68.7% of total billed charges,$560.00 ,80 percent of total billed charges,$485.56 ,Pays 100% Medicare OPPS,$437.00 ,Pays 90% Medicare OPPS,$406.00 ,58% of total billed charges,$142.59 ,20.37% based on GA Medicaid OP CCR Rate,$508.83 ,Pays 100% Medicare OPPS,$661.48 ,Pays 130% Medicare OPPS,$595.00 ,85% of total billed charges,$485.56 ,Pays 100% Medicare OPPS,$142.59 ,$661.48 ,$560.00 
Outpatient Medical Services,RADIOLOGY,32555,THORACENTESIS W/ TUBE INSERT,324,$700.00 ,$595.00 ,85% of total billed charges,$485.56 ,Pays 100% Medicare OPPS,$485.56 ,Pays 100% Medicare OPPS,$485.56 ,Pays 100% Medicare OPPS,$661.48 ,Pays 130% Medicare OPPS,$142.59 ,20.37% based on GA Medicaid OP CCR Rate,$395.50 ,56.5 percent of total billed charges,$395.50 ,56.5 percent of total billed charges,$395.50 ,56.5 percent of total billed charges,$393.40 ,56.5 percent of total billed charges,$495.27 ,Pays 102% Medicare OPPS,$630.00 ,90% of total billed charges,$245.00 ,35% based on GA Medicaid OP CCR Rate,$480.90 ,68.7% of total billed charges,$560.00 ,80 percent of total billed charges,$485.56 ,Pays 100% Medicare OPPS,$437.00 ,Pays 90% Medicare OPPS,$406.00 ,58% of total billed charges,$142.59 ,20.37% based on GA Medicaid OP CCR Rate,$508.83 ,Pays 100% Medicare OPPS,$661.48 ,Pays 130% Medicare OPPS,$595.00 ,85% of total billed charges,$485.56 ,Pays 100% Medicare OPPS,$142.59 ,$661.48 ,$560.00 
Outpatient Medical Services,RADIOLOGY,42550,XR INJECTION PROCEDURE FOR  SIALOGRAPHY,324,$565.00 ,$480.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$115.09 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,49424,XR INJECTION SINUS TRACT OR DRAIN,320,$415.00 ,$352.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$84.54 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$233.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$145.25 ,35% based on GA Medicaid OP CCR Rate,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$84.54 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$84.54 ,$373.50 ,$332.00 
Outpatient Medical Services,RADIOLOGY,70100,XR MANDIBLE/LTD LESS 4 VIEWS,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,70110,XR MANDIBLE 4 VIEWS COMPLETE,320,$565.00 ,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,76499,XR EXTRA VIEWS,320,$300.00 ,$255.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$168.60 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$105.00 ,35% based on GA Medicaid OP CCR Rate,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$61.11 ,$270.00 ,$240.00 
Outpatient Medical Services,RADIOLOGY,70160,XR NASAL BONES 3 VIEWS,320,$435.00 ,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,70200,XR ORBITS 4 VIEWS,320,$565.00 ,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,70220,XR SINUSES 4 VIEWS,320,$565.00 ,$480.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,70250,XR SKULL/LTD 2 VIEWS,320,$565.00 ,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,70260,XR SKULL 4 VIEWS,320,$640.00 ,$544.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$130.37 ,20.37% based on GA Medicaid OP CCR Rate,$361.60 ,56.5 percent of total billed charges,$361.60 ,56.5 percent of total billed charges,$361.60 ,56.5 percent of total billed charges,$359.68 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$576.00 ,90% of total billed charges,$224.00 ,35% based on GA Medicaid OP CCR Rate,$439.68 ,68.7% of total billed charges,$512.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$371.20 ,58% of total billed charges,$130.37 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$544.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$576.00 ,$512.00 
Outpatient Medical Services,RADIOLOGY,70330,XR T-M JOINTS TOMO/BILATERAL,320,$525.00 ,$446.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$106.94 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$295.05 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$183.75 ,35% based on GA Medicaid OP CCR Rate,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$106.94 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$472.50 ,$420.00 
Outpatient Medical Services,RADIOLOGY,70360,XR NECK SOFT TISSUE,320,$325.00 ,$276.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$66.20 ,20.37% based on GA Medicaid OP CCR Rate,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$182.65 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$292.50 ,90% of total billed charges,$113.75 ,35% based on GA Medicaid OP CCR Rate,$223.28 ,68.7% of total billed charges,$260.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$188.50 ,58% of total billed charges,$66.20 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$276.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$292.50 ,$260.00 
Outpatient Medical Services,RADIOLOGY,76000,"Flouroscopy, or x-ray ""movie"" that takes less than an hour",320,"$1,010.00 ",$858.50 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$205.74 ,20.37% based on GA Medicaid OP CCR Rate,$570.65 ,56.5 percent of total billed charges,$570.65 ,56.5 percent of total billed charges,$570.65 ,56.5 percent of total billed charges,$567.62 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,$909.00 ,90% of total billed charges,$353.50 ,35% based on GA Medicaid OP CCR Rate,$693.87 ,68.7% of total billed charges,$808.00 ,80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$585.80 ,58% of total billed charges,$205.74 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$858.50 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,$909.00 ,$808.00 
Outpatient Medical Services,RADIOLOGY,70390,XR SIALOGRAPHY,324,$465.00 ,$395.25 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$94.72 ,20.37% based on GA Medicaid OP CCR Rate,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$262.73 ,56.5 percent of total billed charges,$261.33 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$162.75 ,35% based on GA Medicaid OP CCR Rate,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$94.72 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$94.72 ,$418.50 ,$372.00 
Outpatient Medical Services,RADIOLOGY,76010,XR KIDIGRAM,320,$370.00 ,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$207.94 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$129.50 ,35% based on GA Medicaid OP CCR Rate,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$333.00 ,$296.00 
Outpatient Medical Services,RADIOLOGY,71045,Single view,324,$365.00 ,$310.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$74.35 ,20.37% based on GA Medicaid OP CCR Rate,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$206.23 ,56.5 percent of total billed charges,$205.13 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$328.50 ,90% of total billed charges,$127.75 ,35% based on GA Medicaid OP CCR Rate,$250.76 ,68.7% of total billed charges,$292.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.38 ,Pays 90% Medicare OPPS,$211.70 ,58% of total billed charges,$74.35 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$310.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.38 ,$328.50 ,$292.00 
Outpatient Medical Services,RADIOLOGY,71046,"2 views, front and back",324,$435.00 ,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.38 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.38 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,71047,3 views,324,$565.00 ,$480.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,71022,XR CHEST AND OBLIQUES,324,$490.00 ,$416.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$99.81 ,20.37% based on GA Medicaid OP CCR Rate,$276.85 ,56.5 percent of total billed charges,$276.85 ,56.5 percent of total billed charges,$276.85 ,56.5 percent of total billed charges,$275.38 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$441.00 ,90% of total billed charges,$171.50 ,35% based on GA Medicaid OP CCR Rate,$336.63 ,68.7% of total billed charges,$392.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$284.20 ,58% of total billed charges,$99.81 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$416.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$99.81 ,$441.00 ,$392.00 
Outpatient Medical Services,RADIOLOGY,71023,XR CHEST FLUOROSCOPY,324,$660.00 ,$561.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$370.92 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$231.00 ,35% based on GA Medicaid OP CCR Rate,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$134.44 ,$594.00 ,$528.00 
Outpatient Medical Services,RADIOLOGY,71046,"2 views, front and back",324,$410.00 ,$348.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$230.42 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$143.50 ,35% based on GA Medicaid OP CCR Rate,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.38 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.38 ,$369.00 ,$328.00 
Outpatient Medical Services,RADIOLOGY,71100,XR RIBS UNILAT LEFT W/O PA CHEST  2 VIEW,320,$395.00 ,$335.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$221.99 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$355.50 ,$316.00 
Outpatient Medical Services,RADIOLOGY,71101,Radiologic examination of one side of the chest/ribs,320,$575.00 ,$488.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$323.15 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$201.25 ,35% based on GA Medicaid OP CCR Rate,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$517.50 ,$460.00 
Outpatient Medical Services,RADIOLOGY,71101,Radiologic examination of one side of the chest/ribs,320,$575.00 ,$488.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$323.15 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$201.25 ,35% based on GA Medicaid OP CCR Rate,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$517.50 ,$460.00 
Outpatient Medical Services,RADIOLOGY,71110,XR RIBS BILAT W/O CHEST  3 VIEWS,320,$850.00 ,$722.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$173.15 ,20.37% based on GA Medicaid OP CCR Rate,$480.25 ,56.5 percent of total billed charges,$480.25 ,56.5 percent of total billed charges,$480.25 ,56.5 percent of total billed charges,$477.70 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$765.00 ,90% of total billed charges,$297.50 ,35% based on GA Medicaid OP CCR Rate,$583.95 ,68.7% of total billed charges,$680.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$493.00 ,58% of total billed charges,$173.15 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$722.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$765.00 ,$680.00 
Outpatient Medical Services,RADIOLOGY,71111,XR RIBS BILAT W PA CHEST 4 VIEWS,320,"$1,045.00 ",$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$587.29 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,71120,XR STERNUM-AP/LAT/OBLIQUES,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,71130,XR STERNO/CLAV JTS 3 VIEWS,320,$500.00 ,$425.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$101.85 ,20.37% based on GA Medicaid OP CCR Rate,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$281.00 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$450.00 ,90% of total billed charges,$175.00 ,35% based on GA Medicaid OP CCR Rate,$343.50 ,68.7% of total billed charges,$400.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$290.00 ,58% of total billed charges,$101.85 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$425.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$450.00 ,$400.00 
Outpatient Medical Services,RADIOLOGY,72020,XR SPINE SINGLE VIEW,320,$350.00 ,$297.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$71.30 ,20.37% based on GA Medicaid OP CCR Rate,$197.75 ,56.5 percent of total billed charges,$197.75 ,56.5 percent of total billed charges,$197.75 ,56.5 percent of total billed charges,$196.70 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$315.00 ,90% of total billed charges,$122.50 ,35% based on GA Medicaid OP CCR Rate,$240.45 ,68.7% of total billed charges,$280.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$203.00 ,58% of total billed charges,$71.30 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$297.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$315.00 ,$280.00 
Outpatient Medical Services,RADIOLOGY,72040,"Radiologic examination of the neck/spine, 2-3 views",320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,72050,"Radiologic examination of the neck/spine, 4-5 views",320,$665.00 ,$565.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,$375.73 ,56.5 percent of total billed charges,$375.73 ,56.5 percent of total billed charges,$375.73 ,56.5 percent of total billed charges,$373.73 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$598.50 ,90% of total billed charges,$232.75 ,35% based on GA Medicaid OP CCR Rate,$456.86 ,68.7% of total billed charges,$532.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$385.70 ,58% of total billed charges,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$565.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$598.50 ,$532.00 
Outpatient Medical Services,RADIOLOGY,72052,XR SPINE/CER SP WITH FLEX & EXT,320,$800.00 ,$680.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$162.96 ,20.37% based on GA Medicaid OP CCR Rate,$452.00 ,56.5 percent of total billed charges,$452.00 ,56.5 percent of total billed charges,$452.00 ,56.5 percent of total billed charges,$449.60 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$720.00 ,90% of total billed charges,$280.00 ,35% based on GA Medicaid OP CCR Rate,$549.60 ,68.7% of total billed charges,$640.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$464.00 ,58% of total billed charges,$162.96 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$680.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$720.00 ,$640.00 
Outpatient Medical Services,RADIOLOGY,72070,"Radiologic examination of the middle spine, 2 views",320,$540.00 ,$459.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$303.48 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$486.00 ,90% of total billed charges,$189.00 ,35% based on GA Medicaid OP CCR Rate,$370.98 ,68.7% of total billed charges,$432.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$313.20 ,58% of total billed charges,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$459.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$486.00 ,$432.00 
Outpatient Medical Services,RADIOLOGY,72074,XR SPINE THORACIC 4 VIEWS,320,$665.00 ,$565.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,$375.73 ,56.5 percent of total billed charges,$375.73 ,56.5 percent of total billed charges,$375.73 ,56.5 percent of total billed charges,$373.73 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$598.50 ,90% of total billed charges,$232.75 ,35% based on GA Medicaid OP CCR Rate,$456.86 ,68.7% of total billed charges,$532.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$385.70 ,58% of total billed charges,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$565.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$598.50 ,$532.00 
Outpatient Medical Services,RADIOLOGY,72082,XR EXAM ENTIRE SPINE 2/3 VIEWS,320,$445.00 ,$378.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$90.65 ,20.37% based on GA Medicaid OP CCR Rate,$251.43 ,56.5 percent of total billed charges,$251.43 ,56.5 percent of total billed charges,$251.43 ,56.5 percent of total billed charges,$250.09 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$400.50 ,90% of total billed charges,$155.75 ,35% based on GA Medicaid OP CCR Rate,$305.72 ,68.7% of total billed charges,$356.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$258.10 ,58% of total billed charges,$90.65 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$378.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$400.50 ,$356.00 
Outpatient Medical Services,RADIOLOGY,72082,XR SCOLIOSIS SURVEY,320,$540.00 ,$459.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$303.48 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$486.00 ,90% of total billed charges,$189.00 ,35% based on GA Medicaid OP CCR Rate,$370.98 ,68.7% of total billed charges,$432.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$313.20 ,58% of total billed charges,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$459.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$486.00 ,$432.00 
Outpatient Medical Services,RADIOLOGY,72100,X-ray of the lower spine 2-3 views,320,$540.00 ,$459.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$303.48 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$486.00 ,90% of total billed charges,$189.00 ,35% based on GA Medicaid OP CCR Rate,$370.98 ,68.7% of total billed charges,$432.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$313.20 ,58% of total billed charges,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$459.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$486.00 ,$432.00 
Outpatient Medical Services,RADIOLOGY,72110,"X-ray of lower and sacral spine, minimum of 4 views",320,$665.00 ,$565.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,$375.73 ,56.5 percent of total billed charges,$375.73 ,56.5 percent of total billed charges,$375.73 ,56.5 percent of total billed charges,$373.73 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$598.50 ,90% of total billed charges,$232.75 ,35% based on GA Medicaid OP CCR Rate,$456.86 ,68.7% of total billed charges,$532.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$385.70 ,58% of total billed charges,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$565.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$598.50 ,$532.00 
Outpatient Medical Services,RADIOLOGY,72114,XR SPINE/LUMBAR  W/FLEX EXT,320,$665.00 ,$565.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,$375.73 ,56.5 percent of total billed charges,$375.73 ,56.5 percent of total billed charges,$375.73 ,56.5 percent of total billed charges,$373.73 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$598.50 ,90% of total billed charges,$232.75 ,35% based on GA Medicaid OP CCR Rate,$456.86 ,68.7% of total billed charges,$532.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$385.70 ,58% of total billed charges,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$565.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$598.50 ,$532.00 
Outpatient Medical Services,RADIOLOGY,72120,XR SPINE/LUMBAR FLEX EX ONLY,320,$540.00 ,$459.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$303.48 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$486.00 ,90% of total billed charges,$189.00 ,35% based on GA Medicaid OP CCR Rate,$370.98 ,68.7% of total billed charges,$432.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$313.20 ,58% of total billed charges,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$459.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$486.00 ,$432.00 
Outpatient Medical Services,RADIOLOGY,72170,Radiologic examination of the pelvis,320,$420.00 ,$357.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$85.55 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,72190,XR PELVIS/BOTH OBLIQUES 3 VW,320,$565.00 ,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,72202,XR SACROILLIAC JOINTS 3 VIEW,320,$410.00 ,$348.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$230.42 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$143.50 ,35% based on GA Medicaid OP CCR Rate,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$83.52 ,$369.00 ,$328.00 
Outpatient Medical Services,RADIOLOGY,73000,Radiologic examination of the collar bone,320,$370.00 ,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$207.94 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$129.50 ,35% based on GA Medicaid OP CCR Rate,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$333.00 ,$296.00 
Outpatient Medical Services,RADIOLOGY,72240,XR MYELO CERVICAL,320,"$1,615.00 ","$1,372.75 ",85% of total billed charges,$642.68 ,Pays 100% Medicare OPPS,$642.68 ,Pays 100% Medicare OPPS,$642.68 ,Pays 100% Medicare OPPS,$847.01 ,Pays 130% Medicare OPPS,$328.98 ,20.37% based on GA Medicaid OP CCR Rate,$912.48 ,56.5 percent of total billed charges,$912.48 ,56.5 percent of total billed charges,$912.48 ,56.5 percent of total billed charges,$907.63 ,56.5 percent of total billed charges,$655.53 ,Pays 102% Medicare OPPS,"$1,453.50 ",90% of total billed charges,$565.25 ,35% based on GA Medicaid OP CCR Rate,"$1,109.51 ",68.7% of total billed charges,"$1,292.00 ",80 percent of total billed charges,$642.68 ,Pays 100% Medicare OPPS,$578.41 ,Pays 90% Medicare OPPS,$936.70 ,58% of total billed charges,$328.98 ,20.37% based on GA Medicaid OP CCR Rate,$651.54 ,Pays 100% Medicare OPPS,$847.01 ,Pays 130% Medicare OPPS,"$1,372.75 ",85% of total billed charges,$642.68 ,Pays 100% Medicare OPPS,$328.98 ,"$1,453.50 ","$1,292.00 "
Outpatient Medical Services,RADIOLOGY,72255,XR MYELO THORACIC,320,"$1,615.00 ","$1,372.75 ",85% of total billed charges,$642.68 ,Pays 100% Medicare OPPS,$642.68 ,Pays 100% Medicare OPPS,$642.68 ,Pays 100% Medicare OPPS,$847.01 ,Pays 130% Medicare OPPS,$328.98 ,20.37% based on GA Medicaid OP CCR Rate,$912.48 ,56.5 percent of total billed charges,$912.48 ,56.5 percent of total billed charges,$912.48 ,56.5 percent of total billed charges,$907.63 ,56.5 percent of total billed charges,$655.53 ,Pays 102% Medicare OPPS,"$1,453.50 ",90% of total billed charges,$565.25 ,35% based on GA Medicaid OP CCR Rate,"$1,109.51 ",68.7% of total billed charges,"$1,292.00 ",80 percent of total billed charges,$642.68 ,Pays 100% Medicare OPPS,$578.41 ,Pays 90% Medicare OPPS,$936.70 ,58% of total billed charges,$328.98 ,20.37% based on GA Medicaid OP CCR Rate,$651.54 ,Pays 100% Medicare OPPS,$847.01 ,Pays 130% Medicare OPPS,"$1,372.75 ",85% of total billed charges,$642.68 ,Pays 100% Medicare OPPS,$328.98 ,"$1,453.50 ","$1,292.00 "
Outpatient Medical Services,RADIOLOGY,72265,XR MYELO LUMBAR,320,"$1,615.00 ","$1,372.75 ",85% of total billed charges,$642.68 ,Pays 100% Medicare OPPS,$642.68 ,Pays 100% Medicare OPPS,$642.68 ,Pays 100% Medicare OPPS,$847.01 ,Pays 130% Medicare OPPS,$328.98 ,20.37% based on GA Medicaid OP CCR Rate,$912.48 ,56.5 percent of total billed charges,$912.48 ,56.5 percent of total billed charges,$912.48 ,56.5 percent of total billed charges,$907.63 ,56.5 percent of total billed charges,$655.53 ,Pays 102% Medicare OPPS,"$1,453.50 ",90% of total billed charges,$565.25 ,35% based on GA Medicaid OP CCR Rate,"$1,109.51 ",68.7% of total billed charges,"$1,292.00 ",80 percent of total billed charges,$642.68 ,Pays 100% Medicare OPPS,$578.41 ,Pays 90% Medicare OPPS,$936.70 ,58% of total billed charges,$328.98 ,20.37% based on GA Medicaid OP CCR Rate,$651.54 ,Pays 100% Medicare OPPS,$847.01 ,Pays 130% Medicare OPPS,"$1,372.75 ",85% of total billed charges,$642.68 ,Pays 100% Medicare OPPS,$328.98 ,"$1,453.50 ","$1,292.00 "
Outpatient Medical Services,RADIOLOGY,73000,Radiologic examination of the collar bone,320,$370.00 ,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$207.94 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$129.50 ,35% based on GA Medicaid OP CCR Rate,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$333.00 ,$296.00 
Outpatient Medical Services,RADIOLOGY,73010,XR SCAPULA RT,320,$420.00 ,$357.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$85.55 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73040,XR ARTHROGRAM SHOULDER,322,"$1,045.00 ",$888.25 ,85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.28 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$587.29 ,56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.28 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$212.87 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,73050,XR A C JOINTS,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73060,XR HUMERUS AP/LATERAL RT,320,$435.00 ,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,74455,XR CYSTOURETHROGRAM,320,$710.00 ,$603.50 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$399.02 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,$639.00 ,90% of total billed charges,$248.50 ,35% based on GA Medicaid OP CCR Rate,$487.77 ,68.7% of total billed charges,$568.00 ,80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$411.80 ,58% of total billed charges,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$603.50 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$144.63 ,$639.00 ,$568.00 
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",320,$440.00 ,$374.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$89.63 ,20.37% based on GA Medicaid OP CCR Rate,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,$247.28 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$396.00 ,90% of total billed charges,$154.00 ,35% based on GA Medicaid OP CCR Rate,$302.28 ,68.7% of total billed charges,$352.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$255.20 ,58% of total billed charges,$89.63 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$374.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$396.00 ,$352.00 
Outpatient Medical Services,RADIOLOGY,73080,"Radiologic examination, elbow; 3 or more views",320,$440.00 ,$374.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$89.63 ,20.37% based on GA Medicaid OP CCR Rate,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,$247.28 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$396.00 ,90% of total billed charges,$154.00 ,35% based on GA Medicaid OP CCR Rate,$302.28 ,68.7% of total billed charges,$352.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$255.20 ,58% of total billed charges,$89.63 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$374.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$396.00 ,$352.00 
Outpatient Medical Services,RADIOLOGY,73090,Radiologic examination of the forearm,320,$370.00 ,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$207.94 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$129.50 ,35% based on GA Medicaid OP CCR Rate,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$333.00 ,$296.00 
Outpatient Medical Services,RADIOLOGY,73092,XR TOTAL EXTRMITY UPPER RT,320,$420.00 ,$357.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$85.55 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,$300.00 ,$255.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$168.60 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$105.00 ,35% based on GA Medicaid OP CCR Rate,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$61.11 ,$270.00 ,$240.00 
Outpatient Medical Services,RADIOLOGY,73502,XR HIP AP/LATERAL RT,320,$435.00 ,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,73552,XR FEMUR AP/LAT RT,320,$435.00 ,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,70150,XR FACIAL BONES 4 VIEWS,320,$565.00 ,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,$435.00 ,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,$510.00 ,$433.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$103.89 ,20.37% based on GA Medicaid OP CCR Rate,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$286.62 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$459.00 ,90% of total billed charges,$178.50 ,35% based on GA Medicaid OP CCR Rate,$350.37 ,68.7% of total billed charges,$408.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$295.80 ,58% of total billed charges,$103.89 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$433.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$459.00 ,$408.00 
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,320,$565.00 ,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,73565,Radiologic examination of both knees,320,$435.00 ,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73592,XR LOWER EXTRMITY TOTAL RT,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73600,Radiologic examination of the ankle with 2 views,320,$295.00 ,$250.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$60.09 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$165.79 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$103.25 ,35% based on GA Medicaid OP CCR Rate,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$60.09 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$60.09 ,$265.50 ,$236.00 
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73630,Radiologic examination of the foot with 3 or more views,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,$300.00 ,$255.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$168.60 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$105.00 ,35% based on GA Medicaid OP CCR Rate,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$61.11 ,$270.00 ,$240.00 
Outpatient Medical Services,RADIOLOGY,74018,XR ABD/KUB,320,$375.00 ,$318.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$210.75 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$131.25 ,35% based on GA Medicaid OP CCR Rate,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$337.50 ,$300.00 
Outpatient Medical Services,RADIOLOGY,74018,XR ABDOMEN FLATUPRIGHT,320,$520.00 ,$442.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$105.92 ,20.37% based on GA Medicaid OP CCR Rate,$293.80 ,56.5 percent of total billed charges,$293.80 ,56.5 percent of total billed charges,$293.80 ,56.5 percent of total billed charges,$292.24 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$468.00 ,90% of total billed charges,$182.00 ,35% based on GA Medicaid OP CCR Rate,$357.24 ,68.7% of total billed charges,$416.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$301.60 ,58% of total billed charges,$105.92 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$442.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$468.00 ,$416.00 
Outpatient Medical Services,RADIOLOGY,74022,Serial radiologic examination of the abdomen,320,$620.00 ,$527.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$126.29 ,20.37% based on GA Medicaid OP CCR Rate,$350.30 ,56.5 percent of total billed charges,$350.30 ,56.5 percent of total billed charges,$350.30 ,56.5 percent of total billed charges,$348.44 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$558.00 ,90% of total billed charges,$217.00 ,35% based on GA Medicaid OP CCR Rate,$425.94 ,68.7% of total billed charges,$496.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$359.60 ,58% of total billed charges,$126.29 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$527.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$558.00 ,$496.00 
Outpatient Medical Services,RADIOLOGY,74220,XR BARIUM SWALLOW,320,$860.00 ,$731.00 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$175.18 ,20.37% based on GA Medicaid OP CCR Rate,$485.90 ,56.5 percent of total billed charges,$485.90 ,56.5 percent of total billed charges,$485.90 ,56.5 percent of total billed charges,$483.32 ,56.5 percent of total billed charges,$163.67 ,Pays 102% Medicare OPPS,$774.00 ,90% of total billed charges,$301.00 ,35% based on GA Medicaid OP CCR Rate,$590.82 ,68.7% of total billed charges,$688.00 ,80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,$498.80 ,58% of total billed charges,$175.18 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$731.00 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,$774.00 ,$688.00 
Outpatient Medical Services,RADIOLOGY,74230,XR BARIUM SWALLOW/MODIFIED,320,$885.00 ,$752.25 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$497.37 ,56.5 percent of total billed charges,$163.67 ,Pays 102% Medicare OPPS,$796.50 ,90% of total billed charges,$309.75 ,35% based on GA Medicaid OP CCR Rate,$608.00 ,68.7% of total billed charges,$708.00 ,80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,$513.30 ,58% of total billed charges,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$752.25 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,$796.50 ,$708.00 
Outpatient Medical Services,RADIOLOGY,74240,XR GI SINGLE CONTRAST,320,"$1,125.00 ",$956.25 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$229.16 ,20.37% based on GA Medicaid OP CCR Rate,$635.63 ,56.5 percent of total billed charges,$635.63 ,56.5 percent of total billed charges,$635.63 ,56.5 percent of total billed charges,$632.25 ,56.5 percent of total billed charges,$163.67 ,Pays 102% Medicare OPPS,"$1,012.50 ",90% of total billed charges,$393.75 ,35% based on GA Medicaid OP CCR Rate,$772.88 ,68.7% of total billed charges,$900.00 ,80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,$652.50 ,58% of total billed charges,$229.16 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$956.25 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$1,012.50 ",$900.00 
Outpatient Medical Services,RADIOLOGY,74245,XR GI W/SB SINGLE CONTRAST,320,"$1,125.00 ",$956.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$229.16 ,20.37% based on GA Medicaid OP CCR Rate,$635.63 ,56.5 percent of total billed charges,$635.63 ,56.5 percent of total billed charges,$635.63 ,56.5 percent of total billed charges,$632.25 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,"$1,012.50 ",90% of total billed charges,$393.75 ,35% based on GA Medicaid OP CCR Rate,$772.88 ,68.7% of total billed charges,$900.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$652.50 ,58% of total billed charges,$229.16 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$956.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$229.16 ,"$1,012.50 ",$900.00 
Outpatient Medical Services,RADIOLOGY,74220,XR GI BARIUM SWALLOW,320,"$1,625.00 ","$1,381.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$331.01 ,20.37% based on GA Medicaid OP CCR Rate,$918.13 ,56.5 percent of total billed charges,$918.13 ,56.5 percent of total billed charges,$918.13 ,56.5 percent of total billed charges,$913.25 ,56.5 percent of total billed charges,$163.67 ,Pays 102% Medicare OPPS,"$1,462.50 ",90% of total billed charges,$568.75 ,35% based on GA Medicaid OP CCR Rate,"$1,116.38 ",68.7% of total billed charges,"$1,300.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,$942.50 ,58% of total billed charges,$331.01 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,"$1,381.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$1,462.50 ","$1,300.00 "
Outpatient Medical Services,RADIOLOGY,74249,XR GI/AC W/SB,320,"$1,125.00 ",$956.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$229.16 ,20.37% based on GA Medicaid OP CCR Rate,$635.63 ,56.5 percent of total billed charges,$635.63 ,56.5 percent of total billed charges,$635.63 ,56.5 percent of total billed charges,$632.25 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,"$1,012.50 ",90% of total billed charges,$393.75 ,35% based on GA Medicaid OP CCR Rate,$772.88 ,68.7% of total billed charges,$900.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$652.50 ,58% of total billed charges,$229.16 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$956.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$229.16 ,"$1,012.50 ",$900.00 
Outpatient Medical Services,RADIOLOGY,74250,XR SMALL BOWEL,320,$800.00 ,$680.00 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$162.96 ,20.37% based on GA Medicaid OP CCR Rate,$452.00 ,56.5 percent of total billed charges,$452.00 ,56.5 percent of total billed charges,$452.00 ,56.5 percent of total billed charges,$449.60 ,56.5 percent of total billed charges,$163.67 ,Pays 102% Medicare OPPS,$720.00 ,90% of total billed charges,$280.00 ,35% based on GA Medicaid OP CCR Rate,$549.60 ,68.7% of total billed charges,$640.00 ,80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,$464.00 ,58% of total billed charges,$162.96 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$680.00 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,$720.00 ,$640.00 
Outpatient Medical Services,RADIOLOGY,74270,XR BARIUM ENEMA - BE,320,"$1,220.00 ","$1,037.00 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$248.51 ,20.37% based on GA Medicaid OP CCR Rate,$689.30 ,56.5 percent of total billed charges,$689.30 ,56.5 percent of total billed charges,$689.30 ,56.5 percent of total billed charges,$685.64 ,56.5 percent of total billed charges,$163.67 ,Pays 102% Medicare OPPS,"$1,098.00 ",90% of total billed charges,$427.00 ,35% based on GA Medicaid OP CCR Rate,$838.14 ,68.7% of total billed charges,$976.00 ,80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,$707.60 ,58% of total billed charges,$248.51 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,"$1,037.00 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$1,098.00 ",$976.00 
Outpatient Medical Services,RADIOLOGY,74280,XR BARIUM ENEMA AIR CON,320,"$1,510.00 ","$1,283.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,$307.59 ,20.37% based on GA Medicaid OP CCR Rate,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$848.62 ,56.5 percent of total billed charges,$163.67 ,Pays 102% Medicare OPPS,"$1,359.00 ",90% of total billed charges,$528.50 ,35% based on GA Medicaid OP CCR Rate,"$1,037.37 ",68.7% of total billed charges,"$1,208.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,$875.80 ,58% of total billed charges,$307.59 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,"$1,283.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$1,359.00 ","$1,208.00 "
Outpatient Medical Services,RADIOLOGY,74300,XR OPER CHOLANGIOGRAM,320,$975.00 ,$828.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$198.61 ,20.37% based on GA Medicaid OP CCR Rate,$550.88 ,56.5 percent of total billed charges,$550.88 ,56.5 percent of total billed charges,$550.88 ,56.5 percent of total billed charges,$547.95 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$877.50 ,90% of total billed charges,$341.25 ,35% based on GA Medicaid OP CCR Rate,$669.83 ,68.7% of total billed charges,$780.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$565.50 ,58% of total billed charges,$198.61 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$828.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$198.61 ,$877.50 ,$780.00 
Outpatient Medical Services,RADIOLOGY,74301,XR OPER CHOLANGI 2ND SET FILMS,320,$820.00 ,$697.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$167.03 ,20.37% based on GA Medicaid OP CCR Rate,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$460.84 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$738.00 ,90% of total billed charges,$287.00 ,35% based on GA Medicaid OP CCR Rate,$563.34 ,68.7% of total billed charges,$656.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$475.60 ,58% of total billed charges,$167.03 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$697.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$167.03 ,$738.00 ,$656.00 
Outpatient Medical Services,RADIOLOGY,74410,XR IVP,320,$940.00 ,$799.00 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$191.48 ,20.37% based on GA Medicaid OP CCR Rate,$531.10 ,56.5 percent of total billed charges,$531.10 ,56.5 percent of total billed charges,$531.10 ,56.5 percent of total billed charges,$528.28 ,56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,$846.00 ,90% of total billed charges,$329.00 ,35% based on GA Medicaid OP CCR Rate,$645.78 ,68.7% of total billed charges,$752.00 ,80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,$545.20 ,58% of total billed charges,$191.48 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$799.00 ,85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,$846.00 ,$752.00 
Outpatient Medical Services,RADIOLOGY,74420,XR RETROGRADE IVP,320,"$1,465.00 ","$1,245.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,$298.42 ,20.37% based on GA Medicaid OP CCR Rate,$827.73 ,56.5 percent of total billed charges,$827.73 ,56.5 percent of total billed charges,$827.73 ,56.5 percent of total billed charges,$823.33 ,56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$1,318.50 ",90% of total billed charges,$512.75 ,35% based on GA Medicaid OP CCR Rate,"$1,006.46 ",68.7% of total billed charges,"$1,172.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,$849.70 ,58% of total billed charges,$298.42 ,20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,245.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$1,318.50 ","$1,172.00 "
Outpatient Medical Services,RADIOLOGY,72220,XR COCCYX OR SACRUM,320,$375.00 ,$318.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$210.75 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$131.25 ,35% based on GA Medicaid OP CCR Rate,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$337.50 ,$300.00 
Outpatient Medical Services,RADIOLOGY,74430,XR CYSTOGRAM,320,$565.00 ,$480.25 ,85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.28 ,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.28 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$115.09 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,74740,XR HYSTERIOSALPINGOGRAM,320,$710.00 ,$603.50 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$399.02 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,$639.00 ,90% of total billed charges,$248.50 ,35% based on GA Medicaid OP CCR Rate,$487.77 ,68.7% of total billed charges,$568.00 ,80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$411.80 ,58% of total billed charges,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$603.50 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$144.63 ,$639.00 ,$568.00 
Outpatient Medical Services,RADIOLOGY,75820,XR VENOGRAM RT,320,"$2,115.00 ","$1,797.75 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,$430.83 ,20.37% based on GA Medicaid OP CCR Rate,"$1,194.98 ",56.5 percent of total billed charges,"$1,194.98 ",56.5 percent of total billed charges,"$1,194.98 ",56.5 percent of total billed charges,"$1,188.63 ",56.5 percent of total billed charges,"$1,288.48 ",Pays 102% Medicare OPPS,"$1,903.50 ",90% of total billed charges,$740.25 ,35% based on GA Medicaid OP CCR Rate,"$1,453.01 ",68.7% of total billed charges,"$1,692.00 ",80 percent of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,136.89 ",Pays 90% Medicare OPPS,"$1,226.70 ",58% of total billed charges,$430.83 ,20.37% based on GA Medicaid OP CCR Rate,"$1,308.68 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,"$1,797.75 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,$430.83 ,"$1,903.50 ","$1,692.00 "
Outpatient Medical Services,RADIOLOGY,77002,XR FLURO GUIDANCE NEEDLE PLACEMENT,320,"$1,195.00 ","$1,015.75 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$243.42 ,20.37% based on GA Medicaid OP CCR Rate,$675.18 ,56.5 percent of total billed charges,$675.18 ,56.5 percent of total billed charges,$675.18 ,56.5 percent of total billed charges,$671.59 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,"$1,075.50 ",90% of total billed charges,$418.25 ,35% based on GA Medicaid OP CCR Rate,$820.97 ,68.7% of total billed charges,$956.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$693.10 ,58% of total billed charges,$243.42 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$1,015.75 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,$243.42 ,"$1,075.50 ",$956.00 
Outpatient Medical Services,RADIOLOGY,70370,XR FLUROSCOPY OF LARYNX,320,"$1,010.00 ",$858.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$205.74 ,20.37% based on GA Medicaid OP CCR Rate,$570.65 ,56.5 percent of total billed charges,$570.65 ,56.5 percent of total billed charges,$570.65 ,56.5 percent of total billed charges,$567.62 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$909.00 ,90% of total billed charges,$353.50 ,35% based on GA Medicaid OP CCR Rate,$693.87 ,68.7% of total billed charges,$808.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$585.80 ,58% of total billed charges,$205.74 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$858.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$909.00 ,$808.00 
Outpatient Medical Services,RADIOLOGY,76010,XR KIDIGRAM,320,$370.00 ,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$209.05 ,56.5 percent of total billed charges,$207.94 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$333.00 ,90% of total billed charges,$129.50 ,35% based on GA Medicaid OP CCR Rate,$254.19 ,68.7% of total billed charges,$296.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$214.60 ,58% of total billed charges,$75.37 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$314.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$333.00 ,$296.00 
Outpatient Medical Services,RADIOLOGY,77072,XR BONE AGE,320,$375.00 ,$318.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$210.75 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$131.25 ,35% based on GA Medicaid OP CCR Rate,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$76.39 ,$337.50 ,$300.00 
Outpatient Medical Services,RADIOLOGY,77075,XR BONE SURVEY-COMPLETE,320,"$1,090.00 ",$926.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$222.03 ,20.37% based on GA Medicaid OP CCR Rate,$615.85 ,56.5 percent of total billed charges,$615.85 ,56.5 percent of total billed charges,$615.85 ,56.5 percent of total billed charges,$612.58 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$981.00 ,90% of total billed charges,$381.50 ,35% based on GA Medicaid OP CCR Rate,$748.83 ,68.7% of total billed charges,$872.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$632.20 ,58% of total billed charges,$222.03 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$926.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$981.00 ,$872.00 
Outpatient Medical Services,RADIOLOGY,49465,XR GASTRIC TUBE INJECTION,320,$820.00 ,$697.00 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$167.03 ,20.37% based on GA Medicaid OP CCR Rate,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$460.84 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,$738.00 ,90% of total billed charges,$287.00 ,35% based on GA Medicaid OP CCR Rate,$563.34 ,68.7% of total billed charges,$656.00 ,80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$475.60 ,58% of total billed charges,$167.03 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$697.00 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$167.03 ,$738.00 ,$656.00 
Outpatient Medical Services,RADIOLOGY,77001,XR FLUROSCOPY PORTACATH INSERT,320,$840.00 ,$714.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$171.11 ,20.37% based on GA Medicaid OP CCR Rate,$474.60 ,56.5 percent of total billed charges,$474.60 ,56.5 percent of total billed charges,$474.60 ,56.5 percent of total billed charges,$472.08 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$756.00 ,90% of total billed charges,$294.00 ,35% based on GA Medicaid OP CCR Rate,$577.08 ,68.7% of total billed charges,$672.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$487.20 ,58% of total billed charges,$171.11 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$714.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$171.11 ,$756.00 ,$672.00 
Outpatient Medical Services,RADIOLOGY,71100,XR RIBS UNILAT RT W/O PA CHEST  2 VIEW,320,$395.00 ,$335.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$221.99 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$355.50 ,$316.00 
Outpatient Medical Services,RADIOLOGY,71101,Radiologic examination of one side of the chest/ribs,320,$575.00 ,$488.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$323.15 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$201.25 ,35% based on GA Medicaid OP CCR Rate,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$517.50 ,$460.00 
Outpatient Medical Services,RADIOLOGY,73010,XR SCAPULA LT,320,$420.00 ,$357.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$85.55 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73030,Radiologic examination of the shoulder,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73060,XR HUMERUS AP/LATERAL LT,320,$435.00 ,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,73092,XR TOTAL EXTRMITY UPPER LT,320,$420.00 ,$357.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$85.55 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73110,Up to 3 views,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73130,X-ray of the hand with 3 or more views,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73140,Radiologic examination of the finger(s),320,$300.00 ,$255.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$168.60 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$105.00 ,35% based on GA Medicaid OP CCR Rate,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$61.11 ,$270.00 ,$240.00 
Outpatient Medical Services,RADIOLOGY,73502,XR HIP AP/LATERAL LT,320,$435.00 ,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,73552,XR FEMUR AP/LAT LT,320,$435.00 ,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,73560,Radiologic examination of the knee with 1 or 2 views,320,$435.00 ,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,73562,Radiologic examination of the knee with 3 views,320,$510.00 ,$433.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$103.89 ,20.37% based on GA Medicaid OP CCR Rate,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$288.15 ,56.5 percent of total billed charges,$286.62 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$459.00 ,90% of total billed charges,$178.50 ,35% based on GA Medicaid OP CCR Rate,$350.37 ,68.7% of total billed charges,$408.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$295.80 ,58% of total billed charges,$103.89 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$433.50 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$459.00 ,$408.00 
Outpatient Medical Services,RADIOLOGY,73564,Radiologic examination of the knee with 4 or more views,320,$565.00 ,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$319.23 ,56.5 percent of total billed charges,$317.53 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$508.50 ,90% of total billed charges,$197.75 ,35% based on GA Medicaid OP CCR Rate,$388.16 ,68.7% of total billed charges,$452.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$327.70 ,58% of total billed charges,$115.09 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$480.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$508.50 ,$452.00 
Outpatient Medical Services,RADIOLOGY,73590,Radiologic examination of the lower leg,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73592,XR LOWER EXTRMITY TOTAL LT,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73600,Radiologic examination of the ankle with 2 views,320,$295.00 ,$250.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$60.09 ,20.37% based on GA Medicaid OP CCR Rate,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$166.68 ,56.5 percent of total billed charges,$165.79 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$265.50 ,90% of total billed charges,$103.25 ,35% based on GA Medicaid OP CCR Rate,$202.67 ,68.7% of total billed charges,$236.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$171.10 ,58% of total billed charges,$60.09 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$250.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$60.09 ,$265.50 ,$236.00 
Outpatient Medical Services,RADIOLOGY,73610,Radiologic examination of the ankle with 3 views,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73650,Radiologic examination of the heel,320,$420.00 ,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$236.04 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$378.00 ,$336.00 
Outpatient Medical Services,RADIOLOGY,73660,Radiologic examination of the toe(s),320,$300.00 ,$255.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$168.60 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$105.00 ,35% based on GA Medicaid OP CCR Rate,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$61.11 ,$270.00 ,$240.00 
Outpatient Medical Services,RADIOLOGY,75820,XR VENOGRAM LT,320,"$2,115.00 ","$1,797.75 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,$430.83 ,20.37% based on GA Medicaid OP CCR Rate,"$1,194.98 ",56.5 percent of total billed charges,"$1,194.98 ",56.5 percent of total billed charges,"$1,194.98 ",56.5 percent of total billed charges,"$1,188.63 ",56.5 percent of total billed charges,"$1,288.48 ",Pays 102% Medicare OPPS,"$1,903.50 ",90% of total billed charges,$740.25 ,35% based on GA Medicaid OP CCR Rate,"$1,453.01 ",68.7% of total billed charges,"$1,692.00 ",80 percent of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,136.89 ",Pays 90% Medicare OPPS,"$1,226.70 ",58% of total billed charges,$430.83 ,20.37% based on GA Medicaid OP CCR Rate,"$1,308.68 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,"$1,797.75 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,$430.83 ,"$1,903.50 ","$1,692.00 "
Outpatient Medical Services,RADIOLOGY,77080,Scan to measure bone mineral density (BMD) at the spine and hip,320,$840.00 ,$714.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$171.11 ,20.37% based on GA Medicaid OP CCR Rate,$474.60 ,56.5 percent of total billed charges,$474.60 ,56.5 percent of total billed charges,$474.60 ,56.5 percent of total billed charges,$472.08 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$756.00 ,90% of total billed charges,$294.00 ,35% based on GA Medicaid OP CCR Rate,$577.08 ,68.7% of total billed charges,$672.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$487.20 ,58% of total billed charges,$171.11 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$714.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$756.00 ,$672.00 
Outpatient Medical Services,RADIOLOGY,77080,Scan to measure bone mineral density (BMD) at the spine and hip,320,$150.00 ,$127.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$30.56 ,20.37% based on GA Medicaid OP CCR Rate,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.75 ,56.5 percent of total billed charges,$84.30 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$52.50 ,35% based on GA Medicaid OP CCR Rate,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$30.56 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$30.56 ,$135.00 ,$120.00 
Outpatient Medical Services,RADIOLOGY,71250,CT scan of the thorax without dye,352,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,71260,CT scan of the thorax with dye,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,71270,CT THORAX W/WO CONTRAST,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,73200,CT UPPER EXT W/O-LEFT,352,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,73201,CT UPPER EXT W/CONT-LEFT,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,73202,CT UPPER EXT W/WO LEFT,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,73701,CT LOWER EXT W/CONTR-LEFT,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,73702,CT LOWER EXT W/WO LEFT,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,72128,CT DORSAL SPN W/O CONTRAS,352,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,72129,CT DORSAL SPINE W/CON,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,62284,INJECTION FOR MYELOGRAPHY,352,$300.00 ,$255.00 ,85% of total billed charges,$75.00 ,Pays 100% Medicare OPPS,$75.00 ,Pays 100% Medicare OPPS,$75.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$168.60 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$105.00 ,35% based on GA Medicaid OP CCR Rate,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$270.00 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$61.11 ,$270.00 ,$240.00 
Outpatient Medical Services,RADIOLOGY,70450,CT scan head or brain without dye,351,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,70460,CT HEAD WITH CONTRAST,351,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,70470,CT HEAD W & W/O CONTRAST,351,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,70480,CT ORBITS W/O,351,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,70481,CT ORBITS WITH,351,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,70482,CT ORBITS W/WO,351,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,70486,CT Scan of the face and jaw without dye,351,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,70487,CT MACILLO FACIAL AREA WITH,351,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,70488,CT MAXILLO FACIAL AREA W/WO,351,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,70490,CT SOFT TISSUE NECK WO,351,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,70491,CT scan of neck with dye,351,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,70492,CT SOFT TISSUE NECK W/WO,351,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,70496,CTA HEAD W/WO,350,"$3,990.00 ","$3,391.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$812.76 ,20.37% based on GA Medicaid OP CCR Rate,"$2,254.35 ",56.5 percent of total billed charges,"$2,254.35 ",56.5 percent of total billed charges,"$2,254.35 ",56.5 percent of total billed charges,"$2,242.38 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,591.00 ",90% of total billed charges,"$1,396.50 ",35% based on GA Medicaid OP CCR Rate,"$2,741.13 ",68.7% of total billed charges,"$3,192.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,314.20 ",58% of total billed charges,$812.76 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,391.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,591.00 ","$3,192.00 "
Outpatient Medical Services,RADIOLOGY,70498,CTA NECK W/WO,351,"$4,070.00 ","$3,459.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$829.06 ,20.37% based on GA Medicaid OP CCR Rate,"$2,299.55 ",56.5 percent of total billed charges,"$2,299.55 ",56.5 percent of total billed charges,"$2,299.55 ",56.5 percent of total billed charges,"$2,287.34 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,663.00 ",90% of total billed charges,"$1,424.50 ",35% based on GA Medicaid OP CCR Rate,"$2,796.09 ",68.7% of total billed charges,"$3,256.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,360.60 ",58% of total billed charges,$829.06 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,459.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,663.00 ","$3,256.00 "
Outpatient Medical Services,RADIOLOGY,71250,CT scan of the thorax without dye,352,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,71260,CT scan of the thorax with dye,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,71270,CT THORAX W/OUT CONTRAST,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,71275,Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,350,"$3,960.00 ","$3,366.00 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$806.65 ,20.37% based on GA Medicaid OP CCR Rate,"$2,237.40 ",56.5 percent of total billed charges,"$2,237.40 ",56.5 percent of total billed charges,"$2,237.40 ",56.5 percent of total billed charges,"$2,225.52 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,564.00 ",90% of total billed charges,"$1,386.00 ",35% based on GA Medicaid OP CCR Rate,"$2,720.52 ",68.7% of total billed charges,"$3,168.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,296.80 ",58% of total billed charges,$806.65 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,366.00 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,564.00 ","$3,168.00 "
Outpatient Medical Services,RADIOLOGY,72130,CT DORSAL SPINE W/WO CONTRAST,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,73701,CT LOWER EXT W/O CONTRAST LEFT,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,72125,CT CERVICAL SPINE W/OUT CONTRAST,352,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,72126,CT CERVICAL SPINE W/CONTRAST,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,72127,CT CERVICAL SPINE W/WO,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,72128,CT THORACIC SPINE W/O,352,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,72129,CT THORACIC SPINE WITH,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,72130,CT THORACIC SPINE W/WO,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,72131,CT scan of lower spine without dye,352,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,72132,CT LUMBAR SPINE W/CONTRAST,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,72133,CT LUMBAR SPINE W/WO,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,72191,CTA PELVIS W/WO,350,"$3,845.00 ","$3,268.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$783.23 ,20.37% based on GA Medicaid OP CCR Rate,"$2,172.43 ",56.5 percent of total billed charges,"$2,172.43 ",56.5 percent of total billed charges,"$2,172.43 ",56.5 percent of total billed charges,"$2,160.89 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,460.50 ",90% of total billed charges,"$1,345.75 ",35% based on GA Medicaid OP CCR Rate,"$2,641.52 ",68.7% of total billed charges,"$3,076.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,230.10 ",58% of total billed charges,$783.23 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,268.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,460.50 ","$3,076.00 "
Outpatient Medical Services,RADIOLOGY,72192,CT of pelvis without dye,352,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,72193,"CT scan, pelvis, with contrast",352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,72194,CT PELVIS W & W/O CON,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,73700,CT scan of leg without dye,352,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,73200,CT UPPER EXT W/O-RIGHT,352,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,73201,CT UPPER EXT W/CONT-RIGHT,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,73202,CT UPPER EXT W&W/O-RIGHT,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,73206,CTA UPPER EXTREMITY W/WO,352,"$3,540.00 ","$3,009.00 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$721.10 ,20.37% based on GA Medicaid OP CCR Rate,"$2,000.10 ",56.5 percent of total billed charges,"$2,000.10 ",56.5 percent of total billed charges,"$2,000.10 ",56.5 percent of total billed charges,"$1,989.48 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,186.00 ",90% of total billed charges,"$1,239.00 ",35% based on GA Medicaid OP CCR Rate,"$2,431.98 ",68.7% of total billed charges,"$2,832.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,053.20 ",58% of total billed charges,$721.10 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,009.00 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,186.00 ","$2,832.00 "
Outpatient Medical Services,RADIOLOGY,73700,CT scan of leg without dye,352,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,73701,CT LOWER EXT W/CONT-RIGHT,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,73702,CT LOWER EXT W/WO RIGHT,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,72130,CT DORSAL SPINE,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,76377,CT 3-D IND/WK STATION,352,"$1,010.00 ",$858.50 ,85% of total billed charges,$252.50 ,Pays 100% Medicare OPPS,$252.50 ,Pays 100% Medicare OPPS,$252.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$205.74 ,20.37% based on GA Medicaid OP CCR Rate,$570.65 ,56.5 percent of total billed charges,$570.65 ,56.5 percent of total billed charges,$570.65 ,56.5 percent of total billed charges,$567.62 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$909.00 ,90% of total billed charges,$353.50 ,35% based on GA Medicaid OP CCR Rate,$693.87 ,68.7% of total billed charges,$808.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$909.00 ,Pays 90% Medicare OPPS,$585.80 ,58% of total billed charges,$205.74 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$858.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$205.74 ,$909.00 ,$808.00 
Outpatient Medical Services,RADIOLOGY,73706,CTA LOWER EXTREMITY W/WO,352,"$3,650.00 ","$3,102.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$743.51 ,20.37% based on GA Medicaid OP CCR Rate,"$2,062.25 ",56.5 percent of total billed charges,"$2,062.25 ",56.5 percent of total billed charges,"$2,062.25 ",56.5 percent of total billed charges,"$2,051.30 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,285.00 ",90% of total billed charges,"$1,277.50 ",35% based on GA Medicaid OP CCR Rate,"$2,507.55 ",68.7% of total billed charges,"$2,920.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,117.00 ",58% of total billed charges,$743.51 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,102.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,285.00 ","$2,920.00 "
Outpatient Medical Services,RADIOLOGY,74160,CT of abdomen with dye,352,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,836.25 ",56.5 percent of total billed charges,"$1,826.50 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,RADIOLOGY,74150,CT of abdomen without dye,352,"$3,245.00 ","$2,758.25 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$661.01 ,20.37% based on GA Medicaid OP CCR Rate,"$1,833.43 ",56.5 percent of total billed charges,"$1,833.43 ",56.5 percent of total billed charges,"$1,833.43 ",56.5 percent of total billed charges,"$1,823.69 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$2,920.50 ",90% of total billed charges,"$1,135.75 ",35% based on GA Medicaid OP CCR Rate,"$2,229.32 ",68.7% of total billed charges,"$2,596.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,882.10 ",58% of total billed charges,$661.01 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$2,758.25 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$2,920.50 ","$2,596.00 "
Outpatient Medical Services,RADIOLOGY,74170,CT of abdomen with and without dye,352,"$3,545.00 ","$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$2,002.93 ",56.5 percent of total billed charges,"$1,992.29 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,190.50 ",90% of total billed charges,"$1,240.75 ",35% based on GA Medicaid OP CCR Rate,"$2,435.42 ",68.7% of total billed charges,"$2,836.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,056.10 ",58% of total billed charges,$722.12 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,013.25 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,190.50 ","$2,836.00 "
Outpatient Medical Services,RADIOLOGY,74174,CTA ABDOMEN AND PELVIS,352,"$4,785.00 ","$4,067.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,$974.70 ,20.37% based on GA Medicaid OP CCR Rate,"$2,703.53 ",56.5 percent of total billed charges,"$2,703.53 ",56.5 percent of total billed charges,"$2,703.53 ",56.5 percent of total billed charges,"$2,689.17 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,306.50 ",90% of total billed charges,"$1,674.75 ",35% based on GA Medicaid OP CCR Rate,"$3,287.30 ",68.7% of total billed charges,"$3,828.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,775.30 ",58% of total billed charges,$974.70 ,20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,067.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,306.50 ","$3,828.00 "
Outpatient Medical Services,RADIOLOGY,74175,CTA ABDOMEN W/WO,352,"$3,915.00 ","$3,327.75 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,$797.49 ,20.37% based on GA Medicaid OP CCR Rate,"$2,211.98 ",56.5 percent of total billed charges,"$2,211.98 ",56.5 percent of total billed charges,"$2,211.98 ",56.5 percent of total billed charges,"$2,200.23 ",56.5 percent of total billed charges,$163.66 ,Pays 102% Medicare OPPS,"$3,523.50 ",90% of total billed charges,"$1,370.25 ",35% based on GA Medicaid OP CCR Rate,"$2,689.61 ",68.7% of total billed charges,"$3,132.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$2,270.70 ",58% of total billed charges,$797.49 ,20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.20 ,Pays 130% Medicare OPPS,"$3,327.75 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$3,523.50 ","$3,132.00 "
Outpatient Medical Services,RADIOLOGY,74176,CT of abdomen and pelvis without dye,352,"$6,445.00 ","$5,478.25 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,312.85 ",20.37% based on GA Medicaid OP CCR Rate,"$3,641.43 ",56.5 percent of total billed charges,"$3,641.43 ",56.5 percent of total billed charges,"$3,641.43 ",56.5 percent of total billed charges,"$3,622.09 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$5,800.50 ",90% of total billed charges,"$2,255.75 ",35% based on GA Medicaid OP CCR Rate,"$4,427.72 ",68.7% of total billed charges,"$5,156.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$3,738.10 ",58% of total billed charges,"$1,312.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$5,478.25 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$5,800.50 ","$5,156.00 "
Outpatient Medical Services,RADIOLOGY,74177,CT scan of abdomen and pelvis with contrast,352,"$6,500.00 ","$5,525.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,324.05 ",20.37% based on GA Medicaid OP CCR Rate,"$3,672.50 ",56.5 percent of total billed charges,"$3,672.50 ",56.5 percent of total billed charges,"$3,672.50 ",56.5 percent of total billed charges,"$3,653.00 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$5,850.00 ",90% of total billed charges,"$2,275.00 ",35% based on GA Medicaid OP CCR Rate,"$4,465.50 ",68.7% of total billed charges,"$5,200.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,770.00 ",58% of total billed charges,"$1,324.05 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,525.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$5,850.00 ","$5,200.00 "
Outpatient Medical Services,RADIOLOGY,74178,"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",352,"$7,090.00 ","$6,026.50 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,444.23 ",20.37% based on GA Medicaid OP CCR Rate,"$4,005.85 ",56.5 percent of total billed charges,"$4,005.85 ",56.5 percent of total billed charges,"$4,005.85 ",56.5 percent of total billed charges,"$3,984.58 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$6,381.00 ",90% of total billed charges,"$2,481.50 ",35% based on GA Medicaid OP CCR Rate,"$4,870.83 ",68.7% of total billed charges,"$5,672.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$4,112.20 ",58% of total billed charges,"$1,444.23 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$6,026.50 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$6,381.00 ","$5,672.00 "
Outpatient Medical Services,RADIOLOGY,76376,CT 3-D RECON AT CT,350,$950.00 ,$807.50 ,85% of total billed charges,$237.50 ,Pays 100% Medicare OPPS,$237.50 ,Pays 100% Medicare OPPS,$237.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$193.52 ,20.37% based on GA Medicaid OP CCR Rate,$536.75 ,56.5 percent of total billed charges,$536.75 ,56.5 percent of total billed charges,$536.75 ,56.5 percent of total billed charges,$533.90 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$855.00 ,90% of total billed charges,$332.50 ,35% based on GA Medicaid OP CCR Rate,$652.65 ,68.7% of total billed charges,$760.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$855.00 ,Pays 90% Medicare OPPS,$551.00 ,58% of total billed charges,$193.52 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$807.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$193.52 ,$855.00 ,$760.00 
Outpatient Medical Services,RADIOLOGY,75635,CTA AORTA W/RUNOFF W/WO,352,"$5,460.00 ","$4,641.00 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$160.46 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,"$1,112.20 ",20.37% based on GA Medicaid OP CCR Rate,"$3,084.90 ",56.5 percent of total billed charges,"$3,084.90 ",56.5 percent of total billed charges,"$3,084.90 ",56.5 percent of total billed charges,"$3,068.52 ",56.5 percent of total billed charges,$163.67 ,Pays 102% Medicare OPPS,"$4,914.00 ",90% of total billed charges,"$1,911.00 ",35% based on GA Medicaid OP CCR Rate,"$3,751.02 ",68.7% of total billed charges,"$4,368.00 ",80 percent of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,Pays 90% Medicare OPPS,"$3,166.80 ",58% of total billed charges,"$1,112.20 ",20.37% based on GA Medicaid OP CCR Rate,$158.62 ,Pays 100% Medicare OPPS,$206.21 ,Pays 130% Medicare OPPS,"$4,641.00 ",85% of total billed charges,$160.46 ,Pays 100% Medicare OPPS,$144.41 ,"$4,914.00 ","$4,368.00 "
Outpatient Medical Services,RADIOLOGY,77012,CT NEEDLE BIOPSY/JT INJECT,350,"$4,390.00 ","$3,731.50 ",85% of total billed charges,"$1,097.50 ",Pays 100% Medicare OPPS,"$1,097.50 ",Pays 100% Medicare OPPS,"$1,097.50 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$894.24 ,20.37% based on GA Medicaid OP CCR Rate,"$2,480.35 ",56.5 percent of total billed charges,"$2,480.35 ",56.5 percent of total billed charges,"$2,480.35 ",56.5 percent of total billed charges,"$2,467.18 ",56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,"$3,951.00 ",90% of total billed charges,"$1,536.50 ",35% based on GA Medicaid OP CCR Rate,"$3,015.93 ",68.7% of total billed charges,"$3,512.00 ",80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,"$3,951.00 ",Pays 90% Medicare OPPS,"$2,546.20 ",58% of total billed charges,$894.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$3,731.50 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,$894.24 ,"$3,951.00 ","$3,512.00 "
Outpatient Medical Services,RADIOLOGY,76380,CT LIMITED/LOCALIZED STUD,350,"$2,950.00 ","$2,507.50 ",85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$600.92 ,20.37% based on GA Medicaid OP CCR Rate,"$1,666.75 ",56.5 percent of total billed charges,"$1,666.75 ",56.5 percent of total billed charges,"$1,666.75 ",56.5 percent of total billed charges,"$1,657.90 ",56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,"$2,655.00 ",90% of total billed charges,"$1,032.50 ",35% based on GA Medicaid OP CCR Rate,"$2,026.65 ",68.7% of total billed charges,"$2,360.00 ",80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,"$1,711.00 ",58% of total billed charges,$600.92 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,"$2,507.50 ",85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,"$2,655.00 ","$2,360.00 "
Outpatient Medical Services,RADIOLOGY,76497,CT UNLISTED DIAG CT PROCEDUR,350,"$3,215.00 ","$2,732.75 ",85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,806.83 ",56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,RADIOLOGY,A9539,NM TC99M DTPA,343,$165.00 ,$140.25 ,85% of total billed charges,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$148.50 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$33.61 ,$148.50 ,$132.00 
Outpatient Medical Services,RADIOLOGY,A9540,NM TC99M MAA  10 MCI,343,$165.00 ,$140.25 ,85% of total billed charges,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$148.50 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$33.61 ,$148.50 ,$132.00 
Outpatient Medical Services,RADIOLOGY,A9537,NM TC99M CHOLETEC (MEBROFENIN),343,$310.00 ,$263.50 ,85% of total billed charges,$77.50 ,Pays 100% Medicare OPPS,$77.50 ,Pays 100% Medicare OPPS,$77.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$63.15 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$108.50 ,35% based on GA Medicaid OP CCR Rate,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$279.00 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$63.15 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$63.15 ,$279.00 ,$248.00 
Outpatient Medical Services,RADIOLOGY,A9500,NM TC99M CARDIOLITE,343,$820.00 ,$697.00 ,85% of total billed charges,$205.00 ,Pays 100% Medicare OPPS,$205.00 ,Pays 100% Medicare OPPS,$205.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$167.03 ,20.37% based on GA Medicaid OP CCR Rate,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,$463.30 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$738.00 ,90% of total billed charges,$287.00 ,35% based on GA Medicaid OP CCR Rate,$563.34 ,68.7% of total billed charges,$656.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$738.00 ,Pays 90% Medicare OPPS,$475.60 ,58% of total billed charges,$167.03 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$697.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$167.03 ,$738.00 ,$656.00 
Outpatient Medical Services,RADIOLOGY,A9500,NM TC04 TECHNETATE,341,$165.00 ,$140.25 ,85% of total billed charges,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$148.50 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$33.61 ,$148.50 ,$132.00 
Outpatient Medical Services,RADIOLOGY,A9516,NM I 123 CAPSULE 200 PER UCI,343,$240.00 ,$204.00 ,85% of total billed charges,$60.00 ,Pays 100% Medicare OPPS,$60.00 ,Pays 100% Medicare OPPS,$60.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$84.00 ,35% based on GA Medicaid OP CCR Rate,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$216.00 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$48.89 ,$216.00 ,$192.00 
Outpatient Medical Services,RADIOLOGY,A9510,NM TC99M HEPATOLITE,343,$210.00 ,$178.50 ,85% of total billed charges,$52.50 ,Pays 100% Medicare OPPS,$52.50 ,Pays 100% Medicare OPPS,$52.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$73.50 ,35% based on GA Medicaid OP CCR Rate,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$189.00 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$42.78 ,$189.00 ,$168.00 
Outpatient Medical Services,RADIOLOGY,A9541,NM TC99M SULFUR COLLOID,343,$165.00 ,$140.25 ,85% of total billed charges,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$148.50 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$33.61 ,$148.50 ,$132.00 
Outpatient Medical Services,RADIOLOGY,78012,NM I 123 THYROID MULTIDETECT,341,"$1,510.00 ","$1,283.50 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$307.59 ,20.37% based on GA Medicaid OP CCR Rate,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$853.15 ,56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,"$1,359.00 ",90% of total billed charges,$528.50 ,35% based on GA Medicaid OP CCR Rate,"$1,037.37 ",68.7% of total billed charges,"$1,208.00 ",80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,$875.80 ,58% of total billed charges,$307.59 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,"$1,283.50 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,"$1,359.00 ","$1,208.00 "
Outpatient Medical Services,RADIOLOGY,78013,NM THYROID IMAGING ONLY,341,"$1,165.00 ",$990.25 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$237.31 ,20.37% based on GA Medicaid OP CCR Rate,$658.23 ,56.5 percent of total billed charges,$658.23 ,56.5 percent of total billed charges,$658.23 ,56.5 percent of total billed charges,$658.23 ,56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,"$1,048.50 ",90% of total billed charges,$407.75 ,35% based on GA Medicaid OP CCR Rate,$800.36 ,68.7% of total billed charges,$932.00 ,80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,$675.70 ,58% of total billed charges,$237.31 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$990.25 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$237.31 ,"$1,048.50 ",$932.00 
Outpatient Medical Services,RADIOLOGY,78014,Scan using a radioactive medication (radiopharmaceutical) to take pictures or images of the thyroid gland.,341,"$1,575.00 ","$1,338.75 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$320.83 ,20.37% based on GA Medicaid OP CCR Rate,$889.88 ,56.5 percent of total billed charges,$889.88 ,56.5 percent of total billed charges,$889.88 ,56.5 percent of total billed charges,$889.88 ,56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,"$1,417.50 ",90% of total billed charges,$551.25 ,35% based on GA Medicaid OP CCR Rate,"$1,082.03 ",68.7% of total billed charges,"$1,260.00 ",80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,$913.50 ,58% of total billed charges,$320.83 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,"$1,338.75 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,"$1,417.50 ","$1,260.00 "
Outpatient Medical Services,RADIOLOGY,78070,NM PARATHYROID,341,$815.00 ,$692.75 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$166.02 ,20.37% based on GA Medicaid OP CCR Rate,$460.48 ,56.5 percent of total billed charges,$460.48 ,56.5 percent of total billed charges,$460.48 ,56.5 percent of total billed charges,$460.48 ,56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,$733.50 ,90% of total billed charges,$285.25 ,35% based on GA Medicaid OP CCR Rate,$559.91 ,68.7% of total billed charges,$652.00 ,80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,$472.70 ,58% of total billed charges,$166.02 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$692.75 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$166.02 ,$733.50 ,$652.00 
Outpatient Medical Services,RADIOLOGY,78215,NM LIVER/SPLEEN (NO SPECT),341,$970.00 ,$824.50 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$197.59 ,20.37% based on GA Medicaid OP CCR Rate,$548.05 ,56.5 percent of total billed charges,$548.05 ,56.5 percent of total billed charges,$548.05 ,56.5 percent of total billed charges,$548.05 ,56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,$873.00 ,90% of total billed charges,$339.50 ,35% based on GA Medicaid OP CCR Rate,$666.39 ,68.7% of total billed charges,$776.00 ,80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,$562.60 ,58% of total billed charges,$197.59 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$824.50 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$197.59 ,$873.00 ,$776.00 
Outpatient Medical Services,RADIOLOGY,78226,NM HIDA W/O EJECTION FRACTION,341,"$1,100.00 ",$935.00 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,$990.00 ,90% of total billed charges,$385.00 ,35% based on GA Medicaid OP CCR Rate,$755.70 ,68.7% of total billed charges,$880.00 ,80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,$638.00 ,58% of total billed charges,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$935.00 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$224.07 ,$990.00 ,$880.00 
Outpatient Medical Services,RADIOLOGY,78227,NM HIDA WITH EJECTION FRACTION,341,"$1,100.00 ",$935.00 ,85% of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$439.59 ,Pays 100% Medicare OPPS,$439.59 ,Pays 100% Medicare OPPS,$576.87 ,Pays 130% Medicare OPPS,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$448.38 ,Pays 102% Medicare OPPS,$990.00 ,90% of total billed charges,$385.00 ,35% based on GA Medicaid OP CCR Rate,$755.70 ,68.7% of total billed charges,$880.00 ,80 percent of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$395.63 ,Pays 90% Medicare OPPS,$638.00 ,58% of total billed charges,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,$443.74 ,Pays 100% Medicare OPPS,$576.87 ,Pays 130% Medicare OPPS,$935.00 ,85% of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$224.07 ,$990.00 ,$880.00 
Outpatient Medical Services,RADIOLOGY,78264,NM GASTRIC EMPTYING,341,"$1,865.00 ","$1,585.25 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$379.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,053.73 ",56.5 percent of total billed charges,"$1,053.73 ",56.5 percent of total billed charges,"$1,053.73 ",56.5 percent of total billed charges,"$1,053.73 ",56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,"$1,678.50 ",90% of total billed charges,$652.75 ,35% based on GA Medicaid OP CCR Rate,"$1,281.26 ",68.7% of total billed charges,"$1,492.00 ",80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,"$1,081.70 ",58% of total billed charges,$379.90 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,"$1,585.25 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,"$1,678.50 ","$1,492.00 "
Outpatient Medical Services,RADIOLOGY,78290,NM INTESTINE IMAGING,341,"$1,865.00 ","$1,585.25 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$379.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,053.73 ",56.5 percent of total billed charges,"$1,053.73 ",56.5 percent of total billed charges,"$1,053.73 ",56.5 percent of total billed charges,"$1,053.73 ",56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,"$1,678.50 ",90% of total billed charges,$652.75 ,35% based on GA Medicaid OP CCR Rate,"$1,281.26 ",68.7% of total billed charges,"$1,492.00 ",80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,"$1,081.70 ",58% of total billed charges,$379.90 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,"$1,585.25 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,"$1,678.50 ","$1,492.00 "
Outpatient Medical Services,RADIOLOGY,78300,NM LTD AREA BONE SCAN,341,"$1,150.00 ",$977.50 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$234.26 ,20.37% based on GA Medicaid OP CCR Rate,$649.75 ,56.5 percent of total billed charges,$649.75 ,56.5 percent of total billed charges,$649.75 ,56.5 percent of total billed charges,$649.75 ,56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,"$1,035.00 ",90% of total billed charges,$402.50 ,35% based on GA Medicaid OP CCR Rate,$790.05 ,68.7% of total billed charges,$920.00 ,80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,$667.00 ,58% of total billed charges,$234.26 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$977.50 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$234.26 ,"$1,035.00 ",$920.00 
Outpatient Medical Services,RADIOLOGY,78306,"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",341,"$1,890.00 ","$1,606.50 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$384.99 ,20.37% based on GA Medicaid OP CCR Rate,"$1,067.85 ",56.5 percent of total billed charges,"$1,067.85 ",56.5 percent of total billed charges,"$1,067.85 ",56.5 percent of total billed charges,"$1,067.85 ",56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,"$1,701.00 ",90% of total billed charges,$661.50 ,35% based on GA Medicaid OP CCR Rate,"$1,298.43 ",68.7% of total billed charges,"$1,512.00 ",80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,"$1,096.20 ",58% of total billed charges,$384.99 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,"$1,606.50 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,"$1,701.00 ","$1,512.00 "
Outpatient Medical Services,RADIOLOGY,78315,NM THREE PHASE BONE SCAN,341,"$1,925.00 ","$1,636.25 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$392.12 ,20.37% based on GA Medicaid OP CCR Rate,"$1,087.63 ",56.5 percent of total billed charges,"$1,087.63 ",56.5 percent of total billed charges,"$1,087.63 ",56.5 percent of total billed charges,"$1,087.63 ",56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,"$1,732.50 ",90% of total billed charges,$673.75 ,35% based on GA Medicaid OP CCR Rate,"$1,322.48 ",68.7% of total billed charges,"$1,540.00 ",80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,"$1,116.50 ",58% of total billed charges,$392.12 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,"$1,636.25 ",85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,"$1,732.50 ","$1,540.00 "
Outpatient Medical Services,RADIOLOGY,78451,NM MYOCARDIAL SPECT SINGLE S,341,"$3,025.00 ","$2,571.25 ",85% of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,517.67 ",Pays 130% Medicare OPPS,$616.19 ,20.37% based on GA Medicaid OP CCR Rate,"$1,709.13 ",56.5 percent of total billed charges,"$1,709.13 ",56.5 percent of total billed charges,"$1,709.13 ",56.5 percent of total billed charges,"$1,709.13 ",56.5 percent of total billed charges,"$1,197.38 ",Pays 102% Medicare OPPS,"$2,722.50 ",90% of total billed charges,"$1,058.75 ",35% based on GA Medicaid OP CCR Rate,"$2,078.18 ",68.7% of total billed charges,"$2,420.00 ",80 percent of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,056.50 ",Pays 90% Medicare OPPS,"$1,754.50 ",58% of total billed charges,$616.19 ,20.37% based on GA Medicaid OP CCR Rate,"$1,167.44 ",Pays 100% Medicare OPPS,"$1,517.67 ",Pays 130% Medicare OPPS,"$2,571.25 ",85% of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,$616.19 ,"$2,722.50 ","$2,420.00 "
Outpatient Medical Services,RADIOLOGY,78452,Image of the heart to assess perfusion,341,"$3,025.00 ","$2,571.25 ",85% of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,517.67 ",Pays 130% Medicare OPPS,$616.19 ,20.37% based on GA Medicaid OP CCR Rate,"$1,709.13 ",56.5 percent of total billed charges,"$1,709.13 ",56.5 percent of total billed charges,"$1,709.13 ",56.5 percent of total billed charges,"$1,709.13 ",56.5 percent of total billed charges,"$1,197.38 ",Pays 102% Medicare OPPS,"$2,722.50 ",90% of total billed charges,"$1,058.75 ",35% based on GA Medicaid OP CCR Rate,"$2,078.18 ",68.7% of total billed charges,"$2,420.00 ",80 percent of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,056.50 ",Pays 90% Medicare OPPS,"$1,754.50 ",58% of total billed charges,$616.19 ,20.37% based on GA Medicaid OP CCR Rate,"$1,167.44 ",Pays 100% Medicare OPPS,"$1,517.67 ",Pays 130% Medicare OPPS,"$2,571.25 ",85% of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,$616.19 ,"$2,722.50 ","$2,420.00 "
Outpatient Medical Services,RADIOLOGY,78452,Image of the heart to assess perfusion,341,$785.00 ,$667.25 ,85% of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,517.67 ",Pays 130% Medicare OPPS,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,"$1,197.38 ",Pays 102% Medicare OPPS,$706.50 ,90% of total billed charges,$274.75 ,35% based on GA Medicaid OP CCR Rate,$539.30 ,68.7% of total billed charges,$628.00 ,80 percent of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,056.50 ",Pays 90% Medicare OPPS,$455.30 ,58% of total billed charges,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,167.44 ",Pays 100% Medicare OPPS,"$1,517.67 ",Pays 130% Medicare OPPS,$667.25 ,85% of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,$159.90 ,"$1,517.67 ",$628.00 
Outpatient Medical Services,RADIOLOGY,78452,Image of the heart to assess perfusion,341,"$4,725.00 ","$4,016.25 ",85% of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,517.67 ",Pays 130% Medicare OPPS,$962.48 ,20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,197.38 ",Pays 102% Medicare OPPS,"$4,252.50 ",90% of total billed charges,"$1,653.75 ",35% based on GA Medicaid OP CCR Rate,"$3,246.08 ",68.7% of total billed charges,"$3,780.00 ",80 percent of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,"$1,056.50 ",Pays 90% Medicare OPPS,"$2,740.50 ",58% of total billed charges,$962.48 ,20.37% based on GA Medicaid OP CCR Rate,"$1,167.44 ",Pays 100% Medicare OPPS,"$1,517.67 ",Pays 130% Medicare OPPS,"$4,016.25 ",85% of total billed charges,"$1,173.90 ",Pays 100% Medicare OPPS,$962.48 ,"$4,252.50 ","$3,780.00 "
Outpatient Medical Services,RADIOLOGY,78481,NM MUGA,341,"$1,465.00 ","$1,245.25 ",85% of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$439.59 ,Pays 100% Medicare OPPS,$439.59 ,Pays 100% Medicare OPPS,$576.87 ,Pays 130% Medicare OPPS,$298.42 ,20.37% based on GA Medicaid OP CCR Rate,$827.73 ,56.5 percent of total billed charges,$827.73 ,56.5 percent of total billed charges,$827.73 ,56.5 percent of total billed charges,$827.73 ,56.5 percent of total billed charges,$448.38 ,Pays 102% Medicare OPPS,"$1,318.50 ",90% of total billed charges,$512.75 ,35% based on GA Medicaid OP CCR Rate,"$1,006.46 ",68.7% of total billed charges,"$1,172.00 ",80 percent of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$395.63 ,Pays 90% Medicare OPPS,$849.70 ,58% of total billed charges,$298.42 ,20.37% based on GA Medicaid OP CCR Rate,$443.74 ,Pays 100% Medicare OPPS,$576.87 ,Pays 130% Medicare OPPS,"$1,245.25 ",85% of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$298.42 ,"$1,318.50 ","$1,172.00 "
Outpatient Medical Services,RADIOLOGY,78580,NM PULMONARY PERFUSION,341,"$1,110.00 ",$943.50 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$226.11 ,20.37% based on GA Medicaid OP CCR Rate,$627.15 ,56.5 percent of total billed charges,$627.15 ,56.5 percent of total billed charges,$627.15 ,56.5 percent of total billed charges,$627.15 ,56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,$999.00 ,90% of total billed charges,$388.50 ,35% based on GA Medicaid OP CCR Rate,$762.57 ,68.7% of total billed charges,$888.00 ,80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,$643.80 ,58% of total billed charges,$226.11 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$943.50 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$226.11 ,$999.00 ,$888.00 
Outpatient Medical Services,RADIOLOGY,78582,NM PULMONARY VENTILATION/PERFUSION,341,$865.00 ,$735.25 ,85% of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$439.59 ,Pays 100% Medicare OPPS,$439.59 ,Pays 100% Medicare OPPS,$576.87 ,Pays 130% Medicare OPPS,$176.20 ,20.37% based on GA Medicaid OP CCR Rate,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$448.38 ,Pays 102% Medicare OPPS,$778.50 ,90% of total billed charges,$302.75 ,35% based on GA Medicaid OP CCR Rate,$594.26 ,68.7% of total billed charges,$692.00 ,80 percent of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$395.63 ,Pays 90% Medicare OPPS,$501.70 ,58% of total billed charges,$176.20 ,20.37% based on GA Medicaid OP CCR Rate,$443.74 ,Pays 100% Medicare OPPS,$576.87 ,Pays 130% Medicare OPPS,$735.25 ,85% of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$176.20 ,$778.50 ,$692.00 
Outpatient Medical Services,RADIOLOGY,78579,NM PULMONARY VENTILATION SCAN,341,$865.00 ,$735.25 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$176.20 ,20.37% based on GA Medicaid OP CCR Rate,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,$778.50 ,90% of total billed charges,$302.75 ,35% based on GA Medicaid OP CCR Rate,$594.26 ,68.7% of total billed charges,$692.00 ,80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,$501.70 ,58% of total billed charges,$176.20 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$735.25 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$176.20 ,$778.50 ,$692.00 
Outpatient Medical Services,RADIOLOGY,78707,NM RENAL SCAN,341,"$1,700.00 ","$1,445.00 ",85% of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$439.59 ,Pays 100% Medicare OPPS,$439.59 ,Pays 100% Medicare OPPS,$576.87 ,Pays 130% Medicare OPPS,$346.29 ,20.37% based on GA Medicaid OP CCR Rate,$960.50 ,56.5 percent of total billed charges,$960.50 ,56.5 percent of total billed charges,$960.50 ,56.5 percent of total billed charges,$960.50 ,56.5 percent of total billed charges,$448.38 ,Pays 102% Medicare OPPS,"$1,530.00 ",90% of total billed charges,$595.00 ,35% based on GA Medicaid OP CCR Rate,"$1,167.90 ",68.7% of total billed charges,"$1,360.00 ",80 percent of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$395.63 ,Pays 90% Medicare OPPS,$986.00 ,58% of total billed charges,$346.29 ,20.37% based on GA Medicaid OP CCR Rate,$443.74 ,Pays 100% Medicare OPPS,$576.87 ,Pays 130% Medicare OPPS,"$1,445.00 ",85% of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$346.29 ,"$1,530.00 ","$1,360.00 "
Outpatient Medical Services,RADIOLOGY,78709,NM RENAL SCAN W/CAPTOPRIL,341,"$1,910.00 ","$1,623.50 ",85% of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$439.59 ,Pays 100% Medicare OPPS,$439.59 ,Pays 100% Medicare OPPS,$576.87 ,Pays 130% Medicare OPPS,$389.07 ,20.37% based on GA Medicaid OP CCR Rate,"$1,079.15 ",56.5 percent of total billed charges,"$1,079.15 ",56.5 percent of total billed charges,"$1,079.15 ",56.5 percent of total billed charges,"$1,079.15 ",56.5 percent of total billed charges,$448.38 ,Pays 102% Medicare OPPS,"$1,719.00 ",90% of total billed charges,$668.50 ,35% based on GA Medicaid OP CCR Rate,"$1,312.17 ",68.7% of total billed charges,"$1,528.00 ",80 percent of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$395.63 ,Pays 90% Medicare OPPS,"$1,107.80 ",58% of total billed charges,$389.07 ,20.37% based on GA Medicaid OP CCR Rate,$443.74 ,Pays 100% Medicare OPPS,$576.87 ,Pays 130% Medicare OPPS,"$1,623.50 ",85% of total billed charges,$439.59 ,Pays 100% Medicare OPPS,$389.07 ,"$1,719.00 ","$1,528.00 "
Outpatient Medical Services,RADIOLOGY,78761,NM TESTICULAR SCAN,341,$990.00 ,$841.50 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$338.63 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$201.66 ,20.37% based on GA Medicaid OP CCR Rate,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$345.39 ,Pays 102% Medicare OPPS,$891.00 ,90% of total billed charges,$346.50 ,35% based on GA Medicaid OP CCR Rate,$680.13 ,68.7% of total billed charges,$792.00 ,80 percent of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,$574.20 ,58% of total billed charges,$201.66 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$841.50 ,85% of total billed charges,$338.63 ,Pays 100% Medicare OPPS,$201.66 ,$891.00 ,$792.00 
Outpatient Medical Services,RADIOLOGY,76942,US GUIDANCE CYS/ANY LOCATION,320,$700.00 ,$595.00 ,85% of total billed charges,$175.00 ,Pays 100% Medicare OPPS,$175.00 ,Pays 100% Medicare OPPS,$175.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$142.59 ,20.37% based on GA Medicaid OP CCR Rate,$395.50 ,56.5 percent of total billed charges,$395.50 ,56.5 percent of total billed charges,$395.50 ,56.5 percent of total billed charges,$393.40 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$630.00 ,90% of total billed charges,$245.00 ,35% based on GA Medicaid OP CCR Rate,$480.90 ,68.7% of total billed charges,$560.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$630.00 ,Pays 90% Medicare OPPS,$406.00 ,58% of total billed charges,$142.59 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$595.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$142.59 ,$630.00 ,$560.00 
Outpatient Medical Services,RADIOLOGY,93882,US CAROTID UNI RIGHT,320,"$1,260.00 ","$1,071.00 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$256.66 ,20.37% based on GA Medicaid OP CCR Rate,$711.90 ,56.5 percent of total billed charges,$711.90 ,56.5 percent of total billed charges,$711.90 ,56.5 percent of total billed charges,$708.12 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$1,134.00 ",90% of total billed charges,$441.00 ,35% based on GA Medicaid OP CCR Rate,$865.62 ,68.7% of total billed charges,"$1,008.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$730.80 ,58% of total billed charges,$256.66 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$1,071.00 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$1,134.00 ","$1,008.00 "
Outpatient Medical Services,RADIOLOGY,G0279,MM 3D MAMMO BIL DIAGNOSTIC,401,$135.00 ,$114.75 ,85% of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$21.26 ,Pays 100% Medicare OPPS,$21.26 ,Pays 100% Medicare OPPS,$27.94 ,Pays 130% Medicare OPPS,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$75.87 ,56.5 percent of total billed charges,$21.69 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$47.25 ,35% based on GA Medicaid OP CCR Rate,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$19.13 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$21.49 ,Pays 100% Medicare OPPS,$27.94 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$19.13 ,$121.50 ,$108.00 
Outpatient Medical Services,RADIOLOGY,G0279,MM 3D MAMMO UNILATERAL LEFT,401,$135.00 ,$114.75 ,85% of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$21.26 ,Pays 100% Medicare OPPS,$21.26 ,Pays 100% Medicare OPPS,$27.94 ,Pays 130% Medicare OPPS,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$75.87 ,56.5 percent of total billed charges,$21.69 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$47.25 ,35% based on GA Medicaid OP CCR Rate,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$19.13 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$21.49 ,Pays 100% Medicare OPPS,$27.94 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$19.13 ,$121.50 ,$108.00 
Outpatient Medical Services,RADIOLOGY,G0279,MM 3D MAMMO UNILATERAL RIGHT,401,$135.00 ,$114.75 ,85% of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$21.26 ,Pays 100% Medicare OPPS,$21.26 ,Pays 100% Medicare OPPS,$27.94 ,Pays 130% Medicare OPPS,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$75.87 ,56.5 percent of total billed charges,$21.69 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$47.25 ,35% based on GA Medicaid OP CCR Rate,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$19.13 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$21.49 ,Pays 100% Medicare OPPS,$27.94 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$19.13 ,$121.50 ,$108.00 
Outpatient Medical Services,RADIOLOGY,77066,"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",401,$435.00 ,$369.75 ,85% of total billed charges,$101.49 ,Pays 100% Medicare OPPS,$101.49 ,Pays 100% Medicare OPPS,$101.49 ,Pays 100% Medicare OPPS,$129.68 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$103.52 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$101.49 ,Pays 100% Medicare OPPS,$91.34 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$99.75 ,Pays 100% Medicare OPPS,$129.68 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$101.49 ,Pays 100% Medicare OPPS,$88.61 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,$435.00 ,$369.75 ,85% of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$79.61 ,Pays 100% Medicare OPPS,$79.61 ,Pays 100% Medicare OPPS,$101.74 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$81.20 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$71.65 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$78.26 ,Pays 100% Medicare OPPS,$101.74 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$71.65 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,$435.00 ,$369.75 ,85% of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$79.61 ,Pays 100% Medicare OPPS,$79.61 ,Pays 100% Medicare OPPS,$101.74 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$81.20 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$71.65 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$78.26 ,Pays 100% Medicare OPPS,$101.74 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$71.65 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,$435.00 ,$369.75 ,85% of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$79.61 ,Pays 100% Medicare OPPS,$79.61 ,Pays 100% Medicare OPPS,$101.74 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$81.20 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$71.65 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$78.26 ,Pays 100% Medicare OPPS,$101.74 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$71.65 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,G0206,MM DIGITAL SPOT MAG BILATERAL,401,$525.00 ,$446.25 ,85% of total billed charges,$131.25 ,Pays 100% Medicare OPPS,$131.25 ,Pays 100% Medicare OPPS,$131.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$106.94 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$295.05 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$183.75 ,35% based on GA Medicaid OP CCR Rate,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$472.50 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$106.94 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$106.94 ,$472.50 ,$420.00 
Outpatient Medical Services,RADIOLOGY,77065,"Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral",401,$595.00 ,$505.75 ,85% of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$79.61 ,Pays 100% Medicare OPPS,$79.61 ,Pays 100% Medicare OPPS,$101.74 ,Pays 130% Medicare OPPS,$121.20 ,20.37% based on GA Medicaid OP CCR Rate,$336.18 ,56.5 percent of total billed charges,$336.18 ,56.5 percent of total billed charges,$336.18 ,56.5 percent of total billed charges,$334.39 ,56.5 percent of total billed charges,$81.20 ,Pays 102% Medicare OPPS,$535.50 ,90% of total billed charges,$208.25 ,35% based on GA Medicaid OP CCR Rate,$408.77 ,68.7% of total billed charges,$476.00 ,80 percent of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$71.65 ,Pays 90% Medicare OPPS,$345.10 ,58% of total billed charges,$121.20 ,20.37% based on GA Medicaid OP CCR Rate,$78.26 ,Pays 100% Medicare OPPS,$101.74 ,Pays 130% Medicare OPPS,$505.75 ,85% of total billed charges,$79.61 ,Pays 100% Medicare OPPS,$71.65 ,$535.50 ,$476.00 
Outpatient Medical Services,RADIOLOGY,19100,MM BREAST BX PERCUT NO IMAGI,401,"$1,420.00 ","$1,207.00 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$289.25 ,20.37% based on GA Medicaid OP CCR Rate,$802.30 ,56.5 percent of total billed charges,$802.30 ,56.5 percent of total billed charges,$802.30 ,56.5 percent of total billed charges,$798.04 ,56.5 percent of total billed charges,"$1,289.21 ",Pays 102% Medicare OPPS,"$1,278.00 ",90% of total billed charges,$497.00 ,35% based on GA Medicaid OP CCR Rate,$975.54 ,68.7% of total billed charges,"$1,136.00 ",80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,$823.60 ,58% of total billed charges,$289.25 ,20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$1,207.00 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,$289.25 ,"$1,714.66 ","$1,136.00 "
Outpatient Medical Services,RADIOLOGY,76937,US GUIDE VASCULAR ACCESS,402,$115.00 ,$97.75 ,85% of total billed charges,$28.75 ,Pays 100% Medicare OPPS,$28.75 ,Pays 100% Medicare OPPS,$28.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$23.43 ,20.37% based on GA Medicaid OP CCR Rate,$64.98 ,56.5 percent of total billed charges,$64.98 ,56.5 percent of total billed charges,$64.98 ,56.5 percent of total billed charges,$64.63 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$103.50 ,90% of total billed charges,$40.25 ,35% based on GA Medicaid OP CCR Rate,$79.01 ,68.7% of total billed charges,$92.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$103.50 ,Pays 90% Medicare OPPS,$66.70 ,58% of total billed charges,$23.43 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$97.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$23.43 ,$103.50 ,$92.00 
Outpatient Medical Services,RADIOLOGY,19001,US ADDITIONAL CYST ASPIRATION,402,$520.00 ,$442.00 ,85% of total billed charges,$130.00 ,Pays 100% Medicare OPPS,$130.00 ,Pays 100% Medicare OPPS,$130.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$105.92 ,20.37% based on GA Medicaid OP CCR Rate,$293.80 ,56.5 percent of total billed charges,$293.80 ,56.5 percent of total billed charges,$293.80 ,56.5 percent of total billed charges,$292.24 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$468.00 ,90% of total billed charges,$182.00 ,35% based on GA Medicaid OP CCR Rate,$357.24 ,68.7% of total billed charges,$416.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$468.00 ,Pays 90% Medicare OPPS,$301.60 ,58% of total billed charges,$105.92 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$442.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$105.92 ,$468.00 ,$416.00 
Outpatient Medical Services,RADIOLOGY,76802,US FETAL < 14 WKS EACH ADDITIONAL,402,$575.00 ,$488.75 ,85% of total billed charges,$143.75 ,Pays 100% Medicare OPPS,$143.75 ,Pays 100% Medicare OPPS,$143.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$323.15 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$201.25 ,35% based on GA Medicaid OP CCR Rate,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$517.50 ,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$117.13 ,$517.50 ,$460.00 
Outpatient Medical Services,RADIOLOGY,76810,US FETAL >14 WKS EACH ADDITIONAL FETUS,402,$575.00 ,$488.75 ,85% of total billed charges,$143.75 ,Pays 100% Medicare OPPS,$143.75 ,Pays 100% Medicare OPPS,$143.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$324.88 ,56.5 percent of total billed charges,$323.15 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$517.50 ,90% of total billed charges,$201.25 ,35% based on GA Medicaid OP CCR Rate,$395.03 ,68.7% of total billed charges,$460.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$517.50 ,Pays 90% Medicare OPPS,$333.50 ,58% of total billed charges,$117.13 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$488.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$117.13 ,$517.50 ,$460.00 
Outpatient Medical Services,RADIOLOGY,76642,Limited ultrasound of the breast,402,$635.00 ,$539.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$129.35 ,20.37% based on GA Medicaid OP CCR Rate,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$356.87 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$571.50 ,90% of total billed charges,$222.25 ,35% based on GA Medicaid OP CCR Rate,$436.25 ,68.7% of total billed charges,$508.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$368.30 ,58% of total billed charges,$129.35 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$539.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$571.50 ,$508.00 
Outpatient Medical Services,RADIOLOGY,76642,Limited ultrasound of the breast,402,$635.00 ,$539.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$72.66 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$129.35 ,20.37% based on GA Medicaid OP CCR Rate,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$356.87 ,56.5 percent of total billed charges,$74.11 ,Pays 102% Medicare OPPS,$571.50 ,90% of total billed charges,$222.25 ,35% based on GA Medicaid OP CCR Rate,$436.25 ,68.7% of total billed charges,$508.00 ,80 percent of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,Pays 90% Medicare OPPS,$368.30 ,58% of total billed charges,$129.35 ,20.37% based on GA Medicaid OP CCR Rate,$76.41 ,Pays 100% Medicare OPPS,$99.34 ,Pays 130% Medicare OPPS,$539.75 ,85% of total billed charges,$72.66 ,Pays 100% Medicare OPPS,$65.39 ,$571.50 ,$508.00 
Outpatient Medical Services,RADIOLOGY,49083,PERITONOCENTESIS,402,$660.00 ,$561.00 ,85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$370.92 ,56.5 percent of total billed charges,$741.40 ,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$231.00 ,35% based on GA Medicaid OP CCR Rate,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$726.10 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$134.44 ,$943.93 ,$528.00 
Outpatient Medical Services,RADIOLOGY,76814,US 1ST TRIM FETAL NUC MEA EACH ADDITION,402,$660.00 ,$561.00 ,85% of total billed charges,$165.00 ,Pays 100% Medicare OPPS,$165.00 ,Pays 100% Medicare OPPS,$165.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$370.92 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$231.00 ,35% based on GA Medicaid OP CCR Rate,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$594.00 ,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$134.44 ,$594.00 ,$528.00 
Outpatient Medical Services,RADIOLOGY,76817,Transvaginal ultrasound of uterus,402,$675.00 ,$573.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$137.50 ,20.37% based on GA Medicaid OP CCR Rate,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$379.35 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$607.50 ,90% of total billed charges,$236.25 ,35% based on GA Medicaid OP CCR Rate,$463.73 ,68.7% of total billed charges,$540.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$391.50 ,58% of total billed charges,$137.50 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$573.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$607.50 ,$540.00 
Outpatient Medical Services,RADIOLOGY,76830,Ultrasound of the pelvis through vagina,402,$675.00 ,$573.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$137.50 ,20.37% based on GA Medicaid OP CCR Rate,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$379.35 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$607.50 ,90% of total billed charges,$236.25 ,35% based on GA Medicaid OP CCR Rate,$463.73 ,68.7% of total billed charges,$540.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$391.50 ,58% of total billed charges,$137.50 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$573.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$607.50 ,$540.00 
Outpatient Medical Services,RADIOLOGY,76818,Fetal biophysical profile with non-stress test,402,$735.00 ,$624.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$413.07 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$661.50 ,90% of total billed charges,$257.25 ,35% based on GA Medicaid OP CCR Rate,$504.95 ,68.7% of total billed charges,$588.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$426.30 ,58% of total billed charges,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$624.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$661.50 ,$588.00 
Outpatient Medical Services,RADIOLOGY,76819,Fetal biophysical profile without non-stress test,402,$735.00 ,$624.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$413.07 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$661.50 ,90% of total billed charges,$257.25 ,35% based on GA Medicaid OP CCR Rate,$504.95 ,68.7% of total billed charges,$588.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$426.30 ,58% of total billed charges,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$624.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$661.50 ,$588.00 
Outpatient Medical Services,RADIOLOGY,76820,US DOPPLER VELOCIMETRY FETAL UMBILICAL,402,$735.00 ,$624.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$413.07 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$661.50 ,90% of total billed charges,$257.25 ,35% based on GA Medicaid OP CCR Rate,$504.95 ,68.7% of total billed charges,$588.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$426.30 ,58% of total billed charges,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$624.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$661.50 ,$588.00 
Outpatient Medical Services,RADIOLOGY,76882,"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",402,$750.00 ,$637.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$421.50 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$675.00 ,90% of total billed charges,$262.50 ,35% based on GA Medicaid OP CCR Rate,$515.25 ,68.7% of total billed charges,$600.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$435.00 ,58% of total billed charges,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$637.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$675.00 ,$600.00 
Outpatient Medical Services,RADIOLOGY,76882,"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",402,$750.00 ,$637.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$421.50 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$675.00 ,90% of total billed charges,$262.50 ,35% based on GA Medicaid OP CCR Rate,$515.25 ,68.7% of total billed charges,$600.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$435.00 ,58% of total billed charges,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$637.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$675.00 ,$600.00 
Outpatient Medical Services,RADIOLOGY,76506,US ECHOENCEPHALOGRAPHY,402,$760.00 ,$646.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$154.81 ,20.37% based on GA Medicaid OP CCR Rate,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$429.40 ,56.5 percent of total billed charges,$427.12 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$684.00 ,90% of total billed charges,$266.00 ,35% based on GA Medicaid OP CCR Rate,$522.12 ,68.7% of total billed charges,$608.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$440.80 ,58% of total billed charges,$154.81 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$646.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$684.00 ,$608.00 
Outpatient Medical Services,RADIOLOGY,76776,US TRANSPLANT KIDNEY,402,$770.00 ,$654.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$156.85 ,20.37% based on GA Medicaid OP CCR Rate,$435.05 ,56.5 percent of total billed charges,$435.05 ,56.5 percent of total billed charges,$435.05 ,56.5 percent of total billed charges,$432.74 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$693.00 ,90% of total billed charges,$269.50 ,35% based on GA Medicaid OP CCR Rate,$528.99 ,68.7% of total billed charges,$616.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$446.60 ,58% of total billed charges,$156.85 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$654.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$693.00 ,$616.00 
Outpatient Medical Services,RADIOLOGY,76536,Ultrasound of head and neck,402,$785.00 ,$667.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$441.17 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$706.50 ,90% of total billed charges,$274.75 ,35% based on GA Medicaid OP CCR Rate,$539.30 ,68.7% of total billed charges,$628.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$455.30 ,58% of total billed charges,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$667.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$706.50 ,$628.00 
Outpatient Medical Services,RADIOLOGY,76536,Ultrasound of head and neck,402,$785.00 ,$667.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$441.17 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$706.50 ,90% of total billed charges,$274.75 ,35% based on GA Medicaid OP CCR Rate,$539.30 ,68.7% of total billed charges,$628.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$455.30 ,58% of total billed charges,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$667.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$706.50 ,$628.00 
Outpatient Medical Services,RADIOLOGY,76815,Ultrasound of fetus with limited views,402,$840.00 ,$714.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$171.11 ,20.37% based on GA Medicaid OP CCR Rate,$474.60 ,56.5 percent of total billed charges,$474.60 ,56.5 percent of total billed charges,$474.60 ,56.5 percent of total billed charges,$472.08 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$756.00 ,90% of total billed charges,$294.00 ,35% based on GA Medicaid OP CCR Rate,$577.08 ,68.7% of total billed charges,$672.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$487.20 ,58% of total billed charges,$171.11 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$714.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$756.00 ,$672.00 
Outpatient Medical Services,RADIOLOGY,76870,Ultrasound of the scrotum,402,$840.00 ,$714.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$171.11 ,20.37% based on GA Medicaid OP CCR Rate,$474.60 ,56.5 percent of total billed charges,$474.60 ,56.5 percent of total billed charges,$474.60 ,56.5 percent of total billed charges,$472.08 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$756.00 ,90% of total billed charges,$294.00 ,35% based on GA Medicaid OP CCR Rate,$577.08 ,68.7% of total billed charges,$672.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$487.20 ,58% of total billed charges,$171.11 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$714.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$756.00 ,$672.00 
Outpatient Medical Services,RADIOLOGY,76946,US AMNIOCENTESIS GUIDANC,402,$860.00 ,$731.00 ,85% of total billed charges,$215.00 ,Pays 100% Medicare OPPS,$215.00 ,Pays 100% Medicare OPPS,$215.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$175.18 ,20.37% based on GA Medicaid OP CCR Rate,$485.90 ,56.5 percent of total billed charges,$485.90 ,56.5 percent of total billed charges,$485.90 ,56.5 percent of total billed charges,$483.32 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$774.00 ,90% of total billed charges,$301.00 ,35% based on GA Medicaid OP CCR Rate,$590.82 ,68.7% of total billed charges,$688.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$774.00 ,Pays 90% Medicare OPPS,$498.80 ,58% of total billed charges,$175.18 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$731.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$175.18 ,$774.00 ,$688.00 
Outpatient Medical Services,RADIOLOGY,76942,US CYST GUIDANCE NEEDLE,402,$875.00 ,$743.75 ,85% of total billed charges,$218.75 ,Pays 100% Medicare OPPS,$218.75 ,Pays 100% Medicare OPPS,$218.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$178.24 ,20.37% based on GA Medicaid OP CCR Rate,$494.38 ,56.5 percent of total billed charges,$494.38 ,56.5 percent of total billed charges,$494.38 ,56.5 percent of total billed charges,$491.75 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$787.50 ,90% of total billed charges,$306.25 ,35% based on GA Medicaid OP CCR Rate,$601.13 ,68.7% of total billed charges,$700.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$787.50 ,Pays 90% Medicare OPPS,$507.50 ,58% of total billed charges,$178.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$743.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$178.24 ,$787.50 ,$700.00 
Outpatient Medical Services,RADIOLOGY,76998,US GUIDANCE INTRAOPERATIVE,402,$875.00 ,$743.75 ,85% of total billed charges,$218.75 ,Pays 100% Medicare OPPS,$218.75 ,Pays 100% Medicare OPPS,$218.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$178.24 ,20.37% based on GA Medicaid OP CCR Rate,$494.38 ,56.5 percent of total billed charges,$494.38 ,56.5 percent of total billed charges,$494.38 ,56.5 percent of total billed charges,$491.75 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$787.50 ,90% of total billed charges,$306.25 ,35% based on GA Medicaid OP CCR Rate,$601.13 ,68.7% of total billed charges,$700.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$787.50 ,Pays 90% Medicare OPPS,$507.50 ,58% of total billed charges,$178.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$743.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$178.24 ,$787.50 ,$700.00 
Outpatient Medical Services,RADIOLOGY,76536,Ultrasound of head and neck,402,$900.00 ,$765.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$183.33 ,20.37% based on GA Medicaid OP CCR Rate,$508.50 ,56.5 percent of total billed charges,$508.50 ,56.5 percent of total billed charges,$508.50 ,56.5 percent of total billed charges,$505.80 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$810.00 ,90% of total billed charges,$315.00 ,35% based on GA Medicaid OP CCR Rate,$618.30 ,68.7% of total billed charges,$720.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$522.00 ,58% of total billed charges,$183.33 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$765.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$810.00 ,$720.00 
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,$975.00 ,$828.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$198.61 ,20.37% based on GA Medicaid OP CCR Rate,$550.88 ,56.5 percent of total billed charges,$550.88 ,56.5 percent of total billed charges,$550.88 ,56.5 percent of total billed charges,$547.95 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$877.50 ,90% of total billed charges,$341.25 ,35% based on GA Medicaid OP CCR Rate,$669.83 ,68.7% of total billed charges,$780.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$565.50 ,58% of total billed charges,$198.61 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$828.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$877.50 ,$780.00 
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,$975.00 ,$828.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$198.61 ,20.37% based on GA Medicaid OP CCR Rate,$550.88 ,56.5 percent of total billed charges,$550.88 ,56.5 percent of total billed charges,$550.88 ,56.5 percent of total billed charges,$547.95 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$877.50 ,90% of total billed charges,$341.25 ,35% based on GA Medicaid OP CCR Rate,$669.83 ,68.7% of total billed charges,$780.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$565.50 ,58% of total billed charges,$198.61 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$828.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$877.50 ,$780.00 
Outpatient Medical Services,RADIOLOGY,76775,Ultrasound of back wall of the abdomen with limited areas viewed,402,$975.00 ,$828.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$198.61 ,20.37% based on GA Medicaid OP CCR Rate,$550.88 ,56.5 percent of total billed charges,$550.88 ,56.5 percent of total billed charges,$550.88 ,56.5 percent of total billed charges,$547.95 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$877.50 ,90% of total billed charges,$341.25 ,35% based on GA Medicaid OP CCR Rate,$669.83 ,68.7% of total billed charges,$780.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$565.50 ,58% of total billed charges,$198.61 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$828.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$877.50 ,$780.00 
Outpatient Medical Services,RADIOLOGY,76801,Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,402,$990.00 ,$841.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$201.66 ,20.37% based on GA Medicaid OP CCR Rate,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$556.38 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$891.00 ,90% of total billed charges,$346.50 ,35% based on GA Medicaid OP CCR Rate,$680.13 ,68.7% of total billed charges,$792.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$574.20 ,58% of total billed charges,$201.66 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$841.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$891.00 ,$792.00 
Outpatient Medical Services,RADIOLOGY,76805,Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,402,$990.00 ,$841.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$201.66 ,20.37% based on GA Medicaid OP CCR Rate,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$556.38 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$891.00 ,90% of total billed charges,$346.50 ,35% based on GA Medicaid OP CCR Rate,$680.13 ,68.7% of total billed charges,$792.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$574.20 ,58% of total billed charges,$201.66 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$841.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$891.00 ,$792.00 
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,"$1,010.00 ",$858.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$205.74 ,20.37% based on GA Medicaid OP CCR Rate,$570.65 ,56.5 percent of total billed charges,$570.65 ,56.5 percent of total billed charges,$570.65 ,56.5 percent of total billed charges,$567.62 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$909.00 ,90% of total billed charges,$353.50 ,35% based on GA Medicaid OP CCR Rate,$693.87 ,68.7% of total billed charges,$808.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$585.80 ,58% of total billed charges,$205.74 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$858.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$909.00 ,$808.00 
Outpatient Medical Services,RADIOLOGY,19000,US CYST ASPIRATION,402,"$1,020.00 ",$867.00 ,85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$207.77 ,20.37% based on GA Medicaid OP CCR Rate,$576.30 ,56.5 percent of total billed charges,$576.30 ,56.5 percent of total billed charges,$576.30 ,56.5 percent of total billed charges,$573.24 ,56.5 percent of total billed charges,$570.17 ,Pays 102% Medicare OPPS,$918.00 ,90% of total billed charges,$357.00 ,35% based on GA Medicaid OP CCR Rate,$700.74 ,68.7% of total billed charges,$816.00 ,80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,$591.60 ,58% of total billed charges,$207.77 ,20.37% based on GA Medicaid OP CCR Rate,$570.82 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$867.00 ,85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$207.77 ,$918.00 ,$816.00 
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,"$1,045.00 ",$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$587.29 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,"$1,045.00 ",$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$587.29 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,76705,A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,402,"$1,045.00 ",$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$587.29 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,76856,Complete ultrasound of the pelvis,402,"$1,045.00 ",$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$587.29 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,76856,Complete ultrasound of the pelvis,402,"$1,045.00 ",$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$587.29 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,76998,US GUIDANCE INTRAOPERATIVE,402,"$1,045.00 ",$888.25 ,85% of total billed charges,$261.25 ,Pays 100% Medicare OPPS,$261.25 ,Pays 100% Medicare OPPS,$261.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$587.29 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$940.50 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$212.87 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,76942,US GUIDE THORA/PARACENTIS,402,"$1,135.00 ",$964.75 ,85% of total billed charges,$283.75 ,Pays 100% Medicare OPPS,$283.75 ,Pays 100% Medicare OPPS,$283.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$231.20 ,20.37% based on GA Medicaid OP CCR Rate,$641.28 ,56.5 percent of total billed charges,$641.28 ,56.5 percent of total billed charges,$641.28 ,56.5 percent of total billed charges,$637.87 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,"$1,021.50 ",90% of total billed charges,$397.25 ,35% based on GA Medicaid OP CCR Rate,$779.75 ,68.7% of total billed charges,$908.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,"$1,021.50 ",Pays 90% Medicare OPPS,$658.30 ,58% of total billed charges,$231.20 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$964.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$231.20 ,"$1,021.50 ",$908.00 
Outpatient Medical Services,RADIOLOGY,76813,Evaluation through measurement of fetal nuchal translucency,402,"$1,145.00 ",$973.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$233.24 ,20.37% based on GA Medicaid OP CCR Rate,$646.93 ,56.5 percent of total billed charges,$646.93 ,56.5 percent of total billed charges,$646.93 ,56.5 percent of total billed charges,$643.49 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$1,030.50 ",90% of total billed charges,$400.75 ,35% based on GA Medicaid OP CCR Rate,$786.62 ,68.7% of total billed charges,$916.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$664.10 ,58% of total billed charges,$233.24 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$973.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,"$1,030.50 ",$916.00 
Outpatient Medical Services,RADIOLOGY,76700,Ultrasound of abdomen with all areas scanned,402,"$1,150.00 ",$977.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$234.26 ,20.37% based on GA Medicaid OP CCR Rate,$649.75 ,56.5 percent of total billed charges,$649.75 ,56.5 percent of total billed charges,$649.75 ,56.5 percent of total billed charges,$646.30 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$1,035.00 ",90% of total billed charges,$402.50 ,35% based on GA Medicaid OP CCR Rate,$790.05 ,68.7% of total billed charges,$920.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$667.00 ,58% of total billed charges,$234.26 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$977.50 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$1,035.00 ",$920.00 
Outpatient Medical Services,RADIOLOGY,76942,US GUIDANCE-NEEDLE BIOPS,402,"$1,195.00 ","$1,015.75 ",85% of total billed charges,$298.75 ,Pays 100% Medicare OPPS,$298.75 ,Pays 100% Medicare OPPS,$298.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$243.42 ,20.37% based on GA Medicaid OP CCR Rate,$675.18 ,56.5 percent of total billed charges,$675.18 ,56.5 percent of total billed charges,$675.18 ,56.5 percent of total billed charges,$671.59 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,"$1,075.50 ",90% of total billed charges,$418.25 ,35% based on GA Medicaid OP CCR Rate,$820.97 ,68.7% of total billed charges,$956.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,"$1,075.50 ",Pays 90% Medicare OPPS,$693.10 ,58% of total billed charges,$243.42 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$1,015.75 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,$243.42 ,"$1,075.50 ",$956.00 
Outpatient Medical Services,RADIOLOGY,76811,Ultrasound of single fetus,402,"$1,310.00 ","$1,113.50 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$266.85 ,20.37% based on GA Medicaid OP CCR Rate,$740.15 ,56.5 percent of total billed charges,$740.15 ,56.5 percent of total billed charges,$740.15 ,56.5 percent of total billed charges,$736.22 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$1,179.00 ",90% of total billed charges,$458.50 ,35% based on GA Medicaid OP CCR Rate,$899.97 ,68.7% of total billed charges,"$1,048.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$759.80 ,58% of total billed charges,$266.85 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,113.50 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$1,179.00 ","$1,048.00 "
Outpatient Medical Services,RADIOLOGY,76816,US FETAL GROWTH PARA IURG FOLLOW-UP,402,"$1,310.00 ","$1,113.50 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$266.85 ,20.37% based on GA Medicaid OP CCR Rate,$740.15 ,56.5 percent of total billed charges,$740.15 ,56.5 percent of total billed charges,$740.15 ,56.5 percent of total billed charges,$736.22 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$1,179.00 ",90% of total billed charges,$458.50 ,35% based on GA Medicaid OP CCR Rate,$899.97 ,68.7% of total billed charges,"$1,048.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$759.80 ,58% of total billed charges,$266.85 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,"$1,113.50 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,"$1,179.00 ","$1,048.00 "
Outpatient Medical Services,RADIOLOGY,76770,Ultrasound of back wall of the abdomen with all areas viewed,402,"$1,460.00 ","$1,241.00 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$297.40 ,20.37% based on GA Medicaid OP CCR Rate,$824.90 ,56.5 percent of total billed charges,$824.90 ,56.5 percent of total billed charges,$824.90 ,56.5 percent of total billed charges,$820.52 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$1,314.00 ",90% of total billed charges,$511.00 ,35% based on GA Medicaid OP CCR Rate,"$1,003.02 ",68.7% of total billed charges,"$1,168.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$846.80 ,58% of total billed charges,$297.40 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$1,241.00 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$1,314.00 ","$1,168.00 "
Outpatient Medical Services,RADIOLOGY,76936,US COMP PSEUDOANURYS GUI,402,"$2,725.00 ","$2,316.25 ",85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$555.08 ,20.37% based on GA Medicaid OP CCR Rate,"$1,539.63 ",56.5 percent of total billed charges,"$1,539.63 ",56.5 percent of total billed charges,"$1,539.63 ",56.5 percent of total billed charges,"$1,531.45 ",56.5 percent of total billed charges,$242.49 ,Pays 102% Medicare OPPS,"$2,452.50 ",90% of total billed charges,$953.75 ,35% based on GA Medicaid OP CCR Rate,"$1,872.08 ",68.7% of total billed charges,"$2,180.00 ",80 percent of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,Pays 90% Medicare OPPS,"$1,580.50 ",58% of total billed charges,$555.08 ,20.37% based on GA Medicaid OP CCR Rate,$246.33 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,"$2,316.25 ",85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,"$2,452.50 ","$2,180.00 "
Outpatient Medical Services,RADIOLOGY,77063,MM 3D MAMMO BIL SCREENING,403,$135.00 ,$114.75 ,85% of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$21.26 ,Pays 100% Medicare OPPS,$21.26 ,Pays 100% Medicare OPPS,$27.94 ,Pays 130% Medicare OPPS,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$75.87 ,56.5 percent of total billed charges,$21.69 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$47.25 ,35% based on GA Medicaid OP CCR Rate,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$19.13 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$21.49 ,Pays 100% Medicare OPPS,$27.94 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$21.26 ,Pays 100% Medicare OPPS,$19.13 ,$121.50 ,$108.00 
Outpatient Medical Services,RADIOLOGY,77067,Mammography of both breasts-2 or more views,403,$435.00 ,$369.75 ,85% of total billed charges,$83.86 ,Pays 100% Medicare OPPS,$83.86 ,Pays 100% Medicare OPPS,$83.86 ,Pays 100% Medicare OPPS,$107.56 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$244.47 ,56.5 percent of total billed charges,$85.54 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$83.86 ,Pays 100% Medicare OPPS,$75.47 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$82.74 ,Pays 100% Medicare OPPS,$107.56 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$83.86 ,Pays 100% Medicare OPPS,$75.47 ,$391.50 ,$348.00 
Outpatient Medical Services,RADIOLOGY,76098,MM MAMMOGRAM/TISSUE,409,$190.00 ,$161.50 ,85% of total billed charges,$434.05 ,Pays 100% Medicare OPPS,$434.05 ,Pays 100% Medicare OPPS,$434.05 ,Pays 100% Medicare OPPS,$575.30 ,Pays 130% Medicare OPPS,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$106.78 ,56.5 percent of total billed charges,$442.73 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$66.50 ,35% based on GA Medicaid OP CCR Rate,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$434.05 ,Pays 100% Medicare OPPS,$390.64 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$442.54 ,Pays 100% Medicare OPPS,$575.30 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$434.05 ,Pays 100% Medicare OPPS,$38.70 ,$575.30 ,$152.00 
Outpatient Medical Services,RADIOLOGY,77032,MM MAMMOGRAM/BIOPSY,409,$665.00 ,$565.25 ,85% of total billed charges,$166.25 ,Pays 100% Medicare OPPS,$166.25 ,Pays 100% Medicare OPPS,$166.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,$375.73 ,56.5 percent of total billed charges,$375.73 ,56.5 percent of total billed charges,$375.73 ,56.5 percent of total billed charges,$373.73 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$598.50 ,90% of total billed charges,$232.75 ,35% based on GA Medicaid OP CCR Rate,$456.86 ,68.7% of total billed charges,$532.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$598.50 ,Pays 90% Medicare OPPS,$385.70 ,58% of total billed charges,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,N/A,Pays 100% Medicare OPPS,$135.46 ,$598.50 ,$532.00 
Outpatient Medical Services,RADIOLOGY,70544,MRA PITUITARY WITH CONTRA,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73218,MRI UPR EXT/NON JNT-LEFT W/O,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73221,MRI of upper extremity without dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73219,MRI UPPER EXTREMITY-LEFT WITH,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73718,MRI of leg without dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73720,MRI LOWER EXT NON JNT W/WO LT,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73722,MRI of lower extremity joint (knee/ankle) with dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$642.67 ,Pays 100% Medicare OPPS,$642.67 ,Pays 100% Medicare OPPS,$642.67 ,Pays 100% Medicare OPPS,$847.00 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$655.53 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$642.67 ,Pays 100% Medicare OPPS,$578.41 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$651.54 ,Pays 100% Medicare OPPS,$847.00 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$642.67 ,Pays 100% Medicare OPPS,$578.41 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,72195,MRI of pelvis without dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,74181,MRI of abdomen without dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73719,MRI LOWER EXT NON JNT W LT,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73725,MRA LOWER EXT  W/O CONTRAST,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,"$1,273.75 ",Pays 100% Medicare OPPS,"$1,273.75 ",Pays 100% Medicare OPPS,"$1,273.75 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,"$4,585.50 ",Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,"$1,037.85 ","$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,70336,MRI TMJ,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,70540,MRI NECK  W/0,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,71550,MRI CHST/HILAR/MEDIASTINA,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,71555,MRA CHEST,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,"$1,273.75 ",Pays 100% Medicare OPPS,"$1,273.75 ",Pays 100% Medicare OPPS,"$1,273.75 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,"$4,585.50 ",Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,"$1,037.85 ","$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73220,MRI UPPER EXT NON-JT WITHOUT,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73221,MRI of upper extremity without dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73222,MRI UPPER EXT JOINT W/CONTRAST,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$642.67 ,Pays 100% Medicare OPPS,$642.67 ,Pays 100% Medicare OPPS,$642.67 ,Pays 100% Medicare OPPS,$847.00 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$655.53 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$642.67 ,Pays 100% Medicare OPPS,$578.41 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$651.54 ,Pays 100% Medicare OPPS,$847.00 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$642.67 ,Pays 100% Medicare OPPS,$578.41 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73219,MRI UPPER EXTREMITY-RIGHT WITH,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73718,MRI of leg without dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73719,MRI LOWER EXT NON JNT W RT,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73720,MRI LOWER EXT NON JNT W/WO RT,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73721,MRI of lower extremity joint (knee/ankle) without dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,73722,MRI of lower extremity joint (knee/ankle) with dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$642.67 ,Pays 100% Medicare OPPS,$642.67 ,Pays 100% Medicare OPPS,$642.67 ,Pays 100% Medicare OPPS,$847.00 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$655.53 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$642.67 ,Pays 100% Medicare OPPS,$578.41 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$651.54 ,Pays 100% Medicare OPPS,$847.00 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$642.67 ,Pays 100% Medicare OPPS,$578.41 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,74181,MRI of abdomen without dye,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,74182,MRI ABD W/ CONTRAST,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,74185,MRA ABDOMEN,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,"$1,273.75 ",Pays 100% Medicare OPPS,"$1,273.75 ",Pays 100% Medicare OPPS,"$1,273.75 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,"$4,585.50 ",Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,"$1,037.85 ","$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,75557,MRI MYOCARDIUM W/O CONTRA,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,77084,MRI BONE MARROW BLOOD,610,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,70546,MRA BRAIN W/WO CONTRAST,610,"$5,700.00 ","$4,845.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,161.09 ",20.37% based on GA Medicaid OP CCR Rate,"$3,220.50 ",56.5 percent of total billed charges,"$3,220.50 ",56.5 percent of total billed charges,"$3,220.50 ",56.5 percent of total billed charges,"$3,203.40 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$5,130.00 ",90% of total billed charges,"$1,995.00 ",35% based on GA Medicaid OP CCR Rate,"$3,915.90 ",68.7% of total billed charges,"$4,560.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,306.00 ",58% of total billed charges,"$1,161.09 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,845.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$5,130.00 ","$4,560.00 "
Outpatient Medical Services,RADIOLOGY,70549,MRA NECK W/WO CONTRAST,610,"$5,700.00 ","$4,845.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,161.09 ",20.37% based on GA Medicaid OP CCR Rate,"$3,220.50 ",56.5 percent of total billed charges,"$3,220.50 ",56.5 percent of total billed charges,"$3,220.50 ",56.5 percent of total billed charges,"$3,203.40 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$5,130.00 ",90% of total billed charges,"$1,995.00 ",35% based on GA Medicaid OP CCR Rate,"$3,915.90 ",68.7% of total billed charges,"$4,560.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,306.00 ",58% of total billed charges,"$1,161.09 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,845.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$5,130.00 ","$4,560.00 "
Outpatient Medical Services,RADIOLOGY,70543,"MRI ORBITS, FACE, AND/OR NECK W/WO",610,"$5,965.00 ","$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,352.33 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$5,368.50 ",90% of total billed charges,"$2,087.75 ",35% based on GA Medicaid OP CCR Rate,"$4,097.96 ",68.7% of total billed charges,"$4,772.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,459.70 ",58% of total billed charges,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$5,368.50 ","$4,772.00 "
Outpatient Medical Services,RADIOLOGY,72197,MRI of pelvis before and after dye,610,"$5,965.00 ","$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,352.33 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$5,368.50 ",90% of total billed charges,"$2,087.75 ",35% based on GA Medicaid OP CCR Rate,"$4,097.96 ",68.7% of total billed charges,"$4,772.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,459.70 ",58% of total billed charges,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$5,368.50 ","$4,772.00 "
Outpatient Medical Services,RADIOLOGY,74183,MRI of abdomen without and with dye,610,"$5,965.00 ","$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,352.33 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$5,368.50 ",90% of total billed charges,"$2,087.75 ",35% based on GA Medicaid OP CCR Rate,"$4,097.96 ",68.7% of total billed charges,"$4,772.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,459.70 ",58% of total billed charges,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$5,368.50 ","$4,772.00 "
Outpatient Medical Services,RADIOLOGY,73725,MRA LOWER EXT W/O & W/CONTRAST,610,"$6,065.00 ","$5,155.25 ",85% of total billed charges,"$1,516.25 ",Pays 100% Medicare OPPS,"$1,516.25 ",Pays 100% Medicare OPPS,"$1,516.25 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$1,235.44 ",20.37% based on GA Medicaid OP CCR Rate,"$3,426.73 ",56.5 percent of total billed charges,"$3,426.73 ",56.5 percent of total billed charges,"$3,426.73 ",56.5 percent of total billed charges,"$3,408.53 ",56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,"$5,458.50 ",90% of total billed charges,"$2,122.75 ",35% based on GA Medicaid OP CCR Rate,"$4,166.66 ",68.7% of total billed charges,"$4,852.00 ",80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,"$5,458.50 ",Pays 90% Medicare OPPS,"$3,517.70 ",58% of total billed charges,"$1,235.44 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$5,155.25 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,"$1,235.44 ","$5,458.50 ","$4,852.00 "
Outpatient Medical Services,RADIOLOGY,73223,MRI UPPER EXT W/WO LEFT JNT,610,"$6,820.00 ","$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,832.84 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$6,138.00 ",90% of total billed charges,"$2,387.00 ",35% based on GA Medicaid OP CCR Rate,"$4,685.34 ",68.7% of total billed charges,"$5,456.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,955.60 ",58% of total billed charges,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$6,138.00 ","$5,456.00 "
Outpatient Medical Services,RADIOLOGY,73723,MRI of lower extremity joint (knee/ankle) with and without dye,610,"$6,820.00 ","$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,832.84 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$6,138.00 ",90% of total billed charges,"$2,387.00 ",35% based on GA Medicaid OP CCR Rate,"$4,685.34 ",68.7% of total billed charges,"$5,456.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,955.60 ",58% of total billed charges,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$6,138.00 ","$5,456.00 "
Outpatient Medical Services,RADIOLOGY,73223,MRI UPPER EXT W/WO RIGHT JNT,610,"$6,820.00 ","$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,832.84 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$6,138.00 ",90% of total billed charges,"$2,387.00 ",35% based on GA Medicaid OP CCR Rate,"$4,685.34 ",68.7% of total billed charges,"$5,456.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,955.60 ",58% of total billed charges,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$6,138.00 ","$5,456.00 "
Outpatient Medical Services,RADIOLOGY,73723,MRI of lower extremity joint (knee/ankle) with and without dye,610,"$6,820.00 ","$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,832.84 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$6,138.00 ",90% of total billed charges,"$2,387.00 ",35% based on GA Medicaid OP CCR Rate,"$4,685.34 ",68.7% of total billed charges,"$5,456.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,955.60 ",58% of total billed charges,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$6,138.00 ","$5,456.00 "
Outpatient Medical Services,RADIOLOGY,70540,MRI FACIAL ORBITS FACE W/O,611,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,70551,MRI of brain stem without dye,611,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,70551,MRI of brain stem without dye,611,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,70540,MRI ORBITS W/O,611,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,70551,MRI of brain stem without dye,611,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,70552,MRI BRAIN W/CONTRAST,611,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,70542,MRI NECK WITH,611,"$5,520.00 ","$4,692.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,124.42 ",20.37% based on GA Medicaid OP CCR Rate,"$3,118.80 ",56.5 percent of total billed charges,"$3,118.80 ",56.5 percent of total billed charges,"$3,118.80 ",56.5 percent of total billed charges,"$3,102.24 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,968.00 ",90% of total billed charges,"$1,932.00 ",35% based on GA Medicaid OP CCR Rate,"$3,792.24 ",68.7% of total billed charges,"$4,416.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,201.60 ",58% of total billed charges,"$1,124.42 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,692.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,968.00 ","$4,416.00 "
Outpatient Medical Services,RADIOLOGY,70542,MRI ORBITS WITH,611,"$5,520.00 ","$4,692.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,124.42 ",20.37% based on GA Medicaid OP CCR Rate,"$3,118.80 ",56.5 percent of total billed charges,"$3,118.80 ",56.5 percent of total billed charges,"$3,118.80 ",56.5 percent of total billed charges,"$3,102.24 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,968.00 ",90% of total billed charges,"$1,932.00 ",35% based on GA Medicaid OP CCR Rate,"$3,792.24 ",68.7% of total billed charges,"$4,416.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,201.60 ",58% of total billed charges,"$1,124.42 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,692.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,968.00 ","$4,416.00 "
Outpatient Medical Services,RADIOLOGY,70542,MRI FACIAL ORBITS FACE WITH,611,"$5,520.00 ","$4,692.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,124.42 ",20.37% based on GA Medicaid OP CCR Rate,"$3,118.80 ",56.5 percent of total billed charges,"$3,118.80 ",56.5 percent of total billed charges,"$3,118.80 ",56.5 percent of total billed charges,"$3,102.24 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,968.00 ",90% of total billed charges,"$1,932.00 ",35% based on GA Medicaid OP CCR Rate,"$3,792.24 ",68.7% of total billed charges,"$4,416.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,201.60 ",58% of total billed charges,"$1,124.42 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,692.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,968.00 ","$4,416.00 "
Outpatient Medical Services,RADIOLOGY,70553,MRI scan of brain before and after contrast,611,"$5,965.00 ","$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,352.33 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$5,368.50 ",90% of total billed charges,"$2,087.75 ",35% based on GA Medicaid OP CCR Rate,"$4,097.96 ",68.7% of total billed charges,"$4,772.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,459.70 ",58% of total billed charges,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$5,368.50 ","$4,772.00 "
Outpatient Medical Services,RADIOLOGY,70553,MRI scan of brain before and after contrast,611,"$5,965.00 ","$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,352.33 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$5,368.50 ",90% of total billed charges,"$2,087.75 ",35% based on GA Medicaid OP CCR Rate,"$4,097.96 ",68.7% of total billed charges,"$4,772.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,459.70 ",58% of total billed charges,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$5,368.50 ","$4,772.00 "
Outpatient Medical Services,RADIOLOGY,70543,MRI FACIAL ORBITS FACE W/WO,611,"$6,820.00 ","$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,832.84 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$6,138.00 ",90% of total billed charges,"$2,387.00 ",35% based on GA Medicaid OP CCR Rate,"$4,685.34 ",68.7% of total billed charges,"$5,456.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,955.60 ",58% of total billed charges,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$6,138.00 ","$5,456.00 "
Outpatient Medical Services,RADIOLOGY,73220,MRI UPPER RXT NON-JT W/WO,611,"$6,820.00 ","$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,853.30 ",56.5 percent of total billed charges,"$3,832.84 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$6,138.00 ",90% of total billed charges,"$2,387.00 ",35% based on GA Medicaid OP CCR Rate,"$4,685.34 ",68.7% of total billed charges,"$5,456.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,955.60 ",58% of total billed charges,"$1,389.23 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,797.00 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$6,138.00 ","$5,456.00 "
Outpatient Medical Services,RADIOLOGY,72141,MRI of the neck or spine without dye,612,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,72142,MRI CERVICAL SPINE W/CON,612,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,72146,MRI of chest and spine without dye,612,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,72148,MRI scan of lower spinal canal,612,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,72149,MRI LUMBAR SPINE WITH,612,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,72157,MRI of chest and spine with and without dye,612,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,72196,MRI PELVIC W/CONTRAST,612,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,72156,MRI of neck/spine with and without dye,612,"$5,965.00 ","$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,352.33 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$5,368.50 ",90% of total billed charges,"$2,087.75 ",35% based on GA Medicaid OP CCR Rate,"$4,097.96 ",68.7% of total billed charges,"$4,772.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,459.70 ",58% of total billed charges,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$5,368.50 ","$4,772.00 "
Outpatient Medical Services,RADIOLOGY,72156,MRI of neck/spine with and without dye,612,"$5,965.00 ","$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,352.33 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$5,368.50 ",90% of total billed charges,"$2,087.75 ",35% based on GA Medicaid OP CCR Rate,"$4,097.96 ",68.7% of total billed charges,"$4,772.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,459.70 ",58% of total billed charges,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$5,368.50 ","$4,772.00 "
Outpatient Medical Services,RADIOLOGY,72158,MRI of lower back with and without dye,612,"$5,965.00 ","$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$330.80 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,370.23 ",56.5 percent of total billed charges,"$3,352.33 ",56.5 percent of total billed charges,$337.41 ,Pays 102% Medicare OPPS,"$5,368.50 ",90% of total billed charges,"$2,087.75 ",35% based on GA Medicaid OP CCR Rate,"$4,097.96 ",68.7% of total billed charges,"$4,772.00 ",80 percent of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,Pays 90% Medicare OPPS,"$3,459.70 ",58% of total billed charges,"$1,215.07 ",20.37% based on GA Medicaid OP CCR Rate,$324.06 ,Pays 100% Medicare OPPS,$421.27 ,Pays 130% Medicare OPPS,"$5,070.25 ",85% of total billed charges,$330.80 ,Pays 100% Medicare OPPS,$297.72 ,"$5,368.50 ","$4,772.00 "
Outpatient Medical Services,RADIOLOGY,70547,MRA NECK W/O,615,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,70544,MRA HEAD W/OUT,615,"$5,095.00 ","$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,878.68 ",56.5 percent of total billed charges,"$2,863.39 ",56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$4,585.50 ",90% of total billed charges,"$1,783.25 ",35% based on GA Medicaid OP CCR Rate,"$3,500.27 ",68.7% of total billed charges,"$4,076.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,"$2,955.10 ",58% of total billed charges,"$1,037.85 ",20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$4,330.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$4,585.50 ","$4,076.00 "
Outpatient Medical Services,RADIOLOGY,93965,US PHYS EXT VENOUS/CMPLT-BIL,921,$785.00 ,$667.25 ,85% of total billed charges,$196.25 ,Pays 100% Medicare OPPS,$196.25 ,Pays 100% Medicare OPPS,$196.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$706.50 ,90% of total billed charges,$274.75 ,35% based on GA Medicaid OP CCR Rate,$539.30 ,68.7% of total billed charges,$628.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$706.50 ,Pays 90% Medicare OPPS,$455.30 ,58% of total billed charges,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$667.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$159.90 ,$706.50 ,$628.00 
Outpatient Medical Services,RADIOLOGY,93976,US DUPLEX ART ABD LTD,921,$865.00 ,$735.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$176.20 ,20.37% based on GA Medicaid OP CCR Rate,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$778.50 ,90% of total billed charges,$302.75 ,35% based on GA Medicaid OP CCR Rate,$594.26 ,68.7% of total billed charges,$692.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$501.70 ,58% of total billed charges,$176.20 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$735.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$778.50 ,$692.00 
Outpatient Medical Services,RADIOLOGY,93976,US ARTERIAL-SCROTAL-LIMITED,921,$875.00 ,$743.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$178.24 ,20.37% based on GA Medicaid OP CCR Rate,$494.38 ,56.5 percent of total billed charges,$494.38 ,56.5 percent of total billed charges,$494.38 ,56.5 percent of total billed charges,$494.38 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$787.50 ,90% of total billed charges,$306.25 ,35% based on GA Medicaid OP CCR Rate,$601.13 ,68.7% of total billed charges,$700.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$507.50 ,58% of total billed charges,$178.24 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$743.75 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$787.50 ,$700.00 
Outpatient Medical Services,RADIOLOGY,93971,One sided or limited bilateral study,921,$885.00 ,$752.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$796.50 ,90% of total billed charges,$309.75 ,35% based on GA Medicaid OP CCR Rate,$608.00 ,68.7% of total billed charges,$708.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$513.30 ,58% of total billed charges,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$752.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$796.50 ,$708.00 
Outpatient Medical Services,RADIOLOGY,93971,One sided or limited bilateral study,921,$885.00 ,$752.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$796.50 ,90% of total billed charges,$309.75 ,35% based on GA Medicaid OP CCR Rate,$608.00 ,68.7% of total billed charges,$708.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$513.30 ,58% of total billed charges,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$752.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$796.50 ,$708.00 
Outpatient Medical Services,RADIOLOGY,93971,One sided or limited bilateral study,921,$885.00 ,$752.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$796.50 ,90% of total billed charges,$309.75 ,35% based on GA Medicaid OP CCR Rate,$608.00 ,68.7% of total billed charges,$708.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$513.30 ,58% of total billed charges,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$752.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$796.50 ,$708.00 
Outpatient Medical Services,RADIOLOGY,93971,One sided or limited bilateral study,921,$885.00 ,$752.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$500.03 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$796.50 ,90% of total billed charges,$309.75 ,35% based on GA Medicaid OP CCR Rate,$608.00 ,68.7% of total billed charges,$708.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$513.30 ,58% of total billed charges,$180.27 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$752.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$796.50 ,$708.00 
Outpatient Medical Services,RADIOLOGY,93990,US AV GRAFT IMAGE,921,$940.00 ,$799.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$191.48 ,20.37% based on GA Medicaid OP CCR Rate,$531.10 ,56.5 percent of total billed charges,$531.10 ,56.5 percent of total billed charges,$531.10 ,56.5 percent of total billed charges,$531.10 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$846.00 ,90% of total billed charges,$329.00 ,35% based on GA Medicaid OP CCR Rate,$645.78 ,68.7% of total billed charges,$752.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$545.20 ,58% of total billed charges,$191.48 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$799.00 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$846.00 ,$752.00 
Outpatient Medical Services,RADIOLOGY,54240,US IMPOT PENILE STUDY PLETHYSMOGRAPHY,921,$950.00 ,$807.50 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$193.52 ,20.37% based on GA Medicaid OP CCR Rate,$536.75 ,56.5 percent of total billed charges,$536.75 ,56.5 percent of total billed charges,$536.75 ,56.5 percent of total billed charges,$536.75 ,56.5 percent of total billed charges,$242.49 ,Pays 102% Medicare OPPS,$855.00 ,90% of total billed charges,$332.50 ,35% based on GA Medicaid OP CCR Rate,$652.65 ,68.7% of total billed charges,$760.00 ,80 percent of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,Pays 90% Medicare OPPS,$551.00 ,58% of total billed charges,$193.52 ,20.37% based on GA Medicaid OP CCR Rate,$246.33 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$807.50 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$193.52 ,$855.00 ,$760.00 
Outpatient Medical Services,RADIOLOGY,93923,US BIL PHYSOLOGIC SEG AR,921,"$1,045.00 ",$888.25 ,85% of total billed charges,$125.42 ,Pays 100% Medicare OPPS,$125.42 ,Pays 100% Medicare OPPS,$125.42 ,Pays 100% Medicare OPPS,$166.28 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$127.92 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$125.42 ,Pays 100% Medicare OPPS,$112.87 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$127.91 ,Pays 100% Medicare OPPS,$166.28 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$125.42 ,Pays 100% Medicare OPPS,$112.87 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,93926,US AORTIC LOW EXT-LEFT,921,"$1,045.00 ",$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,93931,US UPPER ARTERIAL-LEFT,921,"$1,045.00 ",$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,93926,US AORTIC LOW EXT-RIGHT,921,"$1,045.00 ",$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,93931,US UPPER ARTERIAL-RIGHT,921,"$1,045.00 ",$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,93975,US ARTERIAL-SCROTAL,921,"$1,045.00 ",$888.25 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,93979,US DUPLX AORTA/IVC/LIMIT,921,"$1,045.00 ",$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$590.43 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,$940.50 ,90% of total billed charges,$365.75 ,35% based on GA Medicaid OP CCR Rate,$717.92 ,68.7% of total billed charges,$836.00 ,80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,Pays 90% Medicare OPPS,$606.10 ,58% of total billed charges,$212.87 ,20.37% based on GA Medicaid OP CCR Rate,$94.00 ,Pays 100% Medicare OPPS,$122.21 ,Pays 130% Medicare OPPS,$888.25 ,85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.02 ,$940.50 ,$836.00 
Outpatient Medical Services,RADIOLOGY,93880,Study of vessels on both sides of the head and neck,921,"$1,065.00 ",$905.25 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$216.94 ,20.37% based on GA Medicaid OP CCR Rate,$601.73 ,56.5 percent of total billed charges,$601.73 ,56.5 percent of total billed charges,$601.73 ,56.5 percent of total billed charges,$601.73 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,$958.50 ,90% of total billed charges,$372.75 ,35% based on GA Medicaid OP CCR Rate,$731.66 ,68.7% of total billed charges,$852.00 ,80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$617.70 ,58% of total billed charges,$216.94 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$905.25 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,$958.50 ,$852.00 
Outpatient Medical Services,RADIOLOGY,93978,US VASCULAR-AORTA-IVC-ILIAC-COMPLETE,921,"$1,195.00 ","$1,015.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$243.42 ,20.37% based on GA Medicaid OP CCR Rate,$675.18 ,56.5 percent of total billed charges,$675.18 ,56.5 percent of total billed charges,$675.18 ,56.5 percent of total billed charges,$675.18 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$1,075.50 ",90% of total billed charges,$418.25 ,35% based on GA Medicaid OP CCR Rate,$820.97 ,68.7% of total billed charges,$956.00 ,80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$693.10 ,58% of total billed charges,$243.42 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,015.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$1,075.50 ",$956.00 
Outpatient Medical Services,RADIOLOGY,93924,US PHYSL SEG EXERCISE-BIL,921,"$1,215.00 ","$1,032.75 ",85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$247.50 ,20.37% based on GA Medicaid OP CCR Rate,$686.48 ,56.5 percent of total billed charges,$686.48 ,56.5 percent of total billed charges,$686.48 ,56.5 percent of total billed charges,$686.48 ,56.5 percent of total billed charges,$242.49 ,Pays 102% Medicare OPPS,"$1,093.50 ",90% of total billed charges,$425.25 ,35% based on GA Medicaid OP CCR Rate,$834.71 ,68.7% of total billed charges,$972.00 ,80 percent of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,Pays 90% Medicare OPPS,$704.70 ,58% of total billed charges,$247.50 ,20.37% based on GA Medicaid OP CCR Rate,$246.33 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,"$1,032.75 ",85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,"$1,093.50 ",$972.00 
Outpatient Medical Services,RADIOLOGY,93882,US CAROTID UNI LEFT,921,"$1,260.00 ","$1,071.00 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$256.66 ,20.37% based on GA Medicaid OP CCR Rate,$711.90 ,56.5 percent of total billed charges,$711.90 ,56.5 percent of total billed charges,$711.90 ,56.5 percent of total billed charges,$711.90 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$1,134.00 ",90% of total billed charges,$441.00 ,35% based on GA Medicaid OP CCR Rate,$865.62 ,68.7% of total billed charges,"$1,008.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$730.80 ,58% of total billed charges,$256.66 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$1,071.00 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$1,134.00 ","$1,008.00 "
Outpatient Medical Services,RADIOLOGY,93971,One sided or limited bilateral study,921,"$1,300.00 ","$1,105.00 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$264.81 ,20.37% based on GA Medicaid OP CCR Rate,$734.50 ,56.5 percent of total billed charges,$734.50 ,56.5 percent of total billed charges,$734.50 ,56.5 percent of total billed charges,$734.50 ,56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$1,170.00 ",90% of total billed charges,$455.00 ,35% based on GA Medicaid OP CCR Rate,$893.10 ,68.7% of total billed charges,"$1,040.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,$754.00 ,58% of total billed charges,$264.81 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$1,105.00 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$1,170.00 ","$1,040.00 "
Outpatient Medical Services,RADIOLOGY,93923,US PHYS UP/LOW ART/MULTI-BIL,921,"$1,315.00 ","$1,117.75 ",85% of total billed charges,$125.42 ,Pays 100% Medicare OPPS,$125.42 ,Pays 100% Medicare OPPS,$125.42 ,Pays 100% Medicare OPPS,$166.28 ,Pays 130% Medicare OPPS,$267.87 ,20.37% based on GA Medicaid OP CCR Rate,$742.98 ,56.5 percent of total billed charges,$742.98 ,56.5 percent of total billed charges,$742.98 ,56.5 percent of total billed charges,$742.98 ,56.5 percent of total billed charges,$127.92 ,Pays 102% Medicare OPPS,"$1,183.50 ",90% of total billed charges,$460.25 ,35% based on GA Medicaid OP CCR Rate,$903.41 ,68.7% of total billed charges,"$1,052.00 ",80 percent of total billed charges,$125.42 ,Pays 100% Medicare OPPS,$112.87 ,Pays 90% Medicare OPPS,$762.70 ,58% of total billed charges,$267.87 ,20.37% based on GA Medicaid OP CCR Rate,$127.91 ,Pays 100% Medicare OPPS,$166.28 ,Pays 130% Medicare OPPS,"$1,117.75 ",85% of total billed charges,$125.42 ,Pays 100% Medicare OPPS,$112.87 ,"$1,183.50 ","$1,052.00 "
Outpatient Medical Services,RADIOLOGY,93922,Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,921,"$1,335.00 ","$1,134.75 ",85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$271.94 ,20.37% based on GA Medicaid OP CCR Rate,$754.28 ,56.5 percent of total billed charges,$754.28 ,56.5 percent of total billed charges,$754.28 ,56.5 percent of total billed charges,$754.28 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,"$1,201.50 ",90% of total billed charges,$467.25 ,35% based on GA Medicaid OP CCR Rate,$917.15 ,68.7% of total billed charges,"$1,068.00 ",80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$774.30 ,58% of total billed charges,$271.94 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,"$1,134.75 ",85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,"$1,201.50 ","$1,068.00 "
Outpatient Medical Services,RADIOLOGY,93924,US PHYS LOWER EXT/REST-BIL,921,"$1,370.00 ","$1,164.50 ",85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$279.07 ,20.37% based on GA Medicaid OP CCR Rate,$774.05 ,56.5 percent of total billed charges,$774.05 ,56.5 percent of total billed charges,$774.05 ,56.5 percent of total billed charges,$774.05 ,56.5 percent of total billed charges,$242.49 ,Pays 102% Medicare OPPS,"$1,233.00 ",90% of total billed charges,$479.50 ,35% based on GA Medicaid OP CCR Rate,$941.19 ,68.7% of total billed charges,"$1,096.00 ",80 percent of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,Pays 90% Medicare OPPS,$794.60 ,58% of total billed charges,$279.07 ,20.37% based on GA Medicaid OP CCR Rate,$246.33 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,"$1,164.50 ",85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,"$1,233.00 ","$1,096.00 "
Outpatient Medical Services,RADIOLOGY,93925,US BILAT ARTERIAL LOW EX,921,"$1,545.00 ","$1,313.25 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$314.72 ,20.37% based on GA Medicaid OP CCR Rate,$872.93 ,56.5 percent of total billed charges,$872.93 ,56.5 percent of total billed charges,$872.93 ,56.5 percent of total billed charges,$872.93 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$1,390.50 ",90% of total billed charges,$540.75 ,35% based on GA Medicaid OP CCR Rate,"$1,061.42 ",68.7% of total billed charges,"$1,236.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$896.10 ,58% of total billed charges,$314.72 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,313.25 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$1,390.50 ","$1,236.00 "
Outpatient Medical Services,RADIOLOGY,93930,US UPPER ARTERIAL-BIL,921,"$1,545.00 ","$1,313.25 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$314.72 ,20.37% based on GA Medicaid OP CCR Rate,$872.93 ,56.5 percent of total billed charges,$872.93 ,56.5 percent of total billed charges,$872.93 ,56.5 percent of total billed charges,$872.93 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$1,390.50 ",90% of total billed charges,$540.75 ,35% based on GA Medicaid OP CCR Rate,"$1,061.42 ",68.7% of total billed charges,"$1,236.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$896.10 ,58% of total billed charges,$314.72 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,313.25 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$1,390.50 ","$1,236.00 "
Outpatient Medical Services,RADIOLOGY,93925,US ARTERIAL LOWER EXT/BIL,921,"$1,550.00 ","$1,317.50 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$315.74 ,20.37% based on GA Medicaid OP CCR Rate,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$1,395.00 ",90% of total billed charges,$542.50 ,35% based on GA Medicaid OP CCR Rate,"$1,064.85 ",68.7% of total billed charges,"$1,240.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$899.00 ,58% of total billed charges,$315.74 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,317.50 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$1,395.00 ","$1,240.00 "
Outpatient Medical Services,RADIOLOGY,93978,US DUP AORTA/IVC/COMPLET,921,"$1,595.00 ","$1,355.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$324.90 ,20.37% based on GA Medicaid OP CCR Rate,$901.18 ,56.5 percent of total billed charges,$901.18 ,56.5 percent of total billed charges,$901.18 ,56.5 percent of total billed charges,$901.18 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$1,435.50 ",90% of total billed charges,$558.25 ,35% based on GA Medicaid OP CCR Rate,"$1,095.77 ",68.7% of total billed charges,"$1,276.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$925.10 ,58% of total billed charges,$324.90 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,355.75 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$1,435.50 ","$1,276.00 "
Outpatient Medical Services,RADIOLOGY,93970,Complete bilateral study of the extremities,921,"$1,690.00 ","$1,436.50 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$344.25 ,20.37% based on GA Medicaid OP CCR Rate,$954.85 ,56.5 percent of total billed charges,$954.85 ,56.5 percent of total billed charges,$954.85 ,56.5 percent of total billed charges,$954.85 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$1,521.00 ",90% of total billed charges,$591.50 ,35% based on GA Medicaid OP CCR Rate,"$1,161.03 ",68.7% of total billed charges,"$1,352.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$980.20 ,58% of total billed charges,$344.25 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,436.50 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$1,521.00 ","$1,352.00 "
Outpatient Medical Services,RADIOLOGY,93970,Complete bilateral study of the extremities,921,"$1,690.00 ","$1,436.50 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$344.25 ,20.37% based on GA Medicaid OP CCR Rate,$954.85 ,56.5 percent of total billed charges,$954.85 ,56.5 percent of total billed charges,$954.85 ,56.5 percent of total billed charges,$954.85 ,56.5 percent of total billed charges,$210.83 ,Pays 102% Medicare OPPS,"$1,521.00 ",90% of total billed charges,$591.50 ,35% based on GA Medicaid OP CCR Rate,"$1,161.03 ",68.7% of total billed charges,"$1,352.00 ",80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$980.20 ,58% of total billed charges,$344.25 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,"$1,436.50 ",85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,"$1,521.00 ","$1,352.00 "
Outpatient Medical Services,RADIOLOGY,93980,US DUPLX SCAN PENILE VES,921,"$1,835.00 ","$1,559.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$97.80 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,$373.79 ,20.37% based on GA Medicaid OP CCR Rate,"$1,036.78 ",56.5 percent of total billed charges,"$1,036.78 ",56.5 percent of total billed charges,"$1,036.78 ",56.5 percent of total billed charges,"$1,036.78 ",56.5 percent of total billed charges,$99.75 ,Pays 102% Medicare OPPS,"$1,651.50 ",90% of total billed charges,$642.25 ,35% based on GA Medicaid OP CCR Rate,"$1,260.65 ",68.7% of total billed charges,"$1,468.00 ",80 percent of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,Pays 90% Medicare OPPS,"$1,064.30 ",58% of total billed charges,$373.79 ,20.37% based on GA Medicaid OP CCR Rate,$94.01 ,Pays 100% Medicare OPPS,$122.20 ,Pays 130% Medicare OPPS,"$1,559.75 ",85% of total billed charges,$97.80 ,Pays 100% Medicare OPPS,$88.01 ,"$1,651.50 ","$1,468.00 "
Outpatient Medical Services,SURGERY,10035,PERQ DEV SOFT TISS 1ST IMG,360,"$2,175.00 ","$1,848.75 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$443.05 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$570.17 ,Pays 102% Medicare OPPS,"$1,957.50 ",90% of total billed charges,$761.25 ,35% based on GA Medicaid OP CCR Rate,"$1,494.23 ",68.7% of total billed charges,"$1,740.00 ",80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,"$1,261.50 ",58% of total billed charges,$443.05 ,20.37% based on GA Medicaid OP CCR Rate,$570.82 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,"$1,848.75 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$443.05 ,"$1,957.50 ","$1,740.00 "
Outpatient Medical Services,SURGERY,10061,I&D ABSC; COMPL OR MULTI,360,"$1,500.00 ","$1,275.00 ",85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$305.55 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$316.70 ,Pays 102% Medicare OPPS,"$1,350.00 ",90% of total billed charges,$525.00 ,35% based on GA Medicaid OP CCR Rate,"$1,030.50 ",68.7% of total billed charges,"$1,200.00 ",80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$870.00 ,58% of total billed charges,$305.55 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,"$1,275.00 ",85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,"$1,350.00 ","$1,200.00 "
Outpatient Medical Services,SURGERY,11008,REMOVE MESH FROM ABD WALL,360,"$1,190.00 ","$1,011.50 ",85% of total billed charges,"$1,190.00 ",Pays 100% Medicare OPPS,"$1,190.00 ",Pays 100% Medicare OPPS,"$1,190.00 ",Pays 100% Medicare OPPS,"$1,190.00 ",Pays 130% Medicare OPPS,$242.40 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,190.00 ",Pays 102% Medicare OPPS,"$1,071.00 ",90% of total billed charges,$416.50 ,35% based on GA Medicaid OP CCR Rate,$817.53 ,68.7% of total billed charges,$952.00 ,80 percent of total billed charges,"$1,190.00 ",Pays 100% Medicare OPPS,"$1,190.00 ",Pays 90% Medicare OPPS,$690.20 ,58% of total billed charges,$242.40 ,20.37% based on GA Medicaid OP CCR Rate,"$1,190.00 ",Pays 100% Medicare OPPS,"$1,190.00 ",Pays 130% Medicare OPPS,"$1,011.50 ",85% of total billed charges,"$1,190.00 ",Pays 100% Medicare OPPS,$242.40 ,"$1,190.00 ",$952.00 
Outpatient Medical Services,SURGERY,11042,DEB SUBQ TISSUE 20 SQ CM/<,360,"$1,500.00 ","$1,275.00 ",85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$305.55 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$316.70 ,Pays 102% Medicare OPPS,"$1,350.00 ",90% of total billed charges,$525.00 ,35% based on GA Medicaid OP CCR Rate,"$1,030.50 ",68.7% of total billed charges,"$1,200.00 ",80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$870.00 ,58% of total billed charges,$305.55 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,"$1,275.00 ",85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,"$1,350.00 ","$1,200.00 "
Outpatient Medical Services,SURGERY,11043,DEBRIDEMENT MUSCLE/FASCIA 20 SQ CM/<,360,"$2,000.00 ","$1,700.00 ",85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,$407.40 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$479.88 ,Pays 102% Medicare OPPS,"$1,800.00 ",90% of total billed charges,$700.00 ,35% based on GA Medicaid OP CCR Rate,"$1,374.00 ",68.7% of total billed charges,"$1,600.00 ",80 percent of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$423.42 ,Pays 90% Medicare OPPS,"$1,160.00 ",58% of total billed charges,$407.40 ,20.37% based on GA Medicaid OP CCR Rate,$510.99 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,"$1,700.00 ",85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$407.40 ,"$1,800.00 ","$1,600.00 "
Outpatient Medical Services,SURGERY,11045,DEB SUBQ TISSUE ADDON ADDL 20 SQ CM,360,$150.00 ,$127.50 ,85% of total billed charges,$37.50 ,Pays 100% Medicare OPPS,$37.50 ,Pays 100% Medicare OPPS,$37.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$30.56 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,N/A,Pays 102% Medicare OPPS,$135.00 ,90% of total billed charges,$52.50 ,35% based on GA Medicaid OP CCR Rate,$103.05 ,68.7% of total billed charges,$120.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$135.00 ,Pays 90% Medicare OPPS,$87.00 ,58% of total billed charges,$30.56 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$127.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$30.56 ,$986.63 ,$120.00 
Outpatient Medical Services,SURGERY,11046,DEBRIDEMENT MUSCLE EA ADDL 20 SQ CM,360,$315.00 ,$267.75 ,85% of total billed charges,$78.75 ,Pays 100% Medicare OPPS,$78.75 ,Pays 100% Medicare OPPS,$78.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$64.17 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,N/A,Pays 102% Medicare OPPS,$283.50 ,90% of total billed charges,$110.25 ,35% based on GA Medicaid OP CCR Rate,$216.41 ,68.7% of total billed charges,$252.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$283.50 ,Pays 90% Medicare OPPS,$182.70 ,58% of total billed charges,$64.17 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$267.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$64.17 ,$986.63 ,$252.00 
Outpatient Medical Services,SURGERY,11403,EXCISION BEN LESION 2.1-3.0CM,360,"$3,725.00 ","$3,166.25 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$758.78 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$570.17 ,Pays 102% Medicare OPPS,"$3,352.50 ",90% of total billed charges,"$1,303.75 ",35% based on GA Medicaid OP CCR Rate,"$2,559.08 ",68.7% of total billed charges,"$2,980.00 ",80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,"$2,160.50 ",58% of total billed charges,$758.78 ,20.37% based on GA Medicaid OP CCR Rate,$570.82 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,"$3,166.25 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,"$3,352.50 ","$2,980.00 "
Outpatient Medical Services,SURGERY,11462,EXCISION HIDRADENITIS INGUINAL SMPL/INTR,360,"$10,315.00 ","$8,767.75 ",85% of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,953.82 ",Pays 130% Medicare OPPS,"$2,101.17 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,172.54 ",Pays 102% Medicare OPPS,"$9,283.50 ",90% of total billed charges,"$3,610.25 ",35% based on GA Medicaid OP CCR Rate,"$7,086.41 ",68.7% of total billed charges,"$8,252.00 ",80 percent of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,"$1,916.94 ",Pays 90% Medicare OPPS,"$5,982.70 ",58% of total billed charges,"$2,101.17 ",20.37% based on GA Medicaid OP CCR Rate,"$2,272.17 ",Pays 100% Medicare OPPS,"$2,953.82 ",Pays 130% Medicare OPPS,"$8,767.75 ",85% of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,$862.48 ,"$9,283.50 ","$8,252.00 "
Outpatient Medical Services,SURGERY,14041,ATT F/C/C/M/N/A/G/H/F; 10.1-30SQCM,360,"$8,125.00 ","$6,906.25 ",85% of total billed charges,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,973.43 ",Pays 130% Medicare OPPS,"$1,655.06 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,569.38 ",Pays 102% Medicare OPPS,"$7,312.50 ",90% of total billed charges,"$2,843.75 ",35% based on GA Medicaid OP CCR Rate,"$5,581.88 ",68.7% of total billed charges,"$6,500.00 ",80 percent of total billed charges,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,384.75 ",Pays 90% Medicare OPPS,"$4,712.50 ",58% of total billed charges,"$1,655.06 ",20.37% based on GA Medicaid OP CCR Rate,"$1,518.03 ",Pays 100% Medicare OPPS,"$1,973.43 ",Pays 130% Medicare OPPS,"$6,906.25 ",85% of total billed charges,"$1,538.61 ",Pays 100% Medicare OPPS,$862.48 ,"$7,312.50 ","$6,500.00 "
Outpatient Medical Services,SURGERY,14061,ATT E/N/E/L;D 10.1-30SQCM,360,"$8,125.00 ","$6,906.25 ",85% of total billed charges,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,973.43 ",Pays 130% Medicare OPPS,"$1,655.06 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,569.38 ",Pays 102% Medicare OPPS,"$7,312.50 ",90% of total billed charges,"$2,843.75 ",35% based on GA Medicaid OP CCR Rate,"$5,581.88 ",68.7% of total billed charges,"$6,500.00 ",80 percent of total billed charges,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,384.75 ",Pays 90% Medicare OPPS,"$4,712.50 ",58% of total billed charges,"$1,655.06 ",20.37% based on GA Medicaid OP CCR Rate,"$1,518.03 ",Pays 100% Medicare OPPS,"$1,973.43 ",Pays 130% Medicare OPPS,"$6,906.25 ",85% of total billed charges,"$1,538.61 ",Pays 100% Medicare OPPS,$862.48 ,"$7,312.50 ","$6,500.00 "
Outpatient Medical Services,SURGERY,15734,MUSCLE FLAP TRUNK,360,"$13,125.00 ","$11,156.25 ",85% of total billed charges,"$3,163.16 ",Pays 100% Medicare OPPS,"$3,163.16 ",Pays 100% Medicare OPPS,"$3,163.16 ",Pays 100% Medicare OPPS,"$3,719.69 ",Pays 130% Medicare OPPS,"$2,673.56 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$3,226.42 ",Pays 102% Medicare OPPS,"$11,812.50 ",90% of total billed charges,"$4,593.75 ",35% based on GA Medicaid OP CCR Rate,"$9,016.88 ",68.7% of total billed charges,"$10,500.00 ",80 percent of total billed charges,"$3,163.16 ",Pays 100% Medicare OPPS,"$2,846.84 ",Pays 90% Medicare OPPS,"$7,612.50 ",58% of total billed charges,"$2,673.56 ",20.37% based on GA Medicaid OP CCR Rate,"$2,861.30 ",Pays 100% Medicare OPPS,"$3,719.69 ",Pays 130% Medicare OPPS,"$11,156.25 ",85% of total billed charges,"$3,163.16 ",Pays 100% Medicare OPPS,$862.48 ,"$11,812.50 ","$10,500.00 "
Outpatient Medical Services,SURGERY,15777,ACELLULAR DERM MATRIX IMPLT,360,$800.00 ,$680.00 ,85% of total billed charges,$200.00 ,Pays 100% Medicare OPPS,$200.00 ,Pays 100% Medicare OPPS,$200.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$162.96 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,N/A,Pays 102% Medicare OPPS,$720.00 ,90% of total billed charges,$280.00 ,35% based on GA Medicaid OP CCR Rate,$549.60 ,68.7% of total billed charges,$640.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$720.00 ,Pays 90% Medicare OPPS,$464.00 ,58% of total billed charges,$162.96 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$680.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$162.96 ,$986.63 ,$640.00 
Outpatient Medical Services,SURGERY,17110,Destruction of 1-14 common or plantar warts,360,$500.00 ,$425.00 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$101.85 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$164.54 ,Pays 102% Medicare OPPS,$450.00 ,90% of total billed charges,$175.00 ,35% based on GA Medicaid OP CCR Rate,$343.50 ,68.7% of total billed charges,$400.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$290.00 ,58% of total billed charges,$101.85 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$425.00 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$101.85 ,$986.63 ,$400.00 
Outpatient Medical Services,SURGERY,19020,MASTOMY W/EXPLORATION/DRAINAGE ABSCESS,360,"$7,500.00 ","$6,375.00 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$1,527.75 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,289.21 ",Pays 102% Medicare OPPS,"$6,750.00 ",90% of total billed charges,"$2,625.00 ",35% based on GA Medicaid OP CCR Rate,"$5,152.50 ",68.7% of total billed charges,"$6,000.00 ",80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,"$4,350.00 ",58% of total billed charges,"$1,527.75 ",20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$6,375.00 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,$862.48 ,"$6,750.00 ","$6,000.00 "
Outpatient Medical Services,SURGERY,19083,BIOPSY BREAST W LOCALIZATION DEVICE,360,"$3,975.00 ","$3,378.75 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$809.71 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,289.21 ",Pays 102% Medicare OPPS,"$3,577.50 ",90% of total billed charges,"$1,391.25 ",35% based on GA Medicaid OP CCR Rate,"$2,730.83 ",68.7% of total billed charges,"$3,180.00 ",80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,"$2,305.50 ",58% of total billed charges,$809.71 ,20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$3,378.75 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,$809.71 ,"$3,577.50 ","$3,180.00 "
Outpatient Medical Services,SURGERY,19101,BIOPSY BREAST OPEN INCISIONAL,360,"$13,815.00 ","$11,742.75 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$2,814.12 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,893.37 ",Pays 102% Medicare OPPS,"$12,433.50 ",90% of total billed charges,"$4,835.25 ",35% based on GA Medicaid OP CCR Rate,"$9,490.91 ",68.7% of total billed charges,"$11,052.00 ",80 percent of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,552.98 ",Pays 90% Medicare OPPS,"$8,012.70 ",58% of total billed charges,"$2,814.12 ",20.37% based on GA Medicaid OP CCR Rate,"$3,023.82 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$11,742.75 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,$862.48 ,"$12,433.50 ","$11,052.00 "
Outpatient Medical Services,SURGERY,19110,NIPPLE EXPLORATION,360,"$10,975.00 ","$9,328.75 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$2,235.61 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,893.37 ",Pays 102% Medicare OPPS,"$9,877.50 ",90% of total billed charges,"$3,841.25 ",35% based on GA Medicaid OP CCR Rate,"$7,539.83 ",68.7% of total billed charges,"$8,780.00 ",80 percent of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,552.98 ",Pays 90% Medicare OPPS,"$6,365.50 ",58% of total billed charges,"$2,235.61 ",20.37% based on GA Medicaid OP CCR Rate,"$3,023.82 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$9,328.75 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,$862.48 ,"$9,877.50 ","$8,780.00 "
Outpatient Medical Services,SURGERY,19120,REMOVAL OF BREAST LESION,360,"$13,440.00 ","$11,424.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$2,737.73 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,893.37 ",Pays 102% Medicare OPPS,"$12,096.00 ",90% of total billed charges,"$4,704.00 ",35% based on GA Medicaid OP CCR Rate,"$9,233.28 ",68.7% of total billed charges,"$10,752.00 ",80 percent of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,552.98 ",Pays 90% Medicare OPPS,"$7,795.20 ",58% of total billed charges,"$2,737.73 ",20.37% based on GA Medicaid OP CCR Rate,"$3,023.82 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$11,424.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,$862.48 ,"$12,096.00 ","$10,752.00 "
Outpatient Medical Services,SURGERY,19125,EXC BREASTLES BY N LOC; SGL,360,"$10,975.00 ","$9,328.75 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$2,235.61 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,893.37 ",Pays 102% Medicare OPPS,"$9,877.50 ",90% of total billed charges,"$3,841.25 ",35% based on GA Medicaid OP CCR Rate,"$7,539.83 ",68.7% of total billed charges,"$8,780.00 ",80 percent of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,552.98 ",Pays 90% Medicare OPPS,"$6,365.50 ",58% of total billed charges,"$2,235.61 ",20.37% based on GA Medicaid OP CCR Rate,"$3,023.82 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$9,328.75 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,$862.48 ,"$9,877.50 ","$8,780.00 "
Outpatient Medical Services,SURGERY,19300,REMOVAL OF BREAST TISSUE,360,"$10,500.00 ","$8,925.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$2,138.85 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,893.37 ",Pays 102% Medicare OPPS,"$9,450.00 ",90% of total billed charges,"$3,675.00 ",35% based on GA Medicaid OP CCR Rate,"$7,213.50 ",68.7% of total billed charges,"$8,400.00 ",80 percent of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,552.98 ",Pays 90% Medicare OPPS,"$6,090.00 ",58% of total billed charges,"$2,138.85 ",20.37% based on GA Medicaid OP CCR Rate,"$3,023.82 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$8,925.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,$862.48 ,"$9,450.00 ","$8,400.00 "
Outpatient Medical Services,SURGERY,19301,PARTIAL MASTECTOMY,360,"$13,440.00 ","$11,424.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$2,737.73 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,893.37 ",Pays 102% Medicare OPPS,"$12,096.00 ",90% of total billed charges,"$4,704.00 ",35% based on GA Medicaid OP CCR Rate,"$9,233.28 ",68.7% of total billed charges,"$10,752.00 ",80 percent of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,552.98 ",Pays 90% Medicare OPPS,"$7,795.20 ",58% of total billed charges,"$2,737.73 ",20.37% based on GA Medicaid OP CCR Rate,"$3,023.82 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$11,424.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,$862.48 ,"$12,096.00 ","$10,752.00 "
Outpatient Medical Services,SURGERY,19302,MASTECTOMY PARTIAL W/LN REMOVAL,360,"$24,190.00 ","$20,561.50 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$4,927.50 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$5,070.89 ",Pays 102% Medicare OPPS,"$21,771.00 ",90% of total billed charges,"$8,466.50 ",35% based on GA Medicaid OP CCR Rate,"$16,618.53 ",68.7% of total billed charges,"$19,352.00 ",80 percent of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,474.32 ",Pays 90% Medicare OPPS,"$14,030.20 ",58% of total billed charges,"$4,927.50 ",20.37% based on GA Medicaid OP CCR Rate,"$5,227.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$20,561.50 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,$862.48 ,"$21,771.00 ","$19,352.00 "
Outpatient Medical Services,SURGERY,19303,MASTECTOMY SIMPLE COMPLETE,360,"$24,250.00 ","$20,612.50 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$4,939.73 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$5,070.89 ",Pays 102% Medicare OPPS,"$21,825.00 ",90% of total billed charges,"$8,487.50 ",35% based on GA Medicaid OP CCR Rate,"$16,659.75 ",68.7% of total billed charges,"$19,400.00 ",80 percent of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,474.32 ",Pays 90% Medicare OPPS,"$14,065.00 ",58% of total billed charges,"$4,939.73 ",20.37% based on GA Medicaid OP CCR Rate,"$5,227.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$20,612.50 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,$862.48 ,"$21,825.00 ","$19,400.00 "
Outpatient Medical Services,SURGERY,19307,MAST MOD RAD,360,"$22,940.00 ","$19,499.00 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$4,672.88 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$5,070.89 ",Pays 102% Medicare OPPS,"$20,646.00 ",90% of total billed charges,"$8,029.00 ",35% based on GA Medicaid OP CCR Rate,"$15,759.78 ",68.7% of total billed charges,"$18,352.00 ",80 percent of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,474.32 ",Pays 90% Medicare OPPS,"$13,305.20 ",58% of total billed charges,"$4,672.88 ",20.37% based on GA Medicaid OP CCR Rate,"$5,227.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$19,499.00 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,$862.48 ,"$20,646.00 ","$18,352.00 "
Outpatient Medical Services,SURGERY,19316,MASTOPEXY,360,"$22,225.00 ","$18,891.25 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$4,527.23 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$5,070.89 ",Pays 102% Medicare OPPS,"$20,002.50 ",90% of total billed charges,"$7,778.75 ",35% based on GA Medicaid OP CCR Rate,"$15,268.58 ",68.7% of total billed charges,"$17,780.00 ",80 percent of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,474.32 ",Pays 90% Medicare OPPS,"$12,890.50 ",58% of total billed charges,"$4,527.23 ",20.37% based on GA Medicaid OP CCR Rate,"$5,227.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$18,891.25 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,$862.48 ,"$20,002.50 ","$17,780.00 "
Outpatient Medical Services,SURGERY,19318,BREAST MAMMAPLASTY,360,"$23,125.00 ","$19,656.25 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$4,710.56 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$5,070.89 ",Pays 102% Medicare OPPS,"$20,812.50 ",90% of total billed charges,"$8,093.75 ",35% based on GA Medicaid OP CCR Rate,"$15,886.88 ",68.7% of total billed charges,"$18,500.00 ",80 percent of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,474.32 ",Pays 90% Medicare OPPS,"$13,412.50 ",58% of total billed charges,"$4,710.56 ",20.37% based on GA Medicaid OP CCR Rate,"$5,227.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$19,656.25 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,$862.48 ,"$20,812.50 ","$18,500.00 "
Outpatient Medical Services,SURGERY,19328,REMOVAL INTACT BREAST IMPLANT,360,"$13,440.00 ","$11,424.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$2,737.73 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,893.37 ",Pays 102% Medicare OPPS,"$12,096.00 ",90% of total billed charges,"$4,704.00 ",35% based on GA Medicaid OP CCR Rate,"$9,233.28 ",68.7% of total billed charges,"$10,752.00 ",80 percent of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,552.98 ",Pays 90% Medicare OPPS,"$7,795.20 ",58% of total billed charges,"$2,737.73 ",20.37% based on GA Medicaid OP CCR Rate,"$3,023.82 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$11,424.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,$862.48 ,"$12,096.00 ","$10,752.00 "
Outpatient Medical Services,SURGERY,19340,INSJ BREAST IMPLT SM D MAST,360,"$24,250.00 ","$20,612.50 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$4,939.73 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$5,070.89 ",Pays 102% Medicare OPPS,"$21,825.00 ",90% of total billed charges,"$8,487.50 ",35% based on GA Medicaid OP CCR Rate,"$16,659.75 ",68.7% of total billed charges,"$19,400.00 ",80 percent of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,474.32 ",Pays 90% Medicare OPPS,"$14,065.00 ",58% of total billed charges,"$4,939.73 ",20.37% based on GA Medicaid OP CCR Rate,"$5,227.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$20,612.50 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,$862.48 ,"$21,825.00 ","$19,400.00 "
Outpatient Medical Services,SURGERY,19357,TISS XPNDR BRST RECNSTJ,360,"$65,440.00 ","$55,624.00 ",85% of total billed charges,"$13,402.79 ",Pays 100% Medicare OPPS,"$13,402.79 ",Pays 100% Medicare OPPS,"$13,402.79 ",Pays 100% Medicare OPPS,"$19,077.12 ",Pays 130% Medicare OPPS,"$13,330.13 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$13,670.84 ",Pays 102% Medicare OPPS,"$58,896.00 ",90% of total billed charges,"$22,904.00 ",35% based on GA Medicaid OP CCR Rate,"$44,957.28 ",68.7% of total billed charges,"$52,352.00 ",80 percent of total billed charges,"$13,402.79 ",Pays 100% Medicare OPPS,"$12,062.50 ",Pays 90% Medicare OPPS,"$37,955.20 ",58% of total billed charges,"$13,330.13 ",20.37% based on GA Medicaid OP CCR Rate,"$14,674.71 ",Pays 100% Medicare OPPS,"$19,077.12 ",Pays 130% Medicare OPPS,"$55,624.00 ",85% of total billed charges,"$13,402.79 ",Pays 100% Medicare OPPS,$862.48 ,"$58,896.00 ","$52,352.00 "
Outpatient Medical Services,SURGERY,19366,BREAST RECONSTRUCT W OTHR,360,"$23,125.00 ","$19,656.25 ",85% of total billed charges,"$5,781.25 ",Pays 100% Medicare OPPS,"$5,781.25 ",Pays 100% Medicare OPPS,"$5,781.25 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$4,710.56 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,N/A,Pays 102% Medicare OPPS,"$20,812.50 ",90% of total billed charges,"$8,093.75 ",35% based on GA Medicaid OP CCR Rate,"$15,886.88 ",68.7% of total billed charges,"$18,500.00 ",80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,"$20,812.50 ",Pays 90% Medicare OPPS,"$13,412.50 ",58% of total billed charges,"$4,710.56 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$19,656.25 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,$862.48 ,"$20,812.50 ","$18,500.00 "
Outpatient Medical Services,SURGERY,19371,PERIPROSTH CAPSULECT BREAST,360,"$13,440.00 ","$11,424.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$2,737.73 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,893.37 ",Pays 102% Medicare OPPS,"$12,096.00 ",90% of total billed charges,"$4,704.00 ",35% based on GA Medicaid OP CCR Rate,"$9,233.28 ",68.7% of total billed charges,"$10,752.00 ",80 percent of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,552.98 ",Pays 90% Medicare OPPS,"$7,795.20 ",58% of total billed charges,"$2,737.73 ",20.37% based on GA Medicaid OP CCR Rate,"$3,023.82 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$11,424.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,$862.48 ,"$12,096.00 ","$10,752.00 "
Outpatient Medical Services,SURGERY,19380,REVISION RECONSTRUCTED BREAST,360,"$23,125.00 ","$19,656.25 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,971.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$4,710.56 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$5,070.89 ",Pays 102% Medicare OPPS,"$20,812.50 ",90% of total billed charges,"$8,093.75 ",35% based on GA Medicaid OP CCR Rate,"$15,886.88 ",68.7% of total billed charges,"$18,500.00 ",80 percent of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,"$4,474.32 ",Pays 90% Medicare OPPS,"$13,412.50 ",58% of total billed charges,"$4,710.56 ",20.37% based on GA Medicaid OP CCR Rate,"$5,227.47 ",Pays 100% Medicare OPPS,"$6,795.71 ",Pays 130% Medicare OPPS,"$19,656.25 ",85% of total billed charges,"$4,971.47 ",Pays 100% Medicare OPPS,$862.48 ,"$20,812.50 ","$18,500.00 "
Outpatient Medical Services,SURGERY,21552,EXC NECK LES SC 3 CM/>,360,"$10,315.00 ","$8,767.75 ",85% of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,953.82 ",Pays 130% Medicare OPPS,"$2,101.17 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,172.54 ",Pays 102% Medicare OPPS,"$9,283.50 ",90% of total billed charges,"$3,610.25 ",35% based on GA Medicaid OP CCR Rate,"$7,086.41 ",68.7% of total billed charges,"$8,252.00 ",80 percent of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,"$1,916.94 ",Pays 90% Medicare OPPS,"$5,982.70 ",58% of total billed charges,"$2,101.17 ",20.37% based on GA Medicaid OP CCR Rate,"$2,272.17 ",Pays 100% Medicare OPPS,"$2,953.82 ",Pays 130% Medicare OPPS,"$8,767.75 ",85% of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,$862.48 ,"$9,283.50 ","$8,252.00 "
Outpatient Medical Services,SURGERY,21558,RESECT NECK TUMOR 5CM/>,360,"$10,160.00 ","$8,636.00 ",85% of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,953.82 ",Pays 130% Medicare OPPS,"$2,069.59 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,172.54 ",Pays 102% Medicare OPPS,"$9,144.00 ",90% of total billed charges,"$3,556.00 ",35% based on GA Medicaid OP CCR Rate,"$6,979.92 ",68.7% of total billed charges,"$8,128.00 ",80 percent of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,"$1,916.94 ",Pays 90% Medicare OPPS,"$5,892.80 ",58% of total billed charges,"$2,069.59 ",20.37% based on GA Medicaid OP CCR Rate,"$2,272.17 ",Pays 100% Medicare OPPS,"$2,953.82 ",Pays 130% Medicare OPPS,"$8,636.00 ",85% of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,$862.48 ,"$9,144.00 ","$8,128.00 "
Outpatient Medical Services,SURGERY,24075,EXCISION TUMOR  UPPER ARM < 3 CM,360,"$4,965.00 ","$4,220.25 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$1,011.37 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,289.21 ",Pays 102% Medicare OPPS,"$4,468.50 ",90% of total billed charges,"$1,737.75 ",35% based on GA Medicaid OP CCR Rate,"$3,410.96 ",68.7% of total billed charges,"$3,972.00 ",80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,"$2,879.70 ",58% of total billed charges,"$1,011.37 ",20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$4,220.25 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,$862.48 ,"$4,468.50 ","$3,972.00 "
Outpatient Medical Services,SURGERY,28008,INCISE FOOT/TOE FASCIA,360,"$16,565.00 ","$14,080.25 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$3,374.29 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,594.86 ",Pays 102% Medicare OPPS,"$14,908.50 ",90% of total billed charges,"$5,797.75 ",35% based on GA Medicaid OP CCR Rate,"$11,380.16 ",68.7% of total billed charges,"$13,252.00 ",80 percent of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,289.59 ",Pays 90% Medicare OPPS,"$9,607.70 ",58% of total billed charges,"$3,374.29 ",20.37% based on GA Medicaid OP CCR Rate,"$2,618.21 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$14,080.25 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,$862.48 ,"$14,908.50 ","$13,252.00 "
Outpatient Medical Services,SURGERY,28124,PARTIAL EXC PHALANX TOE BONE,360,"$16,565.00 ","$14,080.25 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$3,374.29 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,594.86 ",Pays 102% Medicare OPPS,"$14,908.50 ",90% of total billed charges,"$5,797.75 ",35% based on GA Medicaid OP CCR Rate,"$11,380.16 ",68.7% of total billed charges,"$13,252.00 ",80 percent of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,289.59 ",Pays 90% Medicare OPPS,"$9,607.70 ",58% of total billed charges,"$3,374.29 ",20.37% based on GA Medicaid OP CCR Rate,"$2,618.21 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$14,080.25 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,$862.48 ,"$14,908.50 ","$13,252.00 "
Outpatient Medical Services,SURGERY,28285,HAMMERTOE OP ONE TOE,360,"$12,815.00 ","$10,892.75 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$2,610.42 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,594.86 ",Pays 102% Medicare OPPS,"$11,533.50 ",90% of total billed charges,"$4,485.25 ",35% based on GA Medicaid OP CCR Rate,"$8,803.91 ",68.7% of total billed charges,"$10,252.00 ",80 percent of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,289.59 ",Pays 90% Medicare OPPS,"$7,432.70 ",58% of total billed charges,"$2,610.42 ",20.37% based on GA Medicaid OP CCR Rate,"$2,618.21 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$10,892.75 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,$862.48 ,"$11,533.50 ","$10,252.00 "
Outpatient Medical Services,SURGERY,28289,CORRJ HALUX RIGDUS W/O IMPCT,360,"$11,160.00 ","$9,486.00 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$2,273.29 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,594.86 ",Pays 102% Medicare OPPS,"$10,044.00 ",90% of total billed charges,"$3,906.00 ",35% based on GA Medicaid OP CCR Rate,"$7,666.92 ",68.7% of total billed charges,"$8,928.00 ",80 percent of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,289.59 ",Pays 90% Medicare OPPS,"$6,472.80 ",58% of total billed charges,"$2,273.29 ",20.37% based on GA Medicaid OP CCR Rate,"$2,618.21 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$9,486.00 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,$862.48 ,"$10,044.00 ","$8,928.00 "
Outpatient Medical Services,SURGERY,28292,CORRECTION HALLUX VALGUS,360,"$16,565.00 ","$14,080.25 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$3,374.29 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,594.86 ",Pays 102% Medicare OPPS,"$14,908.50 ",90% of total billed charges,"$5,797.75 ",35% based on GA Medicaid OP CCR Rate,"$11,380.16 ",68.7% of total billed charges,"$13,252.00 ",80 percent of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,289.59 ",Pays 90% Medicare OPPS,"$9,607.70 ",58% of total billed charges,"$3,374.29 ",20.37% based on GA Medicaid OP CCR Rate,"$2,618.21 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$14,080.25 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,$862.48 ,"$14,908.50 ","$13,252.00 "
Outpatient Medical Services,SURGERY,29822,SHO ARTHR SRG LMTD DRBDMT,360,"$15,250.00 ","$12,962.50 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$3,106.43 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,594.86 ",Pays 102% Medicare OPPS,"$13,725.00 ",90% of total billed charges,"$5,337.50 ",35% based on GA Medicaid OP CCR Rate,"$10,476.75 ",68.7% of total billed charges,"$12,200.00 ",80 percent of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,289.59 ",Pays 90% Medicare OPPS,"$8,845.00 ",58% of total billed charges,"$3,106.43 ",20.37% based on GA Medicaid OP CCR Rate,"$2,618.21 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$12,962.50 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,$862.48 ,"$13,725.00 ","$12,200.00 "
Outpatient Medical Services,SURGERY,29824,SHO ARTHRS SRG DSTL CLAVICLC,360,"$17,250.00 ","$14,662.50 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$3,513.83 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,594.86 ",Pays 102% Medicare OPPS,"$15,525.00 ",90% of total billed charges,"$6,037.50 ",35% based on GA Medicaid OP CCR Rate,"$11,850.75 ",68.7% of total billed charges,"$13,800.00 ",80 percent of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,289.59 ",Pays 90% Medicare OPPS,"$10,005.00 ",58% of total billed charges,"$3,513.83 ",20.37% based on GA Medicaid OP CCR Rate,"$2,618.21 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$14,662.50 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,$862.48 ,"$15,525.00 ","$13,800.00 "
Outpatient Medical Services,SURGERY,29826,Shaving of shoulder bone using an endoscope,360,$600.00 ,$510.00 ,85% of total billed charges,$150.00 ,Pays 100% Medicare OPPS,$150.00 ,Pays 100% Medicare OPPS,$150.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$122.22 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,N/A,Pays 102% Medicare OPPS,$540.00 ,90% of total billed charges,$210.00 ,35% based on GA Medicaid OP CCR Rate,$412.20 ,68.7% of total billed charges,$480.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$540.00 ,Pays 90% Medicare OPPS,$348.00 ,58% of total billed charges,$122.22 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$510.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$122.22 ,$986.63 ,$480.00 
Outpatient Medical Services,SURGERY,29827,SURGICAL ARTHROSCOPY SHOLDER W/ROTATOR,360,"$32,000.00 ","$27,200.00 ",85% of total billed charges,"$5,626.71 ",Pays 100% Medicare OPPS,"$5,626.71 ",Pays 100% Medicare OPPS,"$5,626.71 ",Pays 100% Medicare OPPS,"$7,563.51 ",Pays 130% Medicare OPPS,"$6,518.40 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$5,739.25 ",Pays 102% Medicare OPPS,"$28,800.00 ",90% of total billed charges,"$11,200.00 ",35% based on GA Medicaid OP CCR Rate,"$21,984.00 ",68.7% of total billed charges,"$25,600.00 ",80 percent of total billed charges,"$5,626.71 ",Pays 100% Medicare OPPS,"$5,064.04 ",Pays 90% Medicare OPPS,"$18,560.00 ",58% of total billed charges,"$6,518.40 ",20.37% based on GA Medicaid OP CCR Rate,"$5,818.09 ",Pays 100% Medicare OPPS,"$7,563.51 ",Pays 130% Medicare OPPS,"$27,200.00 ",85% of total billed charges,"$5,626.71 ",Pays 100% Medicare OPPS,$862.48 ,"$28,800.00 ","$25,600.00 "
Outpatient Medical Services,SURGERY,29828,SHO ARTHRS SRG BICP TENODSIS,360,"$19,500.00 ","$16,575.00 ",85% of total billed charges,"$5,626.71 ",Pays 100% Medicare OPPS,"$5,626.71 ",Pays 100% Medicare OPPS,"$5,626.71 ",Pays 100% Medicare OPPS,"$7,563.51 ",Pays 130% Medicare OPPS,"$3,972.15 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$5,739.25 ",Pays 102% Medicare OPPS,"$17,550.00 ",90% of total billed charges,"$6,825.00 ",35% based on GA Medicaid OP CCR Rate,"$13,396.50 ",68.7% of total billed charges,"$15,600.00 ",80 percent of total billed charges,"$5,626.71 ",Pays 100% Medicare OPPS,"$5,064.04 ",Pays 90% Medicare OPPS,"$11,310.00 ",58% of total billed charges,"$3,972.15 ",20.37% based on GA Medicaid OP CCR Rate,"$5,818.09 ",Pays 100% Medicare OPPS,"$7,563.51 ",Pays 130% Medicare OPPS,"$16,575.00 ",85% of total billed charges,"$5,626.71 ",Pays 100% Medicare OPPS,$862.48 ,"$17,550.00 ","$15,600.00 "
Outpatient Medical Services,SURGERY,29880,Surgery to remove of all or part of a torn meniscus in both medial and lateral compartments,360,"$20,625.00 ","$17,531.25 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$4,201.31 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,594.86 ",Pays 102% Medicare OPPS,"$18,562.50 ",90% of total billed charges,"$7,218.75 ",35% based on GA Medicaid OP CCR Rate,"$14,169.38 ",68.7% of total billed charges,"$16,500.00 ",80 percent of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,289.59 ",Pays 90% Medicare OPPS,"$11,962.50 ",58% of total billed charges,"$4,201.31 ",20.37% based on GA Medicaid OP CCR Rate,"$2,618.21 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$17,531.25 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,$862.48 ,"$18,562.50 ","$16,500.00 "
Outpatient Medical Services,SURGERY,29881,Surgery to remove of all or part of a torn meniscus in one compartment,360,"$20,625.00 ","$17,531.25 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$4,201.31 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,594.86 ",Pays 102% Medicare OPPS,"$18,562.50 ",90% of total billed charges,"$7,218.75 ",35% based on GA Medicaid OP CCR Rate,"$14,169.38 ",68.7% of total billed charges,"$16,500.00 ",80 percent of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,289.59 ",Pays 90% Medicare OPPS,"$11,962.50 ",58% of total billed charges,"$4,201.31 ",20.37% based on GA Medicaid OP CCR Rate,"$2,618.21 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$17,531.25 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,$862.48 ,"$18,562.50 ","$16,500.00 "
Outpatient Medical Services,SURGERY,29883,ARTHROSC KNEE; W MEN REPAIR-MED/LAT,360,"$21,520.00 ","$18,292.00 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,543.98 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$4,383.62 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,594.86 ",Pays 102% Medicare OPPS,"$19,368.00 ",90% of total billed charges,"$7,532.00 ",35% based on GA Medicaid OP CCR Rate,"$14,784.24 ",68.7% of total billed charges,"$17,216.00 ",80 percent of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,"$2,289.59 ",Pays 90% Medicare OPPS,"$12,481.60 ",58% of total billed charges,"$4,383.62 ",20.37% based on GA Medicaid OP CCR Rate,"$2,618.21 ",Pays 100% Medicare OPPS,"$3,403.66 ",Pays 130% Medicare OPPS,"$18,292.00 ",85% of total billed charges,"$2,543.98 ",Pays 100% Medicare OPPS,$862.48 ,"$19,368.00 ","$17,216.00 "
Outpatient Medical Services,SURGERY,33286,REMOVAL SUBQ RHYTHM MNTR,360,"$2,815.00 ","$2,392.75 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$573.42 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$570.18 ,Pays 102% Medicare OPPS,"$2,533.50 ",90% of total billed charges,$985.25 ,35% based on GA Medicaid OP CCR Rate,"$1,933.91 ",68.7% of total billed charges,"$2,252.00 ",80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,"$1,632.70 ",58% of total billed charges,$573.42 ,20.37% based on GA Medicaid OP CCR Rate,$570.82 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,"$2,392.75 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,"$2,533.50 ","$2,252.00 "
Outpatient Medical Services,SURGERY,36573,INSJ PICC RS&I 5YR+,360,"$4,375.00 ","$3,718.75 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,$891.19 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,288.48 ",Pays 102% Medicare OPPS,"$3,937.50 ",90% of total billed charges,"$1,531.25 ",35% based on GA Medicaid OP CCR Rate,"$3,005.63 ",68.7% of total billed charges,"$3,500.00 ",80 percent of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,136.89 ",Pays 90% Medicare OPPS,"$2,537.50 ",58% of total billed charges,$891.19 ,20.37% based on GA Medicaid OP CCR Rate,"$1,308.68 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,"$3,718.75 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,$862.48 ,"$3,937.50 ","$3,500.00 "
Outpatient Medical Services,SURGERY,36590,REMOVAL OF TUNNELED CV CATH,360,"$3,775.00 ","$3,208.75 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,$768.97 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,288.48 ",Pays 102% Medicare OPPS,"$3,397.50 ",90% of total billed charges,"$1,321.25 ",35% based on GA Medicaid OP CCR Rate,"$2,593.43 ",68.7% of total billed charges,"$3,020.00 ",80 percent of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,136.89 ",Pays 90% Medicare OPPS,"$2,189.50 ",58% of total billed charges,$768.97 ,20.37% based on GA Medicaid OP CCR Rate,"$1,308.68 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,"$3,208.75 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,$768.97 ,"$3,397.50 ","$3,020.00 "
Outpatient Medical Services,SURGERY,36590,REMOVAL OF TUNNELED CVAD W PORT/PUMP,360,"$4,965.00 ","$4,220.25 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,"$1,011.37 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,288.48 ",Pays 102% Medicare OPPS,"$4,468.50 ",90% of total billed charges,"$1,737.75 ",35% based on GA Medicaid OP CCR Rate,"$3,410.96 ",68.7% of total billed charges,"$3,972.00 ",80 percent of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,136.89 ",Pays 90% Medicare OPPS,"$2,879.70 ",58% of total billed charges,"$1,011.37 ",20.37% based on GA Medicaid OP CCR Rate,"$1,308.68 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,"$4,220.25 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,$862.48 ,"$4,468.50 ","$3,972.00 "
Outpatient Medical Services,SURGERY,38500,OPEN BX OR EXC LN; SUPERFICIAL,360,"$13,815.00 ","$11,742.75 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$2,814.12 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,893.37 ",Pays 102% Medicare OPPS,"$12,433.50 ",90% of total billed charges,"$4,835.25 ",35% based on GA Medicaid OP CCR Rate,"$9,490.91 ",68.7% of total billed charges,"$11,052.00 ",80 percent of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,552.98 ",Pays 90% Medicare OPPS,"$8,012.70 ",58% of total billed charges,"$2,814.12 ",20.37% based on GA Medicaid OP CCR Rate,"$3,023.82 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$11,742.75 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,$862.48 ,"$12,433.50 ","$11,052.00 "
Outpatient Medical Services,SURGERY,38525,OPEN BX/EXC AXILLARY NODE,360,"$13,440.00 ","$11,424.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,836.64 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$2,737.73 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,893.37 ",Pays 102% Medicare OPPS,"$12,096.00 ",90% of total billed charges,"$4,704.00 ",35% based on GA Medicaid OP CCR Rate,"$9,233.28 ",68.7% of total billed charges,"$10,752.00 ",80 percent of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,"$2,552.98 ",Pays 90% Medicare OPPS,"$7,795.20 ",58% of total billed charges,"$2,737.73 ",20.37% based on GA Medicaid OP CCR Rate,"$3,023.82 ",Pays 100% Medicare OPPS,"$3,930.96 ",Pays 130% Medicare OPPS,"$11,424.00 ",85% of total billed charges,"$2,836.64 ",Pays 100% Medicare OPPS,$862.48 ,"$12,096.00 ","$10,752.00 "
Outpatient Medical Services,SURGERY,38792,RA TRACER ID OF SENTINL NODE,360,"$2,500.00 ","$2,125.00 ",85% of total billed charges,$338.62 ,Pays 100% Medicare OPPS,$338.62 ,Pays 100% Medicare OPPS,$338.62 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,$509.25 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$345.40 ,Pays 102% Medicare OPPS,"$2,250.00 ",90% of total billed charges,$875.00 ,35% based on GA Medicaid OP CCR Rate,"$1,717.50 ",68.7% of total billed charges,"$2,000.00 ",80 percent of total billed charges,$338.62 ,Pays 100% Medicare OPPS,$304.76 ,Pays 90% Medicare OPPS,"$1,450.00 ",58% of total billed charges,$509.25 ,20.37% based on GA Medicaid OP CCR Rate,$341.87 ,Pays 100% Medicare OPPS,$444.43 ,Pays 130% Medicare OPPS,"$2,125.00 ",85% of total billed charges,$338.62 ,Pays 100% Medicare OPPS,$304.76 ,"$2,250.00 ","$2,000.00 "
Outpatient Medical Services,SURGERY,38900,IO MAP OF SENT LYMPH NODE,360,"$1,500.00 ","$1,275.00 ",85% of total billed charges,$375.00 ,Pays 100% Medicare OPPS,$375.00 ,Pays 100% Medicare OPPS,$375.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$305.55 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,N/A,Pays 102% Medicare OPPS,"$1,350.00 ",90% of total billed charges,$525.00 ,35% based on GA Medicaid OP CCR Rate,"$1,030.50 ",68.7% of total billed charges,"$1,200.00 ",80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,"$1,350.00 ",Pays 90% Medicare OPPS,$870.00 ,58% of total billed charges,$305.55 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$1,275.00 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,$305.55 ,"$1,350.00 ","$1,200.00 "
Outpatient Medical Services,SURGERY,42440,EXCISION OF SUBMANDIBULARGLAND,360,"$23,125.00 ","$19,656.25 ",85% of total billed charges,"$4,568.77 ",Pays 100% Medicare OPPS,"$4,568.77 ",Pays 100% Medicare OPPS,"$4,568.77 ",Pays 100% Medicare OPPS,"$6,105.66 ",Pays 130% Medicare OPPS,"$4,710.56 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,660.14 ",Pays 102% Medicare OPPS,"$20,812.50 ",90% of total billed charges,"$8,093.75 ",35% based on GA Medicaid OP CCR Rate,"$15,886.88 ",68.7% of total billed charges,"$18,500.00 ",80 percent of total billed charges,"$4,568.77 ",Pays 100% Medicare OPPS,"$4,111.89 ",Pays 90% Medicare OPPS,"$13,412.50 ",58% of total billed charges,"$4,710.56 ",20.37% based on GA Medicaid OP CCR Rate,"$4,696.66 ",Pays 100% Medicare OPPS,"$6,105.66 ",Pays 130% Medicare OPPS,"$19,656.25 ",85% of total billed charges,"$4,568.77 ",Pays 100% Medicare OPPS,$862.48 ,"$20,812.50 ","$18,500.00 "
Outpatient Medical Services,SURGERY,43202,ESOPHAGOSCOPY FLEX BIOSPSY,750,"$4,690.00 ","$3,986.50 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,$955.35 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,488.23 ",Pays 102% Medicare OPPS,"$4,221.00 ",90% of total billed charges,"$1,641.50 ",35% based on GA Medicaid OP CCR Rate,"$3,222.03 ",68.7% of total billed charges,"$3,752.00 ",80 percent of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,313.14 ",Pays 90% Medicare OPPS,"$2,720.20 ",58% of total billed charges,$955.35 ,20.37% based on GA Medicaid OP CCR Rate,"$1,531.86 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$3,986.50 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,$862.48 ,"$4,221.00 ","$3,752.00 "
Outpatient Medical Services,SURGERY,43220,ESOPHAGOSCOPY WITH BALLOON <30MM,750,"$6,240.00 ","$5,304.00 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$1,271.09 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,488.23 ",Pays 102% Medicare OPPS,"$5,616.00 ",90% of total billed charges,"$2,184.00 ",35% based on GA Medicaid OP CCR Rate,"$4,286.88 ",68.7% of total billed charges,"$4,992.00 ",80 percent of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,313.14 ",Pays 90% Medicare OPPS,"$3,619.20 ",58% of total billed charges,"$1,271.09 ",20.37% based on GA Medicaid OP CCR Rate,"$1,531.86 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$5,304.00 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,$862.48 ,"$5,616.00 ","$4,992.00 "
Outpatient Medical Services,SURGERY,43229,ESOPHAGOSCOPY LESION ABLATE,750,"$10,340.00 ","$8,789.00 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$2,106.26 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,813.43 ",Pays 102% Medicare OPPS,"$9,306.00 ",90% of total billed charges,"$3,619.00 ",35% based on GA Medicaid OP CCR Rate,"$7,103.58 ",68.7% of total billed charges,"$8,272.00 ",80 percent of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,482.44 ",Pays 90% Medicare OPPS,"$5,997.20 ",58% of total billed charges,"$2,106.26 ",20.37% based on GA Medicaid OP CCR Rate,"$2,868.03 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$8,789.00 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,$862.48 ,"$9,306.00 ","$8,272.00 "
Outpatient Medical Services,SURGERY,43235,"Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope",360,"$3,500.00 ","$2,975.00 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$712.95 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$741.40 ,Pays 102% Medicare OPPS,"$3,150.00 ",90% of total billed charges,"$1,225.00 ",35% based on GA Medicaid OP CCR Rate,"$2,404.50 ",68.7% of total billed charges,"$2,800.00 ",80 percent of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,Pays 90% Medicare OPPS,"$2,030.00 ",58% of total billed charges,$712.95 ,20.37% based on GA Medicaid OP CCR Rate,$726.10 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,"$2,975.00 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,"$3,150.00 ","$2,800.00 "
Outpatient Medical Services,SURGERY,43236,UPPER GI SCOPE W SUBMUC INJ,750,"$3,940.00 ","$3,349.00 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$802.58 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$741.40 ,Pays 102% Medicare OPPS,"$3,546.00 ",90% of total billed charges,"$1,379.00 ",35% based on GA Medicaid OP CCR Rate,"$2,706.78 ",68.7% of total billed charges,"$3,152.00 ",80 percent of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,Pays 90% Medicare OPPS,"$2,285.20 ",58% of total billed charges,$802.58 ,20.37% based on GA Medicaid OP CCR Rate,$726.10 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,"$3,349.00 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,"$3,546.00 ","$3,152.00 "
Outpatient Medical Services,SURGERY,43243,EGD INJECTION VARICES,750,"$6,240.00 ","$5,304.00 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$1,271.09 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,488.23 ",Pays 102% Medicare OPPS,"$5,616.00 ",90% of total billed charges,"$2,184.00 ",35% based on GA Medicaid OP CCR Rate,"$4,286.88 ",68.7% of total billed charges,"$4,992.00 ",80 percent of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,313.14 ",Pays 90% Medicare OPPS,"$3,619.20 ",58% of total billed charges,"$1,271.09 ",20.37% based on GA Medicaid OP CCR Rate,"$1,531.86 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$5,304.00 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,$862.48 ,"$5,616.00 ","$4,992.00 "
Outpatient Medical Services,SURGERY,43244,EGD W/BAND LIGATION  AND/OR GASTRIC VARI,750,"$6,240.00 ","$5,304.00 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$1,271.09 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,488.23 ",Pays 102% Medicare OPPS,"$5,616.00 ",90% of total billed charges,"$2,184.00 ",35% based on GA Medicaid OP CCR Rate,"$4,286.88 ",68.7% of total billed charges,"$4,992.00 ",80 percent of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,313.14 ",Pays 90% Medicare OPPS,"$3,619.20 ",58% of total billed charges,"$1,271.09 ",20.37% based on GA Medicaid OP CCR Rate,"$1,531.86 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$5,304.00 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,$862.48 ,"$5,616.00 ","$4,992.00 "
Outpatient Medical Services,SURGERY,43245,EGD DILATE STRICTURE,750,"$6,240.00 ","$5,304.00 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$1,271.09 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,488.23 ",Pays 102% Medicare OPPS,"$5,616.00 ",90% of total billed charges,"$2,184.00 ",35% based on GA Medicaid OP CCR Rate,"$4,286.88 ",68.7% of total billed charges,"$4,992.00 ",80 percent of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,313.14 ",Pays 90% Medicare OPPS,"$3,619.20 ",58% of total billed charges,"$1,271.09 ",20.37% based on GA Medicaid OP CCR Rate,"$1,531.86 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$5,304.00 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,$862.48 ,"$5,616.00 ","$4,992.00 "
Outpatient Medical Services,SURGERY,43246,EGD PLACE GASTROSTOMY TUBE,360,"$8,125.00 ","$6,906.25 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$1,655.06 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,488.23 ",Pays 102% Medicare OPPS,"$7,312.50 ",90% of total billed charges,"$2,843.75 ",35% based on GA Medicaid OP CCR Rate,"$5,581.88 ",68.7% of total billed charges,"$6,500.00 ",80 percent of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,313.14 ",Pays 90% Medicare OPPS,"$4,712.50 ",58% of total billed charges,"$1,655.06 ",20.37% based on GA Medicaid OP CCR Rate,"$1,531.86 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$6,906.25 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,$862.48 ,"$7,312.50 ","$6,500.00 "
Outpatient Medical Services,SURGERY,43246,EGD WITH PEG PLACEMENT,750,"$3,575.00 ","$3,038.75 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,$728.23 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,488.23 ",Pays 102% Medicare OPPS,"$3,217.50 ",90% of total billed charges,"$1,251.25 ",35% based on GA Medicaid OP CCR Rate,"$2,456.03 ",68.7% of total billed charges,"$2,860.00 ",80 percent of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,313.14 ",Pays 90% Medicare OPPS,"$2,073.50 ",58% of total billed charges,$728.23 ,20.37% based on GA Medicaid OP CCR Rate,"$1,531.86 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$3,038.75 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,$728.23 ,"$3,217.50 ","$2,860.00 "
Outpatient Medical Services,SURGERY,43247,EGD WITH REMOVAL FOREIGN,750,"$4,360.00 ","$3,706.00 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$888.13 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$741.40 ,Pays 102% Medicare OPPS,"$3,924.00 ",90% of total billed charges,"$1,526.00 ",35% based on GA Medicaid OP CCR Rate,"$2,995.32 ",68.7% of total billed charges,"$3,488.00 ",80 percent of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,Pays 90% Medicare OPPS,"$2,528.80 ",58% of total billed charges,$888.13 ,20.37% based on GA Medicaid OP CCR Rate,$726.10 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,"$3,706.00 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,"$3,924.00 ","$3,488.00 "
Outpatient Medical Services,SURGERY,43248,EGD W/DILITATION GDE WIRE,750,"$3,575.00 ","$3,038.75 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$728.23 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$741.40 ,Pays 102% Medicare OPPS,"$3,217.50 ",90% of total billed charges,"$1,251.25 ",35% based on GA Medicaid OP CCR Rate,"$2,456.03 ",68.7% of total billed charges,"$2,860.00 ",80 percent of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,Pays 90% Medicare OPPS,"$2,073.50 ",58% of total billed charges,$728.23 ,20.37% based on GA Medicaid OP CCR Rate,$726.10 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,"$3,038.75 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,"$3,217.50 ","$2,860.00 "
Outpatient Medical Services,SURGERY,43248,ESOPHAGAL DILITATION,750,"$3,910.00 ","$3,323.50 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$796.47 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$741.40 ,Pays 102% Medicare OPPS,"$3,519.00 ",90% of total billed charges,"$1,368.50 ",35% based on GA Medicaid OP CCR Rate,"$2,686.17 ",68.7% of total billed charges,"$3,128.00 ",80 percent of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,Pays 90% Medicare OPPS,"$2,267.80 ",58% of total billed charges,$796.47 ,20.37% based on GA Medicaid OP CCR Rate,$726.10 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,"$3,323.50 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,"$3,519.00 ","$3,128.00 "
Outpatient Medical Services,SURGERY,43248,EGD GUIDE WIRE INSERTION,750,"$4,695.00 ","$3,990.75 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$956.37 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$741.40 ,Pays 102% Medicare OPPS,"$4,225.50 ",90% of total billed charges,"$1,643.25 ",35% based on GA Medicaid OP CCR Rate,"$3,225.47 ",68.7% of total billed charges,"$3,756.00 ",80 percent of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,Pays 90% Medicare OPPS,"$2,723.10 ",58% of total billed charges,$956.37 ,20.37% based on GA Medicaid OP CCR Rate,$726.10 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,"$3,990.75 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,"$4,225.50 ","$3,756.00 "
Outpatient Medical Services,SURGERY,43260,ERCP W/SPECIMEN COLLECTION,750,"$10,835.00 ","$9,209.75 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$2,207.09 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,813.43 ",Pays 102% Medicare OPPS,"$9,751.50 ",90% of total billed charges,"$3,792.25 ",35% based on GA Medicaid OP CCR Rate,"$7,443.65 ",68.7% of total billed charges,"$8,668.00 ",80 percent of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,482.44 ",Pays 90% Medicare OPPS,"$6,284.30 ",58% of total billed charges,"$2,207.09 ",20.37% based on GA Medicaid OP CCR Rate,"$2,868.03 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$9,209.75 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,$862.48 ,"$9,751.50 ","$8,668.00 "
Outpatient Medical Services,SURGERY,43261,ERCP W BX SINGLE/MULTIBLE,750,"$9,845.00 ","$8,368.25 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$2,005.43 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,813.43 ",Pays 102% Medicare OPPS,"$8,860.50 ",90% of total billed charges,"$3,445.75 ",35% based on GA Medicaid OP CCR Rate,"$6,763.52 ",68.7% of total billed charges,"$7,876.00 ",80 percent of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,482.44 ",Pays 90% Medicare OPPS,"$5,710.10 ",58% of total billed charges,"$2,005.43 ",20.37% based on GA Medicaid OP CCR Rate,"$2,868.03 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$8,368.25 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,$862.48 ,"$8,860.50 ","$7,876.00 "
Outpatient Medical Services,SURGERY,43262,ERCP W SPHINCTER PAPILLOTOMY,750,"$10,175.00 ","$8,648.75 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$2,072.65 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,813.43 ",Pays 102% Medicare OPPS,"$9,157.50 ",90% of total billed charges,"$3,561.25 ",35% based on GA Medicaid OP CCR Rate,"$6,990.23 ",68.7% of total billed charges,"$8,140.00 ",80 percent of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,482.44 ",Pays 90% Medicare OPPS,"$5,901.50 ",58% of total billed charges,"$2,072.65 ",20.37% based on GA Medicaid OP CCR Rate,"$2,868.03 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$8,648.75 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,$862.48 ,"$9,157.50 ","$8,140.00 "
Outpatient Medical Services,SURGERY,43264,ERCP REMOVE DUCT CALCULI,750,"$10,175.00 ","$8,648.75 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$2,072.65 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,813.43 ",Pays 102% Medicare OPPS,"$9,157.50 ",90% of total billed charges,"$3,561.25 ",35% based on GA Medicaid OP CCR Rate,"$6,990.23 ",68.7% of total billed charges,"$8,140.00 ",80 percent of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,482.44 ",Pays 90% Medicare OPPS,"$5,901.50 ",58% of total billed charges,"$2,072.65 ",20.37% based on GA Medicaid OP CCR Rate,"$2,868.03 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$8,648.75 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,$862.48 ,"$9,157.50 ","$8,140.00 "
Outpatient Medical Services,SURGERY,43266,EGD ENDOSCOPIC STENT PLACEMENT,750,"$16,865.00 ","$14,335.25 ",85% of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,521.78 ",Pays 100% Medicare OPPS,"$5,992.51 ",Pays 130% Medicare OPPS,"$3,435.40 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,612.21 ",Pays 102% Medicare OPPS,"$15,178.50 ",90% of total billed charges,"$5,902.75 ",35% based on GA Medicaid OP CCR Rate,"$11,586.26 ",68.7% of total billed charges,"$13,492.00 ",80 percent of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,069.60 ",Pays 90% Medicare OPPS,"$9,781.70 ",58% of total billed charges,"$3,435.40 ",20.37% based on GA Medicaid OP CCR Rate,"$4,609.63 ",Pays 100% Medicare OPPS,"$5,992.51 ",Pays 130% Medicare OPPS,"$14,335.25 ",85% of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,$862.48 ,"$15,178.50 ","$13,492.00 "
Outpatient Medical Services,SURGERY,43270,EGD WITH LESION ABLATION,750,"$6,240.00 ","$5,304.00 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$1,271.09 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,488.23 ",Pays 102% Medicare OPPS,"$5,616.00 ",90% of total billed charges,"$2,184.00 ",35% based on GA Medicaid OP CCR Rate,"$4,286.88 ",68.7% of total billed charges,"$4,992.00 ",80 percent of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,313.14 ",Pays 90% Medicare OPPS,"$3,619.20 ",58% of total billed charges,"$1,271.09 ",20.37% based on GA Medicaid OP CCR Rate,"$1,531.86 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$5,304.00 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,$862.48 ,"$5,616.00 ","$4,992.00 "
Outpatient Medical Services,SURGERY,43273,ENDOSCOPIC PANCREATOSCOPY,750,"$9,845.00 ","$8,368.25 ",85% of total billed charges,"$2,461.25 ",Pays 100% Medicare OPPS,"$2,461.25 ",Pays 100% Medicare OPPS,"$2,461.25 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$2,005.43 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,N/A,Pays 102% Medicare OPPS,"$8,860.50 ",90% of total billed charges,"$3,445.75 ",35% based on GA Medicaid OP CCR Rate,"$6,763.52 ",68.7% of total billed charges,"$7,876.00 ",80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,"$8,860.50 ",Pays 90% Medicare OPPS,"$5,710.10 ",58% of total billed charges,"$2,005.43 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$8,368.25 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,$862.48 ,"$8,860.50 ","$7,876.00 "
Outpatient Medical Services,SURGERY,43274,ERCP DUCT STENT PLACEMENT,750,"$15,750.00 ","$13,387.50 ",85% of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,521.78 ",Pays 100% Medicare OPPS,"$5,992.51 ",Pays 130% Medicare OPPS,"$3,208.28 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,612.21 ",Pays 102% Medicare OPPS,"$14,175.00 ",90% of total billed charges,"$5,512.50 ",35% based on GA Medicaid OP CCR Rate,"$10,820.25 ",68.7% of total billed charges,"$12,600.00 ",80 percent of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,069.60 ",Pays 90% Medicare OPPS,"$9,135.00 ",58% of total billed charges,"$3,208.28 ",20.37% based on GA Medicaid OP CCR Rate,"$4,609.63 ",Pays 100% Medicare OPPS,"$5,992.51 ",Pays 130% Medicare OPPS,"$13,387.50 ",85% of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,$862.48 ,"$14,175.00 ","$12,600.00 "
Outpatient Medical Services,SURGERY,43276,ERCP STENT EXCHANGE W/DILATE,750,"$15,750.00 ","$13,387.50 ",85% of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,521.78 ",Pays 100% Medicare OPPS,"$5,992.51 ",Pays 130% Medicare OPPS,"$3,208.28 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,612.21 ",Pays 102% Medicare OPPS,"$14,175.00 ",90% of total billed charges,"$5,512.50 ",35% based on GA Medicaid OP CCR Rate,"$10,820.25 ",68.7% of total billed charges,"$12,600.00 ",80 percent of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,069.60 ",Pays 90% Medicare OPPS,"$9,135.00 ",58% of total billed charges,"$3,208.28 ",20.37% based on GA Medicaid OP CCR Rate,"$4,609.63 ",Pays 100% Medicare OPPS,"$5,992.51 ",Pays 130% Medicare OPPS,"$13,387.50 ",85% of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,$862.48 ,"$14,175.00 ","$12,600.00 "
Outpatient Medical Services,SURGERY,43277,ERCP EA DUCT/AMPULLA DILATE,750,"$10,175.00 ","$8,648.75 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,758.27 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$2,072.65 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,813.43 ",Pays 102% Medicare OPPS,"$9,157.50 ",90% of total billed charges,"$3,561.25 ",35% based on GA Medicaid OP CCR Rate,"$6,990.23 ",68.7% of total billed charges,"$8,140.00 ",80 percent of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,"$2,482.44 ",Pays 90% Medicare OPPS,"$5,901.50 ",58% of total billed charges,"$2,072.65 ",20.37% based on GA Medicaid OP CCR Rate,"$2,868.03 ",Pays 100% Medicare OPPS,"$3,728.44 ",Pays 130% Medicare OPPS,"$8,648.75 ",85% of total billed charges,"$2,758.27 ",Pays 100% Medicare OPPS,$862.48 ,"$9,157.50 ","$8,140.00 "
Outpatient Medical Services,SURGERY,43280,LAPS ESOPHAGOGASTRIC FUNDOPLASTY,360,"$36,875.00 ","$31,343.75 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,"$10,390.91 ",Pays 130% Medicare OPPS,"$7,511.44 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$8,161.07 ",Pays 102% Medicare OPPS,"$33,187.50 ",90% of total billed charges,"$12,906.25 ",35% based on GA Medicaid OP CCR Rate,"$25,333.13 ",68.7% of total billed charges,"$29,500.00 ",80 percent of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$7,200.95 ",Pays 90% Medicare OPPS,"$21,387.50 ",58% of total billed charges,"$7,511.44 ",20.37% based on GA Medicaid OP CCR Rate,"$7,992.99 ",Pays 100% Medicare OPPS,"$10,390.91 ",Pays 130% Medicare OPPS,"$31,343.75 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,$862.48 ,"$33,187.50 ","$29,500.00 "
Outpatient Medical Services,SURGERY,43282,LAPS RPR PARAESOPH HER RPR W/MESH,360,"$35,315.00 ","$30,017.75 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,"$10,390.91 ",Pays 130% Medicare OPPS,"$7,193.67 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$8,161.07 ",Pays 102% Medicare OPPS,"$31,783.50 ",90% of total billed charges,"$12,360.25 ",35% based on GA Medicaid OP CCR Rate,"$24,261.41 ",68.7% of total billed charges,"$28,252.00 ",80 percent of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$7,200.95 ",Pays 90% Medicare OPPS,"$20,482.70 ",58% of total billed charges,"$7,193.67 ",20.37% based on GA Medicaid OP CCR Rate,"$7,992.99 ",Pays 100% Medicare OPPS,"$10,390.91 ",Pays 130% Medicare OPPS,"$30,017.75 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,$862.48 ,"$31,783.50 ","$28,252.00 "
Outpatient Medical Services,SURGERY,43289,UNLISTED LAPAROSCOPY ESOPHAGUS,360,"$21,875.00 ","$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,687.50 ",90% of total billed charges,"$7,656.25 ",35% based on GA Medicaid OP CCR Rate,"$15,028.13 ",68.7% of total billed charges,"$17,500.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,687.50 ",58% of total billed charges,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,687.50 ","$17,500.00 "
Outpatient Medical Services,SURGERY,44005,FREEING OF BOWEL ADHESION,360,"$12,500.00 ","$10,625.00 ",85% of total billed charges,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 130% Medicare OPPS,"$2,546.25 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$12,500.00 ",Pays 102% Medicare OPPS,"$11,250.00 ",90% of total billed charges,"$4,375.00 ",35% based on GA Medicaid OP CCR Rate,"$8,587.50 ",68.7% of total billed charges,"$10,000.00 ",80 percent of total billed charges,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 90% Medicare OPPS,"$7,250.00 ",58% of total billed charges,"$2,546.25 ",20.37% based on GA Medicaid OP CCR Rate,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 130% Medicare OPPS,"$10,625.00 ",85% of total billed charges,"$12,500.00 ",Pays 100% Medicare OPPS,$862.48 ,"$12,500.00 ","$10,000.00 "
Outpatient Medical Services,SURGERY,44139,MOBILIZATION OF COLON,360,"$12,500.00 ","$10,625.00 ",85% of total billed charges,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 130% Medicare OPPS,"$2,546.25 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$12,500.00 ",Pays 102% Medicare OPPS,"$11,250.00 ",90% of total billed charges,"$4,375.00 ",35% based on GA Medicaid OP CCR Rate,"$8,587.50 ",68.7% of total billed charges,"$10,000.00 ",80 percent of total billed charges,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 90% Medicare OPPS,"$7,250.00 ",58% of total billed charges,"$2,546.25 ",20.37% based on GA Medicaid OP CCR Rate,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 130% Medicare OPPS,"$10,625.00 ",85% of total billed charges,"$12,500.00 ",Pays 100% Medicare OPPS,$862.48 ,"$12,500.00 ","$10,000.00 "
Outpatient Medical Services,SURGERY,44140,PARTIAL REMOVAL OF COLON,360,"$18,500.00 ","$15,725.00 ",85% of total billed charges,"$18,500.00 ",Pays 100% Medicare OPPS,"$18,500.00 ",Pays 100% Medicare OPPS,"$18,500.00 ",Pays 100% Medicare OPPS,"$18,500.00 ",Pays 130% Medicare OPPS,"$3,768.45 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$18,500.00 ",Pays 102% Medicare OPPS,"$16,650.00 ",90% of total billed charges,"$6,475.00 ",35% based on GA Medicaid OP CCR Rate,"$12,709.50 ",68.7% of total billed charges,"$14,800.00 ",80 percent of total billed charges,"$18,500.00 ",Pays 100% Medicare OPPS,"$18,500.00 ",Pays 90% Medicare OPPS,"$10,730.00 ",58% of total billed charges,"$3,768.45 ",20.37% based on GA Medicaid OP CCR Rate,"$18,500.00 ",Pays 100% Medicare OPPS,"$18,500.00 ",Pays 130% Medicare OPPS,"$15,725.00 ",85% of total billed charges,"$18,500.00 ",Pays 100% Medicare OPPS,$862.48 ,"$18,500.00 ","$14,800.00 "
Outpatient Medical Services,SURGERY,44143,COLECTOMY PARTIAL W/END COLOSTOMY CLSR,360,"$9,375.00 ","$7,968.75 ",85% of total billed charges,"$9,375.00 ",Pays 100% Medicare OPPS,"$9,375.00 ",Pays 100% Medicare OPPS,"$9,375.00 ",Pays 100% Medicare OPPS,"$9,375.00 ",Pays 130% Medicare OPPS,"$1,909.69 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$9,375.00 ",Pays 102% Medicare OPPS,"$8,437.50 ",90% of total billed charges,"$3,281.25 ",35% based on GA Medicaid OP CCR Rate,"$6,440.63 ",68.7% of total billed charges,"$7,500.00 ",80 percent of total billed charges,"$9,375.00 ",Pays 100% Medicare OPPS,"$9,375.00 ",Pays 90% Medicare OPPS,"$5,437.50 ",58% of total billed charges,"$1,909.69 ",20.37% based on GA Medicaid OP CCR Rate,"$9,375.00 ",Pays 100% Medicare OPPS,"$9,375.00 ",Pays 130% Medicare OPPS,"$7,968.75 ",85% of total billed charges,"$9,375.00 ",Pays 100% Medicare OPPS,$862.48 ,"$9,375.00 ","$7,500.00 "
Outpatient Medical Services,SURGERY,44180,LAP ENTEROLYSIS,360,"$20,000.00 ","$17,000.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,074.00 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$18,000.00 ",90% of total billed charges,"$7,000.00 ",35% based on GA Medicaid OP CCR Rate,"$13,740.00 ",68.7% of total billed charges,"$16,000.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$11,600.00 ",58% of total billed charges,"$4,074.00 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$17,000.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$18,000.00 ","$16,000.00 "
Outpatient Medical Services,SURGERY,44204,LAP PARTIAL COLECTOMY,360,"$12,500.00 ","$10,625.00 ",85% of total billed charges,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 130% Medicare OPPS,"$2,546.25 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$12,500.00 ",Pays 102% Medicare OPPS,"$11,250.00 ",90% of total billed charges,"$4,375.00 ",35% based on GA Medicaid OP CCR Rate,"$8,587.50 ",68.7% of total billed charges,"$10,000.00 ",80 percent of total billed charges,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 90% Medicare OPPS,"$7,250.00 ",58% of total billed charges,"$2,546.25 ",20.37% based on GA Medicaid OP CCR Rate,"$12,500.00 ",Pays 100% Medicare OPPS,"$12,500.00 ",Pays 130% Medicare OPPS,"$10,625.00 ",85% of total billed charges,"$12,500.00 ",Pays 100% Medicare OPPS,$862.48 ,"$12,500.00 ","$10,000.00 "
Outpatient Medical Services,SURGERY,44205,LAP P COLECTOMY W REM ILEVM,360,"$21,875.00 ","$18,593.75 ",85% of total billed charges,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 130% Medicare OPPS,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$21,875.00 ",Pays 102% Medicare OPPS,"$19,687.50 ",90% of total billed charges,"$7,656.25 ",35% based on GA Medicaid OP CCR Rate,"$15,028.13 ",68.7% of total billed charges,"$17,500.00 ",80 percent of total billed charges,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 90% Medicare OPPS,"$12,687.50 ",58% of total billed charges,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 130% Medicare OPPS,"$18,593.75 ",85% of total billed charges,"$21,875.00 ",Pays 100% Medicare OPPS,$862.48 ,"$21,875.00 ","$17,500.00 "
Outpatient Medical Services,SURGERY,44208,L COLECTOMY/COLECTMY PRTL W COLOSTOMY,360,"$21,875.00 ","$18,593.75 ",85% of total billed charges,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 130% Medicare OPPS,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$21,875.00 ",Pays 102% Medicare OPPS,"$19,687.50 ",90% of total billed charges,"$7,656.25 ",35% based on GA Medicaid OP CCR Rate,"$15,028.13 ",68.7% of total billed charges,"$17,500.00 ",80 percent of total billed charges,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 90% Medicare OPPS,"$12,687.50 ",58% of total billed charges,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 130% Medicare OPPS,"$18,593.75 ",85% of total billed charges,"$21,875.00 ",Pays 100% Medicare OPPS,$862.48 ,"$21,875.00 ","$17,500.00 "
Outpatient Medical Services,SURGERY,44213,LAPS MOBIL SPLENIC FL ADDON,360,"$8,125.00 ","$6,906.25 ",85% of total billed charges,"$8,125.00 ",Pays 100% Medicare OPPS,"$8,125.00 ",Pays 100% Medicare OPPS,"$8,125.00 ",Pays 100% Medicare OPPS,"$8,125.00 ",Pays 130% Medicare OPPS,"$1,655.06 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$8,125.00 ",Pays 102% Medicare OPPS,"$7,312.50 ",90% of total billed charges,"$2,843.75 ",35% based on GA Medicaid OP CCR Rate,"$5,581.88 ",68.7% of total billed charges,"$6,500.00 ",80 percent of total billed charges,"$8,125.00 ",Pays 100% Medicare OPPS,"$8,125.00 ",Pays 90% Medicare OPPS,"$4,712.50 ",58% of total billed charges,"$1,655.06 ",20.37% based on GA Medicaid OP CCR Rate,"$8,125.00 ",Pays 100% Medicare OPPS,"$8,125.00 ",Pays 130% Medicare OPPS,"$6,906.25 ",85% of total billed charges,"$8,125.00 ",Pays 100% Medicare OPPS,$862.48 ,"$8,125.00 ","$6,500.00 "
Outpatient Medical Services,SURGERY,44360,SMALL BOWEL ENDOSCOPY,750,"$6,565.00 ","$5,580.25 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$1,337.29 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,488.23 ",Pays 102% Medicare OPPS,"$5,908.50 ",90% of total billed charges,"$2,297.75 ",35% based on GA Medicaid OP CCR Rate,"$4,510.16 ",68.7% of total billed charges,"$5,252.00 ",80 percent of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,313.14 ",Pays 90% Medicare OPPS,"$3,807.70 ",58% of total billed charges,"$1,337.29 ",20.37% based on GA Medicaid OP CCR Rate,"$1,531.86 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$5,580.25 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,$862.48 ,"$5,908.50 ","$5,252.00 "
Outpatient Medical Services,SURGERY,44366,ENTEROSCOPY W BLEED CONTROL,750,"$6,895.00 ","$5,860.75 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$1,404.51 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,488.23 ",Pays 102% Medicare OPPS,"$6,205.50 ",90% of total billed charges,"$2,413.25 ",35% based on GA Medicaid OP CCR Rate,"$4,736.87 ",68.7% of total billed charges,"$5,516.00 ",80 percent of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,313.14 ",Pays 90% Medicare OPPS,"$3,999.10 ",58% of total billed charges,"$1,404.51 ",20.37% based on GA Medicaid OP CCR Rate,"$1,531.86 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$5,860.75 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,$862.48 ,"$6,205.50 ","$5,516.00 "
Outpatient Medical Services,SURGERY,44376,SMALL INTESTINAL ENDO,750,"$4,725.00 ","$4,016.25 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,$962.48 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,488.23 ",Pays 102% Medicare OPPS,"$4,252.50 ",90% of total billed charges,"$1,653.75 ",35% based on GA Medicaid OP CCR Rate,"$3,246.08 ",68.7% of total billed charges,"$3,780.00 ",80 percent of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,"$1,313.14 ",Pays 90% Medicare OPPS,"$2,740.50 ",58% of total billed charges,$962.48 ,20.37% based on GA Medicaid OP CCR Rate,"$1,531.86 ",Pays 100% Medicare OPPS,"$1,991.42 ",Pays 130% Medicare OPPS,"$4,016.25 ",85% of total billed charges,"$1,459.05 ",Pays 100% Medicare OPPS,$862.48 ,"$4,252.50 ","$3,780.00 "
Outpatient Medical Services,SURGERY,44388,Diagnostic examination of large bowel using an endoscope which is inserted through abdominal opening,750,"$4,595.00 ","$3,905.75 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,$936.00 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$727.13 ,Pays 102% Medicare OPPS,"$4,135.50 ",90% of total billed charges,"$1,608.25 ",35% based on GA Medicaid OP CCR Rate,"$3,156.77 ",68.7% of total billed charges,"$3,676.00 ",80 percent of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,Pays 90% Medicare OPPS,"$2,665.10 ",58% of total billed charges,$936.00 ,20.37% based on GA Medicaid OP CCR Rate,$730.96 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,"$3,905.75 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,"$4,135.50 ","$3,676.00 "
Outpatient Medical Services,SURGERY,44389,Biopsies of large bowel using an endoscope which is inserted through abdominal opening,360,"$5,940.00 ","$5,049.00 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$1,209.98 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$5,346.00 ",90% of total billed charges,"$2,079.00 ",35% based on GA Medicaid OP CCR Rate,"$4,080.78 ",68.7% of total billed charges,"$4,752.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$3,445.20 ",58% of total billed charges,"$1,209.98 ",20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$5,049.00 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,"$5,346.00 ","$4,752.00 "
Outpatient Medical Services,SURGERY,44960,APPY; FOR RUPT APPENDIX W PERITONITIS,360,"$21,875.00 ","$18,593.75 ",85% of total billed charges,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 130% Medicare OPPS,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$21,875.00 ",Pays 102% Medicare OPPS,"$19,687.50 ",90% of total billed charges,"$7,656.25 ",35% based on GA Medicaid OP CCR Rate,"$15,028.13 ",68.7% of total billed charges,"$17,500.00 ",80 percent of total billed charges,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 90% Medicare OPPS,"$12,687.50 ",58% of total billed charges,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,"$21,875.00 ",Pays 100% Medicare OPPS,"$21,875.00 ",Pays 130% Medicare OPPS,"$18,593.75 ",85% of total billed charges,"$21,875.00 ",Pays 100% Medicare OPPS,$862.48 ,"$21,875.00 ","$17,500.00 "
Outpatient Medical Services,SURGERY,44970,LAPAROSCOPY APPENDECTOMY,360,"$21,875.00 ","$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,687.50 ",90% of total billed charges,"$7,656.25 ",35% based on GA Medicaid OP CCR Rate,"$15,028.13 ",68.7% of total billed charges,"$17,500.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,687.50 ",58% of total billed charges,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,687.50 ","$17,500.00 "
Outpatient Medical Services,SURGERY,45100,BIOPSY OF ANORECTAL WALL ANAL APPROACH,360,"$9,515.00 ","$8,087.75 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$1,938.21 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,238.46 ",Pays 102% Medicare OPPS,"$8,563.50 ",90% of total billed charges,"$3,330.25 ",35% based on GA Medicaid OP CCR Rate,"$6,536.81 ",68.7% of total billed charges,"$7,612.00 ",80 percent of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$1,975.12 ",Pays 90% Medicare OPPS,"$5,518.70 ",58% of total billed charges,"$1,938.21 ",20.37% based on GA Medicaid OP CCR Rate,"$2,260.04 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$8,087.75 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,$862.48 ,"$8,563.50 ","$7,612.00 "
Outpatient Medical Services,SURGERY,45331,SIGMOIDOSCOPY AND BIOPSY,750,"$3,575.00 ","$3,038.75 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,$728.23 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$727.13 ,Pays 102% Medicare OPPS,"$3,217.50 ",90% of total billed charges,"$1,251.25 ",35% based on GA Medicaid OP CCR Rate,"$2,456.03 ",68.7% of total billed charges,"$2,860.00 ",80 percent of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,Pays 90% Medicare OPPS,"$2,073.50 ",58% of total billed charges,$728.23 ,20.37% based on GA Medicaid OP CCR Rate,$730.96 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,"$3,038.75 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,"$3,217.50 ","$2,860.00 "
Outpatient Medical Services,SURGERY,45335,SIGMOIDOSCOPE W/SUBMUC INJ,750,"$4,695.00 ","$3,990.75 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,$956.37 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$727.13 ,Pays 102% Medicare OPPS,"$4,225.50 ",90% of total billed charges,"$1,643.25 ",35% based on GA Medicaid OP CCR Rate,"$3,225.47 ",68.7% of total billed charges,"$3,756.00 ",80 percent of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,Pays 90% Medicare OPPS,"$2,723.10 ",58% of total billed charges,$956.37 ,20.37% based on GA Medicaid OP CCR Rate,$730.96 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,"$3,990.75 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,"$4,225.50 ","$3,756.00 "
Outpatient Medical Services,SURGERY,45338,SIGMOIDOSCOPY FLEX W POLY,750,"$3,575.00 ","$3,038.75 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,$728.23 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$3,217.50 ",90% of total billed charges,"$1,251.25 ",35% based on GA Medicaid OP CCR Rate,"$2,456.03 ",68.7% of total billed charges,"$2,860.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$2,073.50 ",58% of total billed charges,$728.23 ,20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$3,038.75 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$728.23 ,"$3,217.50 ","$2,860.00 "
Outpatient Medical Services,SURGERY,45346,SIGMODOSCOPY W/ABLATION,360,"$4,200.00 ","$3,570.00 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,$855.54 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$3,780.00 ",90% of total billed charges,"$1,470.00 ",35% based on GA Medicaid OP CCR Rate,"$2,885.40 ",68.7% of total billed charges,"$3,360.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$2,436.00 ",58% of total billed charges,$855.54 ,20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$3,570.00 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,"$3,780.00 ","$3,360.00 "
Outpatient Medical Services,SURGERY,45379,Removal of foreign bodies in large bowel using an endoscope,360,"$5,940.00 ","$5,049.00 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$1,209.98 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$5,346.00 ",90% of total billed charges,"$2,079.00 ",35% based on GA Medicaid OP CCR Rate,"$4,080.78 ",68.7% of total billed charges,"$4,752.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$3,445.20 ",58% of total billed charges,"$1,209.98 ",20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$5,049.00 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,"$5,346.00 ","$4,752.00 "
Outpatient Medical Services,SURGERY,45381,Injections of large bowel using an endoscope,750,"$4,345.00 ","$3,693.25 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,$885.08 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$3,910.50 ",90% of total billed charges,"$1,520.75 ",35% based on GA Medicaid OP CCR Rate,"$2,985.02 ",68.7% of total billed charges,"$3,476.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$2,520.10 ",58% of total billed charges,$885.08 ,20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$3,693.25 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,"$3,910.50 ","$3,476.00 "
Outpatient Medical Services,SURGERY,45389,COLONOSCOPY W STENT PLACEMENT,750,"$15,750.00 ","$13,387.50 ",85% of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,521.78 ",Pays 100% Medicare OPPS,"$5,992.51 ",Pays 130% Medicare OPPS,"$3,208.28 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,612.21 ",Pays 102% Medicare OPPS,"$14,175.00 ",90% of total billed charges,"$5,512.50 ",35% based on GA Medicaid OP CCR Rate,"$10,820.25 ",68.7% of total billed charges,"$12,600.00 ",80 percent of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,"$4,069.60 ",Pays 90% Medicare OPPS,"$9,135.00 ",58% of total billed charges,"$3,208.28 ",20.37% based on GA Medicaid OP CCR Rate,"$4,609.63 ",Pays 100% Medicare OPPS,"$5,992.51 ",Pays 130% Medicare OPPS,"$13,387.50 ",85% of total billed charges,"$4,521.78 ",Pays 100% Medicare OPPS,$862.48 ,"$14,175.00 ","$12,600.00 "
Outpatient Medical Services,SURGERY,45390,Removal of large bowel tissue using an endoscope,360,"$10,690.00 ","$9,086.50 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$2,177.55 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,238.46 ",Pays 102% Medicare OPPS,"$9,621.00 ",90% of total billed charges,"$3,741.50 ",35% based on GA Medicaid OP CCR Rate,"$7,344.03 ",68.7% of total billed charges,"$8,552.00 ",80 percent of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$1,975.12 ",Pays 90% Medicare OPPS,"$6,200.20 ",58% of total billed charges,"$2,177.55 ",20.37% based on GA Medicaid OP CCR Rate,"$2,260.04 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$9,086.50 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,$862.48 ,"$9,621.00 ","$8,552.00 "
Outpatient Medical Services,SURGERY,45398,Tying of large bowel using an endoscope,750,"$4,695.00 ","$3,990.75 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,$956.37 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$4,225.50 ",90% of total billed charges,"$1,643.25 ",35% based on GA Medicaid OP CCR Rate,"$3,225.47 ",68.7% of total billed charges,"$3,756.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$2,723.10 ",58% of total billed charges,$956.37 ,20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$3,990.75 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,"$4,225.50 ","$3,756.00 "
Outpatient Medical Services,SURGERY,46255,REMOVE INT/EXT HEM 1 GROUP,360,"$10,270.00 ","$8,729.50 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$2,092.00 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,238.46 ",Pays 102% Medicare OPPS,"$9,243.00 ",90% of total billed charges,"$3,594.50 ",35% based on GA Medicaid OP CCR Rate,"$7,055.49 ",68.7% of total billed charges,"$8,216.00 ",80 percent of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$1,975.12 ",Pays 90% Medicare OPPS,"$5,956.60 ",58% of total billed charges,"$2,092.00 ",20.37% based on GA Medicaid OP CCR Rate,"$2,260.04 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$8,729.50 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,$862.48 ,"$9,243.00 ","$8,216.00 "
Outpatient Medical Services,SURGERY,46260,HEMORRHOIDECTOMY INT XTRNL,360,"$9,250.00 ","$7,862.50 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$1,884.23 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,238.46 ",Pays 102% Medicare OPPS,"$8,325.00 ",90% of total billed charges,"$3,237.50 ",35% based on GA Medicaid OP CCR Rate,"$6,354.75 ",68.7% of total billed charges,"$7,400.00 ",80 percent of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$1,975.12 ",Pays 90% Medicare OPPS,"$5,365.00 ",58% of total billed charges,"$1,884.23 ",20.37% based on GA Medicaid OP CCR Rate,"$2,260.04 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$7,862.50 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,$862.48 ,"$8,325.00 ","$7,400.00 "
Outpatient Medical Services,SURGERY,46320,REMOVAL OF HEMORRHOID CLOT,360,"$3,750.00 ","$3,187.50 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,$763.88 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$3,375.00 ",90% of total billed charges,"$1,312.50 ",35% based on GA Medicaid OP CCR Rate,"$2,576.25 ",68.7% of total billed charges,"$3,000.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$2,175.00 ",58% of total billed charges,$763.88 ,20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$3,187.50 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$763.88 ,"$3,375.00 ","$3,000.00 "
Outpatient Medical Services,SURGERY,46320,REMOVAL OF HEMORRHOID CLOT,750,"$7,445.00 ","$6,328.25 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$1,516.55 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$6,700.50 ",90% of total billed charges,"$2,605.75 ",35% based on GA Medicaid OP CCR Rate,"$5,114.72 ",68.7% of total billed charges,"$5,956.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$4,318.10 ",58% of total billed charges,"$1,516.55 ",20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$6,328.25 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,"$6,700.50 ","$5,956.00 "
Outpatient Medical Services,SURGERY,46500,INJ SCLEROSING SOLUTION HEMORRHOIDS,360,"$2,150.00 ","$1,827.50 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,$437.96 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$727.13 ,Pays 102% Medicare OPPS,"$1,935.00 ",90% of total billed charges,$752.50 ,35% based on GA Medicaid OP CCR Rate,"$1,477.05 ",68.7% of total billed charges,"$1,720.00 ",80 percent of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,Pays 90% Medicare OPPS,"$1,247.00 ",58% of total billed charges,$437.96 ,20.37% based on GA Medicaid OP CCR Rate,$730.96 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,"$1,827.50 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$437.96 ,"$1,935.00 ","$1,720.00 "
Outpatient Medical Services,SURGERY,46600,ANOSCOPY;W OR W/O SPECIME,750,"$3,250.00 ","$2,762.50 ",85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$103.31 ,Pays 102% Medicare OPPS,"$2,925.00 ",90% of total billed charges,"$1,137.50 ",35% based on GA Medicaid OP CCR Rate,"$2,232.75 ",68.7% of total billed charges,"$2,600.00 ",80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,"$1,885.00 ",58% of total billed charges,$662.03 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,"$2,762.50 ",85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,"$2,925.00 ","$2,600.00 "
Outpatient Medical Services,SURGERY,46910,DESTRUCTION OF ANAL LESION(S),360,"$9,250.00 ","$7,862.50 ",85% of total billed charges,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,973.43 ",Pays 130% Medicare OPPS,"$1,884.23 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,569.38 ",Pays 102% Medicare OPPS,"$8,325.00 ",90% of total billed charges,"$3,237.50 ",35% based on GA Medicaid OP CCR Rate,"$6,354.75 ",68.7% of total billed charges,"$7,400.00 ",80 percent of total billed charges,"$1,538.61 ",Pays 100% Medicare OPPS,"$1,384.75 ",Pays 90% Medicare OPPS,"$5,365.00 ",58% of total billed charges,"$1,884.23 ",20.37% based on GA Medicaid OP CCR Rate,"$1,518.03 ",Pays 100% Medicare OPPS,"$1,973.43 ",Pays 130% Medicare OPPS,"$7,862.50 ",85% of total billed charges,"$1,538.61 ",Pays 100% Medicare OPPS,$862.48 ,"$8,325.00 ","$7,400.00 "
Outpatient Medical Services,SURGERY,46922,DESTROY ANAL LESION SIMPLE,360,"$9,515.00 ","$8,087.75 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$1,938.21 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,238.46 ",Pays 102% Medicare OPPS,"$8,563.50 ",90% of total billed charges,"$3,330.25 ",35% based on GA Medicaid OP CCR Rate,"$6,536.81 ",68.7% of total billed charges,"$7,612.00 ",80 percent of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$1,975.12 ",Pays 90% Medicare OPPS,"$5,518.70 ",58% of total billed charges,"$1,938.21 ",20.37% based on GA Medicaid OP CCR Rate,"$2,260.04 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$8,087.75 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,$862.48 ,"$8,563.50 ","$7,612.00 "
Outpatient Medical Services,SURGERY,46930,DESTROY INTERNAL HEMORRHOIDS,750,"$5,250.00 ","$4,462.50 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$1,069.43 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$4,725.00 ",90% of total billed charges,"$1,837.50 ",35% based on GA Medicaid OP CCR Rate,"$3,606.75 ",68.7% of total billed charges,"$4,200.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$3,045.00 ",58% of total billed charges,"$1,069.43 ",20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$4,462.50 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,"$4,725.00 ","$4,200.00 "
Outpatient Medical Services,SURGERY,46946,INT HRHC LIG 2 HROID W/O IMG,360,"$10,710.00 ","$9,103.50 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$2,181.63 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,238.46 ",Pays 102% Medicare OPPS,"$9,639.00 ",90% of total billed charges,"$3,748.50 ",35% based on GA Medicaid OP CCR Rate,"$7,357.77 ",68.7% of total billed charges,"$8,568.00 ",80 percent of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$1,975.12 ",Pays 90% Medicare OPPS,"$6,211.80 ",58% of total billed charges,"$2,181.63 ",20.37% based on GA Medicaid OP CCR Rate,"$2,260.04 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$9,103.50 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,$862.48 ,"$9,639.00 ","$8,568.00 "
Outpatient Medical Services,SURGERY,46947,HEMORRHOIDOPEXY BY STAPLING,360,"$10,270.00 ","$8,729.50 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,194.58 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$2,092.00 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,238.46 ",Pays 102% Medicare OPPS,"$9,243.00 ",90% of total billed charges,"$3,594.50 ",35% based on GA Medicaid OP CCR Rate,"$7,055.49 ",68.7% of total billed charges,"$8,216.00 ",80 percent of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,"$1,975.12 ",Pays 90% Medicare OPPS,"$5,956.60 ",58% of total billed charges,"$2,092.00 ",20.37% based on GA Medicaid OP CCR Rate,"$2,260.04 ",Pays 100% Medicare OPPS,"$2,938.07 ",Pays 130% Medicare OPPS,"$8,729.50 ",85% of total billed charges,"$2,194.58 ",Pays 100% Medicare OPPS,$862.48 ,"$9,243.00 ","$8,216.00 "
Outpatient Medical Services,SURGERY,46999,UNLISTED PROCEDURE ANUS,360,"$3,500.00 ","$2,975.00 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,$712.95 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$727.13 ,Pays 102% Medicare OPPS,"$3,150.00 ",90% of total billed charges,"$1,225.00 ",35% based on GA Medicaid OP CCR Rate,"$2,404.50 ",68.7% of total billed charges,"$2,800.00 ",80 percent of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,Pays 90% Medicare OPPS,"$2,030.00 ",58% of total billed charges,$712.95 ,20.37% based on GA Medicaid OP CCR Rate,$730.96 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,"$2,975.00 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,"$3,150.00 ","$2,800.00 "
Outpatient Medical Services,SURGERY,47001,NEEDLE BIOPSY LIVER ADD ON,360,$750.00 ,$637.50 ,85% of total billed charges,$187.50 ,Pays 100% Medicare OPPS,$187.50 ,Pays 100% Medicare OPPS,$187.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,N/A,Pays 102% Medicare OPPS,$675.00 ,90% of total billed charges,$262.50 ,35% based on GA Medicaid OP CCR Rate,$515.25 ,68.7% of total billed charges,$600.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$675.00 ,Pays 90% Medicare OPPS,$435.00 ,58% of total billed charges,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$637.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$152.78 ,$986.63 ,$600.00 
Outpatient Medical Services,SURGERY,47562,Removal of gallbladder using an endoscope,360,"$24,375.00 ","$20,718.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,965.19 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$21,937.50 ",90% of total billed charges,"$8,531.25 ",35% based on GA Medicaid OP CCR Rate,"$16,745.63 ",68.7% of total billed charges,"$19,500.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$14,137.50 ",58% of total billed charges,"$4,965.19 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$20,718.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$21,937.50 ","$19,500.00 "
Outpatient Medical Services,SURGERY,47563,Gallbladder removal with use of an x-ray exam of the bile ducts,360,"$21,250.00 ","$18,062.50 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,328.63 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,125.00 ",90% of total billed charges,"$7,437.50 ",35% based on GA Medicaid OP CCR Rate,"$14,598.75 ",68.7% of total billed charges,"$17,000.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,325.00 ",58% of total billed charges,"$4,328.63 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,062.50 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,125.00 ","$17,000.00 "
Outpatient Medical Services,SURGERY,49084,PERITONEAL LAVAGE,360,"$3,500.00 ","$2,975.00 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$712.95 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$741.40 ,Pays 102% Medicare OPPS,"$3,150.00 ",90% of total billed charges,"$1,225.00 ",35% based on GA Medicaid OP CCR Rate,"$2,404.50 ",68.7% of total billed charges,"$2,800.00 ",80 percent of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,Pays 90% Medicare OPPS,"$2,030.00 ",58% of total billed charges,$712.95 ,20.37% based on GA Medicaid OP CCR Rate,$726.10 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,"$2,975.00 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,"$3,150.00 ","$2,800.00 "
Outpatient Medical Services,SURGERY,49320,LAP; DX ABDOMEN PERRITONEUM OMENTUM,360,"$21,875.00 ","$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,687.50 ",90% of total billed charges,"$7,656.25 ",35% based on GA Medicaid OP CCR Rate,"$15,028.13 ",68.7% of total billed charges,"$17,500.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,687.50 ",58% of total billed charges,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,687.50 ","$17,500.00 "
Outpatient Medical Services,SURGERY,49322,LAP; ABD PERIT OMENTUM W ASP CYST,360,"$21,875.00 ","$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,687.50 ",90% of total billed charges,"$7,656.25 ",35% based on GA Medicaid OP CCR Rate,"$15,028.13 ",68.7% of total billed charges,"$17,500.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,687.50 ",58% of total billed charges,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,687.50 ","$17,500.00 "
Outpatient Medical Services,SURGERY,49329,UNLISTED LAPAROSCOPY ABD PERIT OMENT,360,"$22,160.00 ","$18,836.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,513.99 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,944.00 ",90% of total billed charges,"$7,756.00 ",35% based on GA Medicaid OP CCR Rate,"$15,223.92 ",68.7% of total billed charges,"$17,728.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,852.80 ",58% of total billed charges,"$4,513.99 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,836.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,944.00 ","$17,728.00 "
Outpatient Medical Services,SURGERY,49505,Repair of groin hernia patient age 5 years or older,360,"$14,065.00 ","$11,955.25 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$4,050.02 ",Pays 130% Medicare OPPS,"$2,865.04 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,915.21 ",Pays 102% Medicare OPPS,"$12,658.50 ",90% of total billed charges,"$4,922.75 ",35% based on GA Medicaid OP CCR Rate,"$9,662.66 ",68.7% of total billed charges,"$11,252.00 ",80 percent of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,572.25 ",Pays 90% Medicare OPPS,"$8,157.70 ",58% of total billed charges,"$2,865.04 ",20.37% based on GA Medicaid OP CCR Rate,"$3,115.41 ",Pays 100% Medicare OPPS,"$4,050.02 ",Pays 130% Medicare OPPS,"$11,955.25 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,$862.48 ,"$12,658.50 ","$11,252.00 "
Outpatient Medical Services,SURGERY,49553,REP INIT FEM HERNIA REDUCABLE; INCARCE,360,"$13,950.00 ","$11,857.50 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$4,050.02 ",Pays 130% Medicare OPPS,"$2,841.62 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,915.21 ",Pays 102% Medicare OPPS,"$12,555.00 ",90% of total billed charges,"$4,882.50 ",35% based on GA Medicaid OP CCR Rate,"$9,583.65 ",68.7% of total billed charges,"$11,160.00 ",80 percent of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,572.25 ",Pays 90% Medicare OPPS,"$8,091.00 ",58% of total billed charges,"$2,841.62 ",20.37% based on GA Medicaid OP CCR Rate,"$3,115.41 ",Pays 100% Medicare OPPS,"$4,050.02 ",Pays 130% Medicare OPPS,"$11,857.50 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,$862.48 ,"$12,555.00 ","$11,160.00 "
Outpatient Medical Services,SURGERY,49560,RPR VENTRAL HERN INIT REDUC,360,"$13,940.00 ","$11,849.00 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$2,839.58 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,915.21 ",Pays 102% Medicare OPPS,"$12,546.00 ",90% of total billed charges,"$4,879.00 ",35% based on GA Medicaid OP CCR Rate,"$9,576.78 ",68.7% of total billed charges,"$11,152.00 ",80 percent of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,572.25 ",Pays 90% Medicare OPPS,"$8,085.20 ",58% of total billed charges,"$2,839.58 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$11,849.00 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,$862.48 ,"$12,546.00 ","$11,152.00 "
Outpatient Medical Services,SURGERY,49561,REPAIR INITIAL INCISIONAL HERNIA INCARC,360,"$13,940.00 ","$11,849.00 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$2,839.58 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,915.21 ",Pays 102% Medicare OPPS,"$12,546.00 ",90% of total billed charges,"$4,879.00 ",35% based on GA Medicaid OP CCR Rate,"$9,576.78 ",68.7% of total billed charges,"$11,152.00 ",80 percent of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,572.25 ",Pays 90% Medicare OPPS,"$8,085.20 ",58% of total billed charges,"$2,839.58 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$11,849.00 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,$862.48 ,"$12,546.00 ","$11,152.00 "
Outpatient Medical Services,SURGERY,49568,HERNIA REPAIR W/MESH,360,"$1,315.00 ","$1,117.75 ",85% of total billed charges,$328.75 ,Pays 100% Medicare OPPS,$328.75 ,Pays 100% Medicare OPPS,$328.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$267.87 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,N/A,Pays 102% Medicare OPPS,"$1,183.50 ",90% of total billed charges,$460.25 ,35% based on GA Medicaid OP CCR Rate,$903.41 ,68.7% of total billed charges,"$1,052.00 ",80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,"$1,183.50 ",Pays 90% Medicare OPPS,$762.70 ,58% of total billed charges,$267.87 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$1,117.75 ",85% of total billed charges,N/A,Pays 100% Medicare OPPS,$267.87 ,"$1,183.50 ","$1,052.00 "
Outpatient Medical Services,SURGERY,49585,Repair of umbilical hernia in patients over 5 years old,360,"$14,065.00 ","$11,955.25 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$2,865.04 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,915.21 ",Pays 102% Medicare OPPS,"$12,658.50 ",90% of total billed charges,"$4,922.75 ",35% based on GA Medicaid OP CCR Rate,"$9,662.66 ",68.7% of total billed charges,"$11,252.00 ",80 percent of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,572.25 ",Pays 90% Medicare OPPS,"$8,157.70 ",58% of total billed charges,"$2,865.04 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$11,955.25 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,$862.48 ,"$12,658.50 ","$11,252.00 "
Outpatient Medical Services,SURGERY,49587,RPR UMBIL HERN BLOCK 5+ YR,360,"$13,815.00 ","$11,742.75 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$2,814.12 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,915.21 ",Pays 102% Medicare OPPS,"$12,433.50 ",90% of total billed charges,"$4,835.25 ",35% based on GA Medicaid OP CCR Rate,"$9,490.91 ",68.7% of total billed charges,"$11,052.00 ",80 percent of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,572.25 ",Pays 90% Medicare OPPS,"$8,012.70 ",58% of total billed charges,"$2,814.12 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$11,742.75 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,$862.48 ,"$12,433.50 ","$11,052.00 "
Outpatient Medical Services,SURGERY,49650,Inguinal hernia repair done by laparoscope,360,"$21,875.00 ","$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,687.50 ",90% of total billed charges,"$7,656.25 ",35% based on GA Medicaid OP CCR Rate,"$15,028.13 ",68.7% of total billed charges,"$17,500.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,687.50 ",58% of total billed charges,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,687.50 ","$17,500.00 "
Outpatient Medical Services,SURGERY,49651,LAP ING HERNIA REPAIR RECUR,360,"$21,190.00 ","$18,011.50 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,316.40 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,071.00 ",90% of total billed charges,"$7,416.50 ",35% based on GA Medicaid OP CCR Rate,"$14,557.53 ",68.7% of total billed charges,"$16,952.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,290.20 ",58% of total billed charges,"$4,316.40 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,011.50 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,071.00 ","$16,952.00 "
Outpatient Medical Services,SURGERY,49652,LAP VENT/ABD HERNIA REPAIR,360,"$21,565.00 ","$18,330.25 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$4,392.79 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,408.50 ",90% of total billed charges,"$7,547.75 ",35% based on GA Medicaid OP CCR Rate,"$14,815.16 ",68.7% of total billed charges,"$17,252.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,507.70 ",58% of total billed charges,"$4,392.79 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$18,330.25 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,408.50 ","$17,252.00 "
Outpatient Medical Services,SURGERY,49653,LAP VENT/ABD HERN PROC COMP,360,"$22,190.00 ","$18,861.50 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$4,520.10 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,971.00 ",90% of total billed charges,"$7,766.50 ",35% based on GA Medicaid OP CCR Rate,"$15,244.53 ",68.7% of total billed charges,"$17,752.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,870.20 ",58% of total billed charges,"$4,520.10 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$18,861.50 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,971.00 ","$17,752.00 "
Outpatient Medical Services,SURGERY,49654,LAP ING HERNIA REPAIR INIT,360,"$21,875.00 ","$18,593.75 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$8,161.07 ",Pays 102% Medicare OPPS,"$19,687.50 ",90% of total billed charges,"$7,656.25 ",35% based on GA Medicaid OP CCR Rate,"$15,028.13 ",68.7% of total billed charges,"$17,500.00 ",80 percent of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$7,200.95 ",Pays 90% Medicare OPPS,"$12,687.50 ",58% of total billed charges,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$18,593.75 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,$862.48 ,"$19,687.50 ","$17,500.00 "
Outpatient Medical Services,SURGERY,49655,LAP INC HERN REPAIR COMP,360,"$36,875.00 ","$31,343.75 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$7,511.44 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$8,161.07 ",Pays 102% Medicare OPPS,"$33,187.50 ",90% of total billed charges,"$12,906.25 ",35% based on GA Medicaid OP CCR Rate,"$25,333.13 ",68.7% of total billed charges,"$29,500.00 ",80 percent of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$7,200.95 ",Pays 90% Medicare OPPS,"$21,387.50 ",58% of total billed charges,"$7,511.44 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$31,343.75 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,$862.48 ,"$33,187.50 ","$29,500.00 "
Outpatient Medical Services,SURGERY,49656,LAP INC HERNIA REPAIR RECUR,360,"$39,020.00 ","$33,167.00 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$7,948.37 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$8,161.07 ",Pays 102% Medicare OPPS,"$35,118.00 ",90% of total billed charges,"$13,657.00 ",35% based on GA Medicaid OP CCR Rate,"$26,806.74 ",68.7% of total billed charges,"$31,216.00 ",80 percent of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$7,200.95 ",Pays 90% Medicare OPPS,"$22,631.60 ",58% of total billed charges,"$7,948.37 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$33,167.00 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,$862.48 ,"$35,118.00 ","$31,216.00 "
Outpatient Medical Services,SURGERY,49657,LAP INC HERN RECUR COMP,360,"$39,020.00 ","$33,167.00 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,"$8,001.05 ",Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$7,948.37 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$8,161.07 ",Pays 102% Medicare OPPS,"$35,118.00 ",90% of total billed charges,"$13,657.00 ",35% based on GA Medicaid OP CCR Rate,"$26,806.74 ",68.7% of total billed charges,"$31,216.00 ",80 percent of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,"$7,200.95 ",Pays 90% Medicare OPPS,"$22,631.60 ",58% of total billed charges,"$7,948.37 ",20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,"$33,167.00 ",85% of total billed charges,"$8,001.05 ",Pays 100% Medicare OPPS,$862.48 ,"$35,118.00 ","$31,216.00 "
Outpatient Medical Services,SURGERY,55041,EXCISE HYDROCELE; BILATERAL,360,"$11,250.00 ","$9,562.50 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$4,050.02 ",Pays 130% Medicare OPPS,"$2,291.63 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,915.21 ",Pays 102% Medicare OPPS,"$10,125.00 ",90% of total billed charges,"$3,937.50 ",35% based on GA Medicaid OP CCR Rate,"$7,728.75 ",68.7% of total billed charges,"$9,000.00 ",80 percent of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,572.25 ",Pays 90% Medicare OPPS,"$6,525.00 ",58% of total billed charges,"$2,291.63 ",20.37% based on GA Medicaid OP CCR Rate,"$3,115.41 ",Pays 100% Medicare OPPS,"$4,050.02 ",Pays 130% Medicare OPPS,"$9,562.50 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,$862.48 ,"$10,125.00 ","$9,000.00 "
Outpatient Medical Services,SURGERY,58660,LAPAROSCOPY; W LYSIS OF ADHESIONS,360,"$21,875.00 ","$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,687.50 ",90% of total billed charges,"$7,656.25 ",35% based on GA Medicaid OP CCR Rate,"$15,028.13 ",68.7% of total billed charges,"$17,500.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,687.50 ",58% of total billed charges,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,687.50 ","$17,500.00 "
Outpatient Medical Services,SURGERY,58661,"Removal of either benign or malignant tissue from the uterus, ovaries, fallopian tubes, or any of the surrounding tissues using a laparoscope",360,"$17,500.00 ","$14,875.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$3,564.75 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$15,750.00 ",90% of total billed charges,"$6,125.00 ",35% based on GA Medicaid OP CCR Rate,"$12,022.50 ",68.7% of total billed charges,"$14,000.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$10,150.00 ",58% of total billed charges,"$3,564.75 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$14,875.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$15,750.00 ","$14,000.00 "
Outpatient Medical Services,SURGERY,58662,"Removal of lesions of the ovary, pelvic viscera, or peritoneal surface",360,"$20,000.00 ","$17,000.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,074.00 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$18,000.00 ",90% of total billed charges,"$7,000.00 ",35% based on GA Medicaid OP CCR Rate,"$13,740.00 ",68.7% of total billed charges,"$16,000.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$11,600.00 ",58% of total billed charges,"$4,074.00 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$17,000.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$18,000.00 ","$16,000.00 "
Outpatient Medical Services,SURGERY,60210,PARTIAL THYROID EXCISION,360,"$18,000.00 ","$15,300.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$3,666.60 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$16,200.00 ",90% of total billed charges,"$6,300.00 ",35% based on GA Medicaid OP CCR Rate,"$12,366.00 ",68.7% of total billed charges,"$14,400.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$10,440.00 ",58% of total billed charges,"$3,666.60 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$15,300.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$16,200.00 ","$14,400.00 "
Outpatient Medical Services,SURGERY,60212,PARTIAL THYROID EXCISION,360,"$18,500.00 ","$15,725.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$3,768.45 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$16,650.00 ",90% of total billed charges,"$6,475.00 ",35% based on GA Medicaid OP CCR Rate,"$12,709.50 ",68.7% of total billed charges,"$14,800.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$10,730.00 ",58% of total billed charges,"$3,768.45 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$15,725.00 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$16,650.00 ","$14,800.00 "
Outpatient Medical Services,SURGERY,60220,TOTAL THYROID LOBECTOMY UNILATERAL,360,"$22,190.00 ","$18,861.50 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,520.10 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,971.00 ",90% of total billed charges,"$7,766.50 ",35% based on GA Medicaid OP CCR Rate,"$15,244.53 ",68.7% of total billed charges,"$17,752.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,870.20 ",58% of total billed charges,"$4,520.10 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,861.50 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,971.00 ","$17,752.00 "
Outpatient Medical Services,SURGERY,60225,TOTAL THYROIDLOBECTOMY; W CSL,360,"$22,190.00 ","$18,861.50 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,520.10 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,971.00 ",90% of total billed charges,"$7,766.50 ",35% based on GA Medicaid OP CCR Rate,"$15,244.53 ",68.7% of total billed charges,"$17,752.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,870.20 ",58% of total billed charges,"$4,520.10 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,861.50 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,971.00 ","$17,752.00 "
Outpatient Medical Services,SURGERY,60240,THYROIDECTOMY TOTAL,360,"$21,875.00 ","$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$19,687.50 ",90% of total billed charges,"$7,656.25 ",35% based on GA Medicaid OP CCR Rate,"$15,028.13 ",68.7% of total billed charges,"$17,500.00 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$12,687.50 ",58% of total billed charges,"$4,455.94 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$18,593.75 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$19,687.50 ","$17,500.00 "
Outpatient Medical Services,SURGERY,64726,DECOMPRESS PLANTAR DIGITAL NERVE,360,"$7,220.00 ","$6,137.00 ",85% of total billed charges,"$1,577.36 ",Pays 100% Medicare OPPS,"$1,577.36 ",Pays 100% Medicare OPPS,"$1,577.36 ",Pays 100% Medicare OPPS,"$2,055.37 ",Pays 130% Medicare OPPS,"$1,470.71 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,608.90 ",Pays 102% Medicare OPPS,"$6,498.00 ",90% of total billed charges,"$2,527.00 ",35% based on GA Medicaid OP CCR Rate,"$4,960.14 ",68.7% of total billed charges,"$5,776.00 ",80 percent of total billed charges,"$1,577.36 ",Pays 100% Medicare OPPS,"$1,419.61 ",Pays 90% Medicare OPPS,"$4,187.60 ",58% of total billed charges,"$1,470.71 ",20.37% based on GA Medicaid OP CCR Rate,"$1,581.06 ",Pays 100% Medicare OPPS,"$2,055.37 ",Pays 130% Medicare OPPS,"$6,137.00 ",85% of total billed charges,"$1,577.36 ",Pays 100% Medicare OPPS,$862.48 ,"$6,498.00 ","$5,776.00 "
Outpatient Medical Services,SURGERY,67715,CANTHOTOMY SEPARATE PROCEDURE,360,"$7,720.00 ","$6,562.00 ",85% of total billed charges,"$1,797.59 ",Pays 100% Medicare OPPS,"$1,797.59 ",Pays 100% Medicare OPPS,"$1,797.59 ",Pays 100% Medicare OPPS,"$2,417.50 ",Pays 130% Medicare OPPS,"$1,572.56 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$1,833.54 ",Pays 102% Medicare OPPS,"$6,948.00 ",90% of total billed charges,"$2,702.00 ",35% based on GA Medicaid OP CCR Rate,"$5,303.64 ",68.7% of total billed charges,"$6,176.00 ",80 percent of total billed charges,"$1,797.59 ",Pays 100% Medicare OPPS,"$1,617.83 ",Pays 90% Medicare OPPS,"$4,477.60 ",58% of total billed charges,"$1,572.56 ",20.37% based on GA Medicaid OP CCR Rate,"$1,859.61 ",Pays 100% Medicare OPPS,"$2,417.50 ",Pays 130% Medicare OPPS,"$6,562.00 ",85% of total billed charges,"$1,797.59 ",Pays 100% Medicare OPPS,$862.48 ,"$6,948.00 ","$6,176.00 "
Outpatient Medical Services,SURGERY,91035,G ESOPH REFLUX MUCOSAL PH,750,"$1,970.00 ","$1,674.50 ",85% of total billed charges,$438.49 ,Pays 100% Medicare OPPS,$438.49 ,Pays 100% Medicare OPPS,$438.49 ,Pays 100% Medicare OPPS,$552.77 ,Pays 130% Medicare OPPS,$401.29 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$447.26 ,Pays 102% Medicare OPPS,"$1,773.00 ",90% of total billed charges,$689.50 ,35% based on GA Medicaid OP CCR Rate,"$1,353.39 ",68.7% of total billed charges,"$1,576.00 ",80 percent of total billed charges,$438.49 ,Pays 100% Medicare OPPS,$394.64 ,Pays 90% Medicare OPPS,"$1,142.60 ",58% of total billed charges,$401.29 ,20.37% based on GA Medicaid OP CCR Rate,$425.21 ,Pays 100% Medicare OPPS,$552.77 ,Pays 130% Medicare OPPS,"$1,674.50 ",85% of total billed charges,$438.49 ,Pays 100% Medicare OPPS,$394.64 ,"$1,773.00 ","$1,576.00 "
Outpatient Medical Services,SURGERY,C9728,MARKER BREAST BIOZORB LP 2CMX2CMX1CM,360,"$5,048.00 ","$4,290.80 ",85% of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,532.99 ",Pays 130% Medicare OPPS,"$1,028.28 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,157.05 ",Pays 102% Medicare OPPS,"$4,543.20 ",90% of total billed charges,"$1,766.80 ",35% based on GA Medicaid OP CCR Rate,"$3,467.98 ",68.7% of total billed charges,"$4,038.40 ",80 percent of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,020.92 ",Pays 90% Medicare OPPS,"$2,927.84 ",58% of total billed charges,"$1,028.28 ",20.37% based on GA Medicaid OP CCR Rate,"$1,179.22 ",Pays 100% Medicare OPPS,"$1,532.99 ",Pays 130% Medicare OPPS,"$4,290.80 ",85% of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,020.92 ","$4,543.20 ","$4,038.40 "
Outpatient Medical Services,SURGERY,C9728,MARKER BREAST BIOZORB LP 2CMX3CMX1CM,360,"$5,175.00 ","$4,398.75 ",85% of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,532.99 ",Pays 130% Medicare OPPS,"$1,054.15 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,157.05 ",Pays 102% Medicare OPPS,"$4,657.50 ",90% of total billed charges,"$1,811.25 ",35% based on GA Medicaid OP CCR Rate,"$3,555.23 ",68.7% of total billed charges,"$4,140.00 ",80 percent of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,020.92 ",Pays 90% Medicare OPPS,"$3,001.50 ",58% of total billed charges,"$1,054.15 ",20.37% based on GA Medicaid OP CCR Rate,"$1,179.22 ",Pays 100% Medicare OPPS,"$1,532.99 ",Pays 130% Medicare OPPS,"$4,398.75 ",85% of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,020.92 ","$4,657.50 ","$4,140.00 "
Outpatient Medical Services,SURGERY,C9728,MARKER BREAST TISSUE BIOZORB 2CM X 2CM,360,"$5,225.00 ","$4,441.25 ",85% of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,532.99 ",Pays 130% Medicare OPPS,"$1,064.33 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,157.05 ",Pays 102% Medicare OPPS,"$4,702.50 ",90% of total billed charges,"$1,828.75 ",35% based on GA Medicaid OP CCR Rate,"$3,589.58 ",68.7% of total billed charges,"$4,180.00 ",80 percent of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,020.92 ",Pays 90% Medicare OPPS,"$3,030.50 ",58% of total billed charges,"$1,064.33 ",20.37% based on GA Medicaid OP CCR Rate,"$1,179.22 ",Pays 100% Medicare OPPS,"$1,532.99 ",Pays 130% Medicare OPPS,"$4,441.25 ",85% of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,020.92 ","$4,702.50 ","$4,180.00 "
Outpatient Medical Services,SURGERY,C9728,MARKER BREAST TISSUE BIOZORB 2CM X 3CM,360,"$5,225.00 ","$4,441.25 ",85% of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,532.99 ",Pays 130% Medicare OPPS,"$1,064.33 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,157.05 ",Pays 102% Medicare OPPS,"$4,702.50 ",90% of total billed charges,"$1,828.75 ",35% based on GA Medicaid OP CCR Rate,"$3,589.58 ",68.7% of total billed charges,"$4,180.00 ",80 percent of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,020.92 ",Pays 90% Medicare OPPS,"$3,030.50 ",58% of total billed charges,"$1,064.33 ",20.37% based on GA Medicaid OP CCR Rate,"$1,179.22 ",Pays 100% Medicare OPPS,"$1,532.99 ",Pays 130% Medicare OPPS,"$4,441.25 ",85% of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,020.92 ","$4,702.50 ","$4,180.00 "
Outpatient Medical Services,SURGERY,C9728,MARKER BREAST TISSUE BIOZORB 3CM X 3CM,360,"$5,275.00 ","$4,483.75 ",85% of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,532.99 ",Pays 130% Medicare OPPS,"$1,074.52 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,157.05 ",Pays 102% Medicare OPPS,"$4,747.50 ",90% of total billed charges,"$1,846.25 ",35% based on GA Medicaid OP CCR Rate,"$3,623.93 ",68.7% of total billed charges,"$4,220.00 ",80 percent of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,020.92 ",Pays 90% Medicare OPPS,"$3,059.50 ",58% of total billed charges,"$1,074.52 ",20.37% based on GA Medicaid OP CCR Rate,"$1,179.22 ",Pays 100% Medicare OPPS,"$1,532.99 ",Pays 130% Medicare OPPS,"$4,483.75 ",85% of total billed charges,"$1,134.35 ",Pays 100% Medicare OPPS,"$1,020.92 ","$4,747.50 ","$4,220.00 "
Outpatient Medical Services,SURGERY,99211,Outpatient visit of established patient not requiring a physician,761,$190.00 ,$161.50 ,85% of total billed charges,$47.50 ,Pays 100% Medicare OPPS,$47.50 ,Pays 100% Medicare OPPS,$47.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$66.50 ,35% based on GA Medicaid OP CCR Rate,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$171.00 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$38.70 ,$171.00 ,$152.00 
Outpatient Medical Services,SURGERY,99211,Outpatient visit of established patient not requiring a physician,761,$220.00 ,$187.00 ,85% of total billed charges,$55.00 ,Pays 100% Medicare OPPS,$55.00 ,Pays 100% Medicare OPPS,$55.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$44.81 ,20.37% based on GA Medicaid OP CCR Rate,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,$124.30 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$198.00 ,90% of total billed charges,$77.00 ,35% based on GA Medicaid OP CCR Rate,$151.14 ,68.7% of total billed charges,$176.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$198.00 ,Pays 90% Medicare OPPS,$127.60 ,58% of total billed charges,$44.81 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$187.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$44.81 ,$198.00 ,$176.00 
Outpatient Medical Services,SURGERY,96372,IM INJECTION OR SUBCUTANEOUS,761,$240.00 ,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$56.80 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$84.00 ,35% based on GA Medicaid OP CCR Rate,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$50.12 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$59.34 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$48.89 ,$216.00 ,$192.00 
Outpatient Medical Services,SURGERY,96372,IM INJECTION OR SUBCUTANEOUS,761,$240.00 ,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$56.80 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$84.00 ,35% based on GA Medicaid OP CCR Rate,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$50.12 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$59.34 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$48.89 ,$216.00 ,$192.00 
Outpatient Medical Services,SURGERY,20552,TRIGGER POINT INJECTION SINGLE/MULTIPLE,761,$265.00 ,$225.25 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$53.98 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$239.38 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$92.75 ,35% based on GA Medicaid OP CCR Rate,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$211.22 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$53.98 ,20.37% based on GA Medicaid OP CCR Rate,$239.14 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$53.98 ,$310.88 ,$212.00 
Outpatient Medical Services,SURGERY,64402,IM INJECT ANESTHETIC AGENT FACIAL NERVE,761,$300.00 ,$255.00 ,85% of total billed charges,$75.00 ,Pays 100% Medicare OPPS,$75.00 ,Pays 100% Medicare OPPS,$75.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$105.00 ,35% based on GA Medicaid OP CCR Rate,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$270.00 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$61.11 ,$270.00 ,$240.00 
Outpatient Medical Services,SURGERY,51702,INS TEMP BLADDER CATH,761,$325.00 ,$276.25 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$66.20 ,20.37% based on GA Medicaid OP CCR Rate,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$292.50 ,90% of total billed charges,$113.75 ,35% based on GA Medicaid OP CCR Rate,$223.28 ,68.7% of total billed charges,$260.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$188.50 ,58% of total billed charges,$66.20 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$276.25 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$66.20 ,$292.50 ,$260.00 
Outpatient Medical Services,SURGERY,99211,Outpatient visit of established patient not requiring a physician,761,$395.00 ,$335.75 ,85% of total billed charges,$98.75 ,Pays 100% Medicare OPPS,$98.75 ,Pays 100% Medicare OPPS,$98.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$355.50 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,SURGERY,G0463,OUTPATIENT PROCEDURE/TREATMENT,761,$395.00 ,$335.75 ,85% of total billed charges,$106.73 ,Pays 100% Medicare OPPS,$106.73 ,Pays 100% Medicare OPPS,$106.73 ,Pays 100% Medicare OPPS,$138.19 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$108.86 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$106.73 ,Pays 100% Medicare OPPS,$96.06 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$106.30 ,Pays 100% Medicare OPPS,$138.19 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$106.73 ,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,SURGERY,99211,Outpatient visit of established patient not requiring a physician,761,$395.00 ,$335.75 ,85% of total billed charges,$98.75 ,Pays 100% Medicare OPPS,$98.75 ,Pays 100% Medicare OPPS,$98.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$355.50 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,SURGERY,10006,FINE NEEDLE ASPIR BX W/US GDN EA ADDL LE,761,$440.00 ,$374.00 ,85% of total billed charges,$110.00 ,Pays 100% Medicare OPPS,$110.00 ,Pays 100% Medicare OPPS,$110.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$89.63 ,20.37% based on GA Medicaid OP CCR Rate,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$396.00 ,90% of total billed charges,$154.00 ,35% based on GA Medicaid OP CCR Rate,$302.28 ,68.7% of total billed charges,$352.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$396.00 ,Pays 90% Medicare OPPS,$255.20 ,58% of total billed charges,$89.63 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$374.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$89.63 ,$396.00 ,$352.00 
Outpatient Medical Services,SURGERY,19084,BIOPSY BREAST ADDL AREA INC US GUIDANNCE,761,$440.00 ,$374.00 ,85% of total billed charges,$110.00 ,Pays 100% Medicare OPPS,$110.00 ,Pays 100% Medicare OPPS,$110.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$89.63 ,20.37% based on GA Medicaid OP CCR Rate,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$396.00 ,90% of total billed charges,$154.00 ,35% based on GA Medicaid OP CCR Rate,$302.28 ,68.7% of total billed charges,$352.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$396.00 ,Pays 90% Medicare OPPS,$255.20 ,58% of total billed charges,$89.63 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$374.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$89.63 ,$396.00 ,$352.00 
Outpatient Medical Services,SURGERY,96523,IRRIGATION OF IMPLANTED VENOUS ACCESS,761,$470.00 ,$399.50 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$95.74 ,20.37% based on GA Medicaid OP CCR Rate,$265.55 ,56.5 percent of total billed charges,$265.55 ,56.5 percent of total billed charges,$265.55 ,56.5 percent of total billed charges,$265.55 ,56.5 percent of total billed charges,$51.00 ,Pays 102% Medicare OPPS,$423.00 ,90% of total billed charges,$164.50 ,35% based on GA Medicaid OP CCR Rate,$322.89 ,68.7% of total billed charges,$376.00 ,80 percent of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,Pays 90% Medicare OPPS,$272.60 ,58% of total billed charges,$95.74 ,20.37% based on GA Medicaid OP CCR Rate,$50.55 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$399.50 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,$423.00 ,$376.00 
Outpatient Medical Services,SURGERY,10040,"Incision and Drainage Procedures on the Skin, Subcutaneous and Accessory Structures",761,$490.00 ,$416.50 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$99.81 ,20.37% based on GA Medicaid OP CCR Rate,$276.85 ,56.5 percent of total billed charges,$276.85 ,56.5 percent of total billed charges,$276.85 ,56.5 percent of total billed charges,$276.85 ,56.5 percent of total billed charges,$164.54 ,Pays 102% Medicare OPPS,$441.00 ,90% of total billed charges,$171.50 ,35% based on GA Medicaid OP CCR Rate,$336.63 ,68.7% of total billed charges,$392.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$284.20 ,58% of total billed charges,$99.81 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$416.50 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$99.81 ,$441.00 ,$392.00 
Outpatient Medical Services,SURGERY,49083,PERITONOCENTESIS,761,$660.00 ,$561.00 ,85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$741.40 ,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$231.00 ,35% based on GA Medicaid OP CCR Rate,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$726.10 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$134.44 ,$943.93 ,$528.00 
Outpatient Medical Services,SURGERY,M0243,CASIRIVI AND IMDEV INFUSION,761,"$1,550.00 ","$1,317.50 ",85% of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$396.25 ,Pays 100% Medicare OPPS,$396.25 ,Pays 100% Medicare OPPS,$515.12 ,Pays 130% Medicare OPPS,$315.74 ,20.37% based on GA Medicaid OP CCR Rate,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$404.17 ,Pays 102% Medicare OPPS,"$1,395.00 ",90% of total billed charges,$542.50 ,35% based on GA Medicaid OP CCR Rate,"$1,064.85 ",68.7% of total billed charges,"$1,240.00 ",80 percent of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$356.62 ,Pays 90% Medicare OPPS,$899.00 ,58% of total billed charges,$315.74 ,20.37% based on GA Medicaid OP CCR Rate,$396.25 ,Pays 100% Medicare OPPS,$515.12 ,Pays 130% Medicare OPPS,"$1,317.50 ",85% of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$315.74 ,"$1,395.00 ","$1,240.00 "
Outpatient Medical Services,SURGERY,M0247,SOTROVIMAB INFUSION,761,"$1,550.00 ","$1,317.50 ",85% of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$396.25 ,Pays 100% Medicare OPPS,$396.25 ,Pays 100% Medicare OPPS,$515.12 ,Pays 130% Medicare OPPS,$315.74 ,20.37% based on GA Medicaid OP CCR Rate,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$404.17 ,Pays 102% Medicare OPPS,"$1,395.00 ",90% of total billed charges,$542.50 ,35% based on GA Medicaid OP CCR Rate,"$1,064.85 ",68.7% of total billed charges,"$1,240.00 ",80 percent of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$356.62 ,Pays 90% Medicare OPPS,$899.00 ,58% of total billed charges,$315.74 ,20.37% based on GA Medicaid OP CCR Rate,$396.25 ,Pays 100% Medicare OPPS,$515.12 ,Pays 130% Medicare OPPS,"$1,317.50 ",85% of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$315.74 ,"$1,395.00 ","$1,240.00 "
Outpatient Medical Services,SURGERY,36430,SB BLOOD ADMINISTRATION,761,"$1,710.00 ","$1,453.50 ",85% of total billed charges,$356.55 ,Pays 100% Medicare OPPS,$356.55 ,Pays 100% Medicare OPPS,$356.55 ,Pays 100% Medicare OPPS,$466.23 ,Pays 130% Medicare OPPS,$348.33 ,20.37% based on GA Medicaid OP CCR Rate,$966.15 ,56.5 percent of total billed charges,$966.15 ,56.5 percent of total billed charges,$966.15 ,56.5 percent of total billed charges,$966.15 ,56.5 percent of total billed charges,$363.68 ,Pays 102% Medicare OPPS,"$1,539.00 ",90% of total billed charges,$598.50 ,35% based on GA Medicaid OP CCR Rate,"$1,174.77 ",68.7% of total billed charges,"$1,368.00 ",80 percent of total billed charges,$356.55 ,Pays 100% Medicare OPPS,$320.89 ,Pays 90% Medicare OPPS,$991.80 ,58% of total billed charges,$348.33 ,20.37% based on GA Medicaid OP CCR Rate,$358.64 ,Pays 100% Medicare OPPS,$466.23 ,Pays 130% Medicare OPPS,"$1,453.50 ",85% of total billed charges,$356.55 ,Pays 100% Medicare OPPS,$320.89 ,"$1,539.00 ","$1,368.00 "
Outpatient Medical Services,SURGERY,19285,PLACEMENT OF BREAST LOCALIZATION DEVICE,761,"$1,875.00 ","$1,593.75 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$381.94 ,20.37% based on GA Medicaid OP CCR Rate,"$1,059.38 ",56.5 percent of total billed charges,"$1,059.38 ",56.5 percent of total billed charges,"$1,059.38 ",56.5 percent of total billed charges,"$1,059.38 ",56.5 percent of total billed charges,$570.18 ,Pays 102% Medicare OPPS,"$1,687.50 ",90% of total billed charges,$656.25 ,35% based on GA Medicaid OP CCR Rate,"$1,288.13 ",68.7% of total billed charges,"$1,500.00 ",80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,"$1,087.50 ",58% of total billed charges,$381.94 ,20.37% based on GA Medicaid OP CCR Rate,$570.82 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,"$1,593.75 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$381.94 ,"$1,687.50 ","$1,500.00 "
Outpatient Medical Services,SURGERY,60100,XR THYROID BPSY PERCU CORE,761,"$2,250.00 ","$1,912.50 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$458.33 ,20.37% based on GA Medicaid OP CCR Rate,"$1,271.25 ",56.5 percent of total billed charges,"$1,271.25 ",56.5 percent of total billed charges,"$1,271.25 ",56.5 percent of total billed charges,"$1,271.25 ",56.5 percent of total billed charges,$570.17 ,Pays 102% Medicare OPPS,"$2,025.00 ",90% of total billed charges,$787.50 ,35% based on GA Medicaid OP CCR Rate,"$1,545.75 ",68.7% of total billed charges,"$1,800.00 ",80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,"$1,305.00 ",58% of total billed charges,$458.33 ,20.37% based on GA Medicaid OP CCR Rate,$570.82 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,"$1,912.50 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$458.33 ,"$2,025.00 ","$1,800.00 "
Outpatient Medical Services,SURGERY,10005,"Fine needle aspiration biopsy, including ultrasound guidance; first lesion",761,"$2,500.00 ","$2,125.00 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$509.25 ,20.37% based on GA Medicaid OP CCR Rate,"$1,412.50 ",56.5 percent of total billed charges,"$1,412.50 ",56.5 percent of total billed charges,"$1,412.50 ",56.5 percent of total billed charges,"$1,412.50 ",56.5 percent of total billed charges,$570.17 ,Pays 102% Medicare OPPS,"$2,250.00 ",90% of total billed charges,$875.00 ,35% based on GA Medicaid OP CCR Rate,"$1,717.50 ",68.7% of total billed charges,"$2,000.00 ",80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,"$1,450.00 ",58% of total billed charges,$509.25 ,20.37% based on GA Medicaid OP CCR Rate,$570.82 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,"$2,125.00 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,"$2,250.00 ","$2,000.00 "
Outpatient Medical Services,SURGERY,60100,BIOPSY OF THYROID,761,"$2,500.00 ","$2,125.00 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$509.25 ,20.37% based on GA Medicaid OP CCR Rate,"$1,412.50 ",56.5 percent of total billed charges,"$1,412.50 ",56.5 percent of total billed charges,"$1,412.50 ",56.5 percent of total billed charges,"$1,412.50 ",56.5 percent of total billed charges,$570.17 ,Pays 102% Medicare OPPS,"$2,250.00 ",90% of total billed charges,$875.00 ,35% based on GA Medicaid OP CCR Rate,"$1,717.50 ",68.7% of total billed charges,"$2,000.00 ",80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,"$1,450.00 ",58% of total billed charges,$509.25 ,20.37% based on GA Medicaid OP CCR Rate,$570.82 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,"$2,125.00 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,"$2,250.00 ","$2,000.00 "
Outpatient Medical Services,SURGERY,50688,CHANGE OF URETER TUBE STINT,761,"$4,965.00 ","$4,220.25 ",85% of total billed charges,"$1,608.44 ",Pays 100% Medicare OPPS,"$1,608.44 ",Pays 100% Medicare OPPS,"$1,608.44 ",Pays 100% Medicare OPPS,"$2,120.96 ",Pays 130% Medicare OPPS,"$1,011.37 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,640.61 ",Pays 102% Medicare OPPS,"$4,468.50 ",90% of total billed charges,"$1,737.75 ",35% based on GA Medicaid OP CCR Rate,"$3,410.96 ",68.7% of total billed charges,"$3,972.00 ",80 percent of total billed charges,"$1,608.44 ",Pays 100% Medicare OPPS,"$1,447.59 ",Pays 90% Medicare OPPS,"$2,879.70 ",58% of total billed charges,"$1,011.37 ",20.37% based on GA Medicaid OP CCR Rate,"$1,631.51 ",Pays 100% Medicare OPPS,"$2,120.96 ",Pays 130% Medicare OPPS,"$4,220.25 ",85% of total billed charges,"$1,608.44 ",Pays 100% Medicare OPPS,"$1,011.37 ","$4,468.50 ","$3,972.00 "
Outpatient Medical Services,SURGERY,19083,BIOPSY BREAST INCLUDING US GUIDANNCE,761,"$5,130.00 ","$4,360.50 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$1,044.98 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,289.21 ",Pays 102% Medicare OPPS,"$4,617.00 ",90% of total billed charges,"$1,795.50 ",35% based on GA Medicaid OP CCR Rate,"$3,524.31 ",68.7% of total billed charges,"$4,104.00 ",80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,"$2,975.40 ",58% of total billed charges,"$1,044.98 ",20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$4,360.50 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,044.98 ","$4,617.00 ","$4,104.00 "
Outpatient Medical Services,SURGERY,21550,SFT TISSUE BX NECK/THORAX,761,"$5,315.00 ","$4,517.75 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$1,082.67 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,289.21 ",Pays 102% Medicare OPPS,"$4,783.50 ",90% of total billed charges,"$1,860.25 ",35% based on GA Medicaid OP CCR Rate,"$3,651.41 ",68.7% of total billed charges,"$4,252.00 ",80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,"$3,082.70 ",58% of total billed charges,"$1,082.67 ",20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$4,517.75 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,082.67 ","$4,783.50 ","$4,252.00 "
Outpatient Medical Services,SURGERY,21555,EXCISION TUMOR SOFT TISSUE < 3CM,761,"$5,795.00 ","$4,925.75 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$1,180.44 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,289.21 ",Pays 102% Medicare OPPS,"$5,215.50 ",90% of total billed charges,"$2,028.25 ",35% based on GA Medicaid OP CCR Rate,"$3,981.17 ",68.7% of total billed charges,"$4,636.00 ",80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,"$3,361.10 ",58% of total billed charges,"$1,180.44 ",20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$4,925.75 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ","$5,215.50 ","$4,636.00 "
Outpatient Medical Services,SURGERY,36571,INSERT PICVAD CATH,761,"$7,450.00 ","$6,332.50 ",85% of total billed charges,"$2,571.56 ",Pays 100% Medicare OPPS,"$2,571.56 ",Pays 100% Medicare OPPS,"$2,571.56 ",Pays 100% Medicare OPPS,"$3,406.31 ",Pays 130% Medicare OPPS,"$1,517.57 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,622.99 ",Pays 102% Medicare OPPS,"$6,705.00 ",90% of total billed charges,"$2,607.50 ",35% based on GA Medicaid OP CCR Rate,"$5,118.15 ",68.7% of total billed charges,"$5,960.00 ",80 percent of total billed charges,"$2,571.56 ",Pays 100% Medicare OPPS,"$2,314.40 ",Pays 90% Medicare OPPS,"$4,321.00 ",58% of total billed charges,"$1,517.57 ",20.37% based on GA Medicaid OP CCR Rate,"$2,620.23 ",Pays 100% Medicare OPPS,"$3,406.31 ",Pays 130% Medicare OPPS,"$6,332.50 ",85% of total billed charges,"$2,571.56 ",Pays 100% Medicare OPPS,"$1,517.57 ","$6,705.00 ","$5,960.00 "
Outpatient Medical Services,SURGERY,43239,"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",360,"$3,305.00 ","$2,809.25 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$673.23 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$741.40 ,Pays 102% Medicare OPPS,"$2,974.50 ",90% of total billed charges,"$1,156.75 ",35% based on GA Medicaid OP CCR Rate,"$2,270.54 ",68.7% of total billed charges,"$2,644.00 ",80 percent of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,Pays 90% Medicare OPPS,"$1,916.90 ",58% of total billed charges,$673.23 ,20.37% based on GA Medicaid OP CCR Rate,$726.10 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,"$2,809.25 ",85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.17 ,"$2,974.50 ","$2,644.00 "
Outpatient Medical Services,SURGERY,45378,Diagnostic examination of large bowel using an endoscope,360,"$3,305.00 ","$2,809.25 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,$673.23 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$727.13 ,Pays 102% Medicare OPPS,"$2,974.50 ",90% of total billed charges,"$1,156.75 ",35% based on GA Medicaid OP CCR Rate,"$2,270.54 ",68.7% of total billed charges,"$2,644.00 ",80 percent of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,Pays 90% Medicare OPPS,"$1,916.90 ",58% of total billed charges,$673.23 ,20.37% based on GA Medicaid OP CCR Rate,$730.96 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,"$2,809.25 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,"$2,974.50 ","$2,644.00 "
Outpatient Medical Services,SURGERY,45380,Biopsy of large bowel using an endoscope,360,"$3,725.00 ","$3,166.25 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,$758.78 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$3,352.50 ",90% of total billed charges,"$1,303.75 ",35% based on GA Medicaid OP CCR Rate,"$2,559.08 ",68.7% of total billed charges,"$2,980.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$2,160.50 ",58% of total billed charges,$758.78 ,20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$3,166.25 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$758.78 ,"$3,352.50 ","$2,980.00 "
Outpatient Medical Services,SURGERY,45385,Removal of polyps or growths of large bowel using an endoscope,360,"$3,725.00 ","$3,166.25 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,$758.78 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$3,352.50 ",90% of total billed charges,"$1,303.75 ",35% based on GA Medicaid OP CCR Rate,"$2,559.08 ",68.7% of total billed charges,"$2,980.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$2,160.50 ",58% of total billed charges,$758.78 ,20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$3,166.25 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$758.78 ,"$3,352.50 ","$2,980.00 "
Outpatient Medical Services,SURGERY,45391,Ultrasound examination of lower large bowel using an endoscope,360,"$3,725.00 ","$3,166.25 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,$758.78 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$950.15 ,Pays 102% Medicare OPPS,"$3,352.50 ",90% of total billed charges,"$1,303.75 ",35% based on GA Medicaid OP CCR Rate,"$2,559.08 ",68.7% of total billed charges,"$2,980.00 ",80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,"$2,160.50 ",58% of total billed charges,$758.78 ,20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,"$3,166.25 ",85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$758.78 ,"$3,352.50 ","$2,980.00 "
Outpatient Medical Services,SURGERY,47562,Removal of gallbladder using an endoscope,360,"$20,668.00 ","$17,567.80 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,545.38 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$4,210.07 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$4,636.30 ",Pays 102% Medicare OPPS,"$18,601.20 ",90% of total billed charges,"$7,233.80 ",35% based on GA Medicaid OP CCR Rate,"$14,198.92 ",68.7% of total billed charges,"$16,534.40 ",80 percent of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,"$4,090.85 ",Pays 90% Medicare OPPS,"$11,987.44 ",58% of total billed charges,"$4,210.07 ",20.37% based on GA Medicaid OP CCR Rate,"$4,584.49 ",Pays 100% Medicare OPPS,"$5,959.85 ",Pays 130% Medicare OPPS,"$17,567.80 ",85% of total billed charges,"$4,545.38 ",Pays 100% Medicare OPPS,$862.48 ,"$18,601.20 ","$16,534.40 "
Outpatient Medical Services,SURGERY,49505,Repair of groin hernia patient age 5 years or older,360,"$12,997.00 ","$11,047.45 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,858.06 ",Pays 100% Medicare OPPS,"$4,050.02 ",Pays 130% Medicare OPPS,"$2,647.49 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,915.21 ",Pays 102% Medicare OPPS,"$11,697.30 ",90% of total billed charges,"$4,548.95 ",35% based on GA Medicaid OP CCR Rate,"$8,928.94 ",68.7% of total billed charges,"$10,397.60 ",80 percent of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,"$2,572.25 ",Pays 90% Medicare OPPS,"$7,538.26 ",58% of total billed charges,"$2,647.49 ",20.37% based on GA Medicaid OP CCR Rate,"$3,115.41 ",Pays 100% Medicare OPPS,"$4,050.02 ",Pays 130% Medicare OPPS,"$11,047.45 ",85% of total billed charges,"$2,858.06 ",Pays 100% Medicare OPPS,$862.48 ,"$11,697.30 ","$10,397.60 "
Outpatient Medical Services,SURGERY,93000,Routine EKG using at least 12 leads including interpretation and report,730,$375.00 ,$318.75 ,85% of total billed charges,$93.75 ,Pays 100% Medicare OPPS,$93.75 ,Pays 100% Medicare OPPS,$93.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,$211.88 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$337.50 ,90% of total billed charges,$131.25 ,35% based on GA Medicaid OP CCR Rate,$257.63 ,68.7% of total billed charges,$300.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$337.50 ,Pays 90% Medicare OPPS,$217.50 ,58% of total billed charges,$76.39 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$318.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$76.39 ,$337.50 ,$300.00 
Outpatient Medical Services,SURGERY,93452,Insertion of catheter into left heart for diagnosis,480,"$11,845.00 ","$10,068.25 ",85% of total billed charges,"$2,604.89 ",Pays 100% Medicare OPPS,"$2,604.89 ",Pays 100% Medicare OPPS,"$2,604.89 ",Pays 100% Medicare OPPS,"$3,382.85 ",Pays 130% Medicare OPPS,"$2,412.83 ",20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,"$2,656.99 ",Pays 102% Medicare OPPS,"$10,660.50 ",90% of total billed charges,"$4,145.75 ",35% based on GA Medicaid OP CCR Rate,"$8,137.52 ",68.7% of total billed charges,"$9,476.00 ",80 percent of total billed charges,"$2,604.89 ",Pays 100% Medicare OPPS,"$2,344.39 ",Pays 90% Medicare OPPS,"$6,870.10 ",58% of total billed charges,"$2,412.83 ",20.37% based on GA Medicaid OP CCR Rate,"$2,602.19 ",Pays 100% Medicare OPPS,"$3,382.85 ",Pays 130% Medicare OPPS,"$10,068.25 ",85% of total billed charges,"$2,604.89 ",Pays 100% Medicare OPPS,$862.48 ,"$10,660.50 ","$9,476.00 "
Outpatient Medical Services,SLEEP,95782,POLYSOMNOGRAPHY YOUNGER 6YRS,920,"$4,000.00 ","$3,400.00 ",85% of total billed charges,$826.46 ,Pays 100% Medicare OPPS,$826.46 ,Pays 100% Medicare OPPS,$826.46 ,Pays 100% Medicare OPPS,"$1,068.41 ",Pays 130% Medicare OPPS,$814.80 ,20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,$842.98 ,Pays 102% Medicare OPPS,"$3,600.00 ",90% of total billed charges,"$1,400.00 ",35% based on GA Medicaid OP CCR Rate,"$2,748.00 ",68.7% of total billed charges,"$3,200.00 ",80 percent of total billed charges,$826.46 ,Pays 100% Medicare OPPS,$743.80 ,Pays 90% Medicare OPPS,"$2,320.00 ",58% of total billed charges,$814.80 ,20.37% based on GA Medicaid OP CCR Rate,$821.86 ,Pays 100% Medicare OPPS,"$1,068.41 ",Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$826.46 ,Pays 100% Medicare OPPS,$743.80 ,"$3,600.00 ","$3,200.00 "
Outpatient Medical Services,SLEEP,95810,Sleep monitoring of patient (6 years or older) in sleep lab,920,"$4,000.00 ","$3,400.00 ",85% of total billed charges,$826.46 ,Pays 100% Medicare OPPS,$826.46 ,Pays 100% Medicare OPPS,$826.46 ,Pays 100% Medicare OPPS,"$1,068.41 ",Pays 130% Medicare OPPS,$814.80 ,20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,$842.98 ,Pays 102% Medicare OPPS,"$3,600.00 ",90% of total billed charges,"$1,400.00 ",35% based on GA Medicaid OP CCR Rate,"$2,748.00 ",68.7% of total billed charges,"$3,200.00 ",80 percent of total billed charges,$826.46 ,Pays 100% Medicare OPPS,$743.80 ,Pays 90% Medicare OPPS,"$2,320.00 ",58% of total billed charges,$814.80 ,20.37% based on GA Medicaid OP CCR Rate,$821.86 ,Pays 100% Medicare OPPS,"$1,068.41 ",Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$826.46 ,Pays 100% Medicare OPPS,$743.80 ,"$3,600.00 ","$3,200.00 "
Outpatient Medical Services,SLEEP,95811,Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,920,"$4,000.00 ","$3,400.00 ",85% of total billed charges,$826.46 ,Pays 100% Medicare OPPS,$826.46 ,Pays 100% Medicare OPPS,$826.46 ,Pays 100% Medicare OPPS,"$1,068.41 ",Pays 130% Medicare OPPS,$814.80 ,20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,$842.98 ,Pays 102% Medicare OPPS,"$3,600.00 ",90% of total billed charges,"$1,400.00 ",35% based on GA Medicaid OP CCR Rate,"$2,748.00 ",68.7% of total billed charges,"$3,200.00 ",80 percent of total billed charges,$826.46 ,Pays 100% Medicare OPPS,$743.80 ,Pays 90% Medicare OPPS,"$2,320.00 ",58% of total billed charges,$814.80 ,20.37% based on GA Medicaid OP CCR Rate,$821.86 ,Pays 100% Medicare OPPS,"$1,068.41 ",Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$826.46 ,Pays 100% Medicare OPPS,$743.80 ,"$3,600.00 ","$3,200.00 "
Outpatient Medical Services,RESPIRATORY,94640,SPUTUM COLLECTION,410,$40.00 ,$34.00 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$172.23 ,Pays 102% Medicare OPPS,$36.00 ,90% of total billed charges,$14.00 ,35% based on GA Medicaid OP CCR Rate,$27.48 ,68.7% of total billed charges,$32.00 ,80 percent of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$151.96 ,Pays 90% Medicare OPPS,$23.20 ,58% of total billed charges,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,$168.43 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$34.00 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$8.15 ,$218.97 ,$32.00 
Outpatient Medical Services,RESPIRATORY,31720,NASO TRACHEAL SUCTION,410,$85.00 ,$72.25 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$48.03 ,56.5 percent of total billed charges,$172.23 ,Pays 102% Medicare OPPS,$76.50 ,90% of total billed charges,$29.75 ,35% based on GA Medicaid OP CCR Rate,$58.40 ,68.7% of total billed charges,$68.00 ,80 percent of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$151.96 ,Pays 90% Medicare OPPS,$49.30 ,58% of total billed charges,$17.31 ,20.37% based on GA Medicaid OP CCR Rate,$168.43 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$72.25 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$17.31 ,$218.97 ,$68.00 
Outpatient Medical Services,RESPIRATORY,94640,SPUTUM INDUCTION,410,$95.00 ,$80.75 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$19.35 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$172.23 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$33.25 ,35% based on GA Medicaid OP CCR Rate,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$151.96 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$19.35 ,20.37% based on GA Medicaid OP CCR Rate,$168.43 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$19.35 ,$218.97 ,$76.00 
Outpatient Medical Services,RESPIRATORY,94645,CONTINUOUS INHALATION EACH ADD HR,410,$95.00 ,$80.75 ,85% of total billed charges,$23.75 ,Pays 100% Medicare OPPS,$23.75 ,Pays 100% Medicare OPPS,$23.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$19.35 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$33.25 ,35% based on GA Medicaid OP CCR Rate,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$85.50 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$19.35 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$19.35 ,$85.50 ,$76.00 
Outpatient Medical Services,RESPIRATORY,94664,EVALUATE PT USE OF INHALER,410,$95.00 ,$80.75 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$19.35 ,20.37% based on GA Medicaid OP CCR Rate,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$53.68 ,56.5 percent of total billed charges,$172.23 ,Pays 102% Medicare OPPS,$85.50 ,90% of total billed charges,$33.25 ,35% based on GA Medicaid OP CCR Rate,$65.27 ,68.7% of total billed charges,$76.00 ,80 percent of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$151.96 ,Pays 90% Medicare OPPS,$55.10 ,58% of total billed charges,$19.35 ,20.37% based on GA Medicaid OP CCR Rate,$168.43 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$80.75 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$19.35 ,$218.97 ,$76.00 
Outpatient Medical Services,RESPIRATORY,36600,ARTERIAL PUNCTURE,410,$100.00 ,$85.00 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$35.00 ,35% based on GA Medicaid OP CCR Rate,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$20.37 ,$132.76 ,$80.00 
Outpatient Medical Services,RESPIRATORY,94668,CPT  (CHEST PHYSIO THER SUBSEQU),410,$110.00 ,$93.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$22.41 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$38.50 ,35% based on GA Medicaid OP CCR Rate,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$22.41 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$93.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$22.41 ,$132.76 ,$88.00 
Outpatient Medical Services,RESPIRATORY,94640,..........IPPB TREATMENT,410,$125.00 ,$106.25 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$25.46 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$172.23 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$43.75 ,35% based on GA Medicaid OP CCR Rate,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$151.96 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$25.46 ,20.37% based on GA Medicaid OP CCR Rate,$168.43 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$25.46 ,$218.97 ,$100.00 
Outpatient Medical Services,RESPIRATORY,94667,CPT (CHEST PHYSIO THER INITIAL),410,$125.00 ,$106.25 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$25.46 ,20.37% based on GA Medicaid OP CCR Rate,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$70.63 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$112.50 ,90% of total billed charges,$43.75 ,35% based on GA Medicaid OP CCR Rate,$85.88 ,68.7% of total billed charges,$100.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$72.50 ,58% of total billed charges,$25.46 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$106.25 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$25.46 ,$132.76 ,$100.00 
Outpatient Medical Services,RESPIRATORY,94644,CONTINUOUS INHALATION TX 1ST HR,410,$390.00 ,$331.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$79.44 ,20.37% based on GA Medicaid OP CCR Rate,$220.35 ,56.5 percent of total billed charges,$220.35 ,56.5 percent of total billed charges,$220.35 ,56.5 percent of total billed charges,$220.35 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$351.00 ,90% of total billed charges,$136.50 ,35% based on GA Medicaid OP CCR Rate,$267.93 ,68.7% of total billed charges,$312.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$226.20 ,58% of total billed charges,$79.44 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$331.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$79.44 ,$351.00 ,$312.00 
Outpatient Medical Services,RESPIRATORY,94640,SUB NEB TX,410,$400.00 ,$340.00 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$81.48 ,20.37% based on GA Medicaid OP CCR Rate,$226.00 ,56.5 percent of total billed charges,$226.00 ,56.5 percent of total billed charges,$226.00 ,56.5 percent of total billed charges,$226.00 ,56.5 percent of total billed charges,$172.23 ,Pays 102% Medicare OPPS,$360.00 ,90% of total billed charges,$140.00 ,35% based on GA Medicaid OP CCR Rate,$274.80 ,68.7% of total billed charges,$320.00 ,80 percent of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$151.96 ,Pays 90% Medicare OPPS,$232.00 ,58% of total billed charges,$81.48 ,20.37% based on GA Medicaid OP CCR Rate,$168.43 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$340.00 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$81.48 ,$360.00 ,$320.00 
Outpatient Medical Services,RESPIRATORY,99465,NEWBORN RESUSCITATION,410,$570.00 ,$484.50 ,85% of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$504.64 ,Pays 100% Medicare OPPS,$504.64 ,Pays 100% Medicare OPPS,$672.51 ,Pays 130% Medicare OPPS,$116.11 ,20.37% based on GA Medicaid OP CCR Rate,$322.05 ,56.5 percent of total billed charges,$322.05 ,56.5 percent of total billed charges,$322.05 ,56.5 percent of total billed charges,$322.05 ,56.5 percent of total billed charges,$514.73 ,Pays 102% Medicare OPPS,$513.00 ,90% of total billed charges,$199.50 ,35% based on GA Medicaid OP CCR Rate,$391.59 ,68.7% of total billed charges,$456.00 ,80 percent of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$454.17 ,Pays 90% Medicare OPPS,$330.60 ,58% of total billed charges,$116.11 ,20.37% based on GA Medicaid OP CCR Rate,$517.30 ,Pays 100% Medicare OPPS,$672.51 ,Pays 130% Medicare OPPS,$484.50 ,85% of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$116.11 ,$672.51 ,$456.00 
Outpatient Medical Services,RESPIRATORY,94640,INCENTIVE SPIROMETER TX,410,$650.00 ,$552.50 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$132.41 ,20.37% based on GA Medicaid OP CCR Rate,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$172.23 ,Pays 102% Medicare OPPS,$585.00 ,90% of total billed charges,$227.50 ,35% based on GA Medicaid OP CCR Rate,$446.55 ,68.7% of total billed charges,$520.00 ,80 percent of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$151.96 ,Pays 90% Medicare OPPS,$377.00 ,58% of total billed charges,$132.41 ,20.37% based on GA Medicaid OP CCR Rate,$168.43 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$552.50 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$132.41 ,$585.00 ,$520.00 
Outpatient Medical Services,RESPIRATORY,94640,INITIAL NEB TX,410,$650.00 ,$552.50 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$132.41 ,20.37% based on GA Medicaid OP CCR Rate,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$172.23 ,Pays 102% Medicare OPPS,$585.00 ,90% of total billed charges,$227.50 ,35% based on GA Medicaid OP CCR Rate,$446.55 ,68.7% of total billed charges,$520.00 ,80 percent of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$151.96 ,Pays 90% Medicare OPPS,$377.00 ,58% of total billed charges,$132.41 ,20.37% based on GA Medicaid OP CCR Rate,$168.43 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$552.50 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$132.41 ,$585.00 ,$520.00 
Outpatient Medical Services,RESPIRATORY,31500,INTUBATION,410,"$1,020.00 ",$867.00 ,85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,$207.77 ,20.37% based on GA Medicaid OP CCR Rate,$576.30 ,56.5 percent of total billed charges,$576.30 ,56.5 percent of total billed charges,$576.30 ,56.5 percent of total billed charges,$576.30 ,56.5 percent of total billed charges,$193.85 ,Pays 102% Medicare OPPS,$918.00 ,90% of total billed charges,$357.00 ,35% based on GA Medicaid OP CCR Rate,$700.74 ,68.7% of total billed charges,$816.00 ,80 percent of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$171.04 ,Pays 90% Medicare OPPS,$591.60 ,58% of total billed charges,$207.77 ,20.37% based on GA Medicaid OP CCR Rate,$182.80 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,$867.00 ,85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$171.04 ,$918.00 ,$816.00 
Outpatient Medical Services,RESPIRATORY,94002,VENTILATOR INITIAL,410,"$1,235.00 ","$1,049.75 ",85% of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$437.62 ,Pays 100% Medicare OPPS,$437.62 ,Pays 100% Medicare OPPS,$636.58 ,Pays 130% Medicare OPPS,$251.57 ,20.37% based on GA Medicaid OP CCR Rate,$697.78 ,56.5 percent of total billed charges,$697.78 ,56.5 percent of total billed charges,$697.78 ,56.5 percent of total billed charges,$697.78 ,56.5 percent of total billed charges,$446.37 ,Pays 102% Medicare OPPS,"$1,111.50 ",90% of total billed charges,$432.25 ,35% based on GA Medicaid OP CCR Rate,$848.45 ,68.7% of total billed charges,$988.00 ,80 percent of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$393.85 ,Pays 90% Medicare OPPS,$716.30 ,58% of total billed charges,$251.57 ,20.37% based on GA Medicaid OP CCR Rate,$489.68 ,Pays 100% Medicare OPPS,$636.58 ,Pays 130% Medicare OPPS,"$1,049.75 ",85% of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$251.57 ,"$1,111.50 ",$988.00 
Outpatient Medical Services,RESPIRATORY,94003,VENT MGMT INPAT SUBQ DAY,410,"$1,235.00 ","$1,049.75 ",85% of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$437.62 ,Pays 100% Medicare OPPS,$437.62 ,Pays 100% Medicare OPPS,$636.58 ,Pays 130% Medicare OPPS,$251.57 ,20.37% based on GA Medicaid OP CCR Rate,$697.78 ,56.5 percent of total billed charges,$697.78 ,56.5 percent of total billed charges,$697.78 ,56.5 percent of total billed charges,$697.78 ,56.5 percent of total billed charges,$446.37 ,Pays 102% Medicare OPPS,"$1,111.50 ",90% of total billed charges,$432.25 ,35% based on GA Medicaid OP CCR Rate,$848.45 ,68.7% of total billed charges,$988.00 ,80 percent of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$393.85 ,Pays 90% Medicare OPPS,$716.30 ,58% of total billed charges,$251.57 ,20.37% based on GA Medicaid OP CCR Rate,$489.68 ,Pays 100% Medicare OPPS,$636.58 ,Pays 130% Medicare OPPS,"$1,049.75 ",85% of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$251.57 ,"$1,111.50 ",$988.00 
Outpatient Medical Services,RESPIRATORY,94002,BIPAP INITIAL,410,"$1,235.00 ","$1,049.75 ",85% of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$437.62 ,Pays 100% Medicare OPPS,$437.62 ,Pays 100% Medicare OPPS,$636.58 ,Pays 130% Medicare OPPS,$251.57 ,20.37% based on GA Medicaid OP CCR Rate,$697.78 ,56.5 percent of total billed charges,$697.78 ,56.5 percent of total billed charges,$697.78 ,56.5 percent of total billed charges,$697.78 ,56.5 percent of total billed charges,$446.37 ,Pays 102% Medicare OPPS,"$1,111.50 ",90% of total billed charges,$432.25 ,35% based on GA Medicaid OP CCR Rate,$848.45 ,68.7% of total billed charges,$988.00 ,80 percent of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$393.85 ,Pays 90% Medicare OPPS,$716.30 ,58% of total billed charges,$251.57 ,20.37% based on GA Medicaid OP CCR Rate,$489.68 ,Pays 100% Medicare OPPS,$636.58 ,Pays 130% Medicare OPPS,"$1,049.75 ",85% of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$251.57 ,"$1,111.50 ",$988.00 
Outpatient Medical Services,RESPIRATORY,94003,BIPAP SUBSEQUENT,410,"$1,250.00 ","$1,062.50 ",85% of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$437.62 ,Pays 100% Medicare OPPS,$437.62 ,Pays 100% Medicare OPPS,$636.58 ,Pays 130% Medicare OPPS,$254.63 ,20.37% based on GA Medicaid OP CCR Rate,$706.25 ,56.5 percent of total billed charges,$706.25 ,56.5 percent of total billed charges,$706.25 ,56.5 percent of total billed charges,$706.25 ,56.5 percent of total billed charges,$446.37 ,Pays 102% Medicare OPPS,"$1,125.00 ",90% of total billed charges,$437.50 ,35% based on GA Medicaid OP CCR Rate,$858.75 ,68.7% of total billed charges,"$1,000.00 ",80 percent of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$393.85 ,Pays 90% Medicare OPPS,$725.00 ,58% of total billed charges,$254.63 ,20.37% based on GA Medicaid OP CCR Rate,$489.68 ,Pays 100% Medicare OPPS,$636.58 ,Pays 130% Medicare OPPS,"$1,062.50 ",85% of total billed charges,$437.62 ,Pays 100% Medicare OPPS,$254.63 ,"$1,125.00 ","$1,000.00 "
Outpatient Medical Services,RESPIRATORY,94760,PULSE OXIMETRY,460,$75.00 ,$63.75 ,85% of total billed charges,$18.75 ,Pays 100% Medicare OPPS,$18.75 ,Pays 100% Medicare OPPS,$18.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$15.28 ,20.37% based on GA Medicaid OP CCR Rate,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,$42.38 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$67.50 ,90% of total billed charges,$26.25 ,35% based on GA Medicaid OP CCR Rate,$51.53 ,68.7% of total billed charges,$60.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$67.50 ,Pays 90% Medicare OPPS,$43.50 ,58% of total billed charges,$15.28 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$63.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$15.28 ,$67.50 ,$60.00 
Outpatient Medical Services,RESPIRATORY,94726,Measures how much air is in the lungs after taking a deep breath,460,$170.00 ,$144.50 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$320.23 ,Pays 130% Medicare OPPS,$34.63 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$242.49 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$59.50 ,35% based on GA Medicaid OP CCR Rate,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$34.63 ,20.37% based on GA Medicaid OP CCR Rate,$246.33 ,Pays 100% Medicare OPPS,$320.23 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$34.63 ,$320.23 ,$136.00 
Outpatient Medical Services,RESPIRATORY,99464,ATTENDANCE AT DELIVERY,460,$210.00 ,$178.50 ,85% of total billed charges,$52.50 ,Pays 100% Medicare OPPS,$52.50 ,Pays 100% Medicare OPPS,$52.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,$118.65 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$189.00 ,90% of total billed charges,$73.50 ,35% based on GA Medicaid OP CCR Rate,$144.27 ,68.7% of total billed charges,$168.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$189.00 ,Pays 90% Medicare OPPS,$121.80 ,58% of total billed charges,$42.78 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$178.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$42.78 ,$189.00 ,$168.00 
Outpatient Medical Services,RESPIRATORY,94010,Test to determine how well oxygen moves from the lungs to the blood stream,460,$395.00 ,$335.75 ,85% of total billed charges,$125.41 ,Pays 100% Medicare OPPS,$125.41 ,Pays 100% Medicare OPPS,$125.41 ,Pays 100% Medicare OPPS,$166.29 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$127.92 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$125.41 ,Pays 100% Medicare OPPS,$112.87 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$127.91 ,Pays 100% Medicare OPPS,$166.29 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$125.41 ,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,RESPIRATORY,94729,Test to measure how well gases diffuse across lung surfaces,460,$395.00 ,$335.75 ,85% of total billed charges,$98.75 ,Pays 100% Medicare OPPS,$98.75 ,Pays 100% Medicare OPPS,$98.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$355.50 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,RESPIRATORY,94727,Measure of lung function and gas exchange,460,$410.00 ,$348.50 ,85% of total billed charges,$125.41 ,Pays 100% Medicare OPPS,$125.41 ,Pays 100% Medicare OPPS,$125.41 ,Pays 100% Medicare OPPS,$166.29 ,Pays 130% Medicare OPPS,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$127.92 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$143.50 ,35% based on GA Medicaid OP CCR Rate,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$125.41 ,Pays 100% Medicare OPPS,$112.87 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,$127.91 ,Pays 100% Medicare OPPS,$166.29 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$125.41 ,Pays 100% Medicare OPPS,$83.52 ,$369.00 ,$328.00 
Outpatient Medical Services,CARDIOLOGY,94618,PULMONARY STRESS TEST SIMPLE 6 MIN WALK,460,$585.00 ,$497.25 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$119.16 ,20.37% based on GA Medicaid OP CCR Rate,$330.53 ,56.5 percent of total billed charges,$330.53 ,56.5 percent of total billed charges,$330.53 ,56.5 percent of total billed charges,$330.53 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$526.50 ,90% of total billed charges,$204.75 ,35% based on GA Medicaid OP CCR Rate,$401.90 ,68.7% of total billed charges,$468.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$339.30 ,58% of total billed charges,$119.16 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$497.25 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,$526.50 ,$468.00 
Outpatient Medical Services,CARDIOLOGY,94060,Test to determine if wheezing is present,460,$660.00 ,$561.00 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$242.49 ,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$231.00 ,35% based on GA Medicaid OP CCR Rate,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$246.33 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$134.44 ,$594.00 ,$528.00 
Outpatient Medical Services,CARDIOLOGY,94660,POS AIRWAY PRESSURE CPAP,460,$795.00 ,$675.75 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$168.85 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$161.94 ,20.37% based on GA Medicaid OP CCR Rate,$449.18 ,56.5 percent of total billed charges,$449.18 ,56.5 percent of total billed charges,$449.18 ,56.5 percent of total billed charges,$449.18 ,56.5 percent of total billed charges,$172.23 ,Pays 102% Medicare OPPS,$715.50 ,90% of total billed charges,$278.25 ,35% based on GA Medicaid OP CCR Rate,$546.17 ,68.7% of total billed charges,$636.00 ,80 percent of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$151.96 ,Pays 90% Medicare OPPS,$461.10 ,58% of total billed charges,$161.94 ,20.37% based on GA Medicaid OP CCR Rate,$168.43 ,Pays 100% Medicare OPPS,$218.97 ,Pays 130% Medicare OPPS,$675.75 ,85% of total billed charges,$168.85 ,Pays 100% Medicare OPPS,$151.96 ,$715.50 ,$636.00 
Outpatient Medical Services,CARDIOLOGY,92587,HEARING SCREENING/NEWBORN,479,$110.00 ,$93.50 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$22.41 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$242.49 ,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$38.50 ,35% based on GA Medicaid OP CCR Rate,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$22.41 ,20.37% based on GA Medicaid OP CCR Rate,$246.33 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,$237.74 ,Pays 100% Medicare OPPS,$22.41 ,$320.22 ,$88.00 
Outpatient Medical Services,CARDIOLOGY,92585,HEARING SCREENING/NEWBORN,479,$110.00 ,$93.50 ,85% of total billed charges,$27.50 ,Pays 100% Medicare OPPS,$27.50 ,Pays 100% Medicare OPPS,$27.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$22.41 ,20.37% based on GA Medicaid OP CCR Rate,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,$62.15 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$99.00 ,90% of total billed charges,$38.50 ,35% based on GA Medicaid OP CCR Rate,$75.57 ,68.7% of total billed charges,$88.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$99.00 ,Pays 90% Medicare OPPS,$63.80 ,58% of total billed charges,$22.41 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,N/A,Not reimbursed per contract,N/A,Pays 100% Medicare OPPS,$22.41 ,$99.00 ,$88.00 
Outpatient Medical Services,CARDIOLOGY,92950,CARDIOPULMONARY RESUSCITA,480,$660.00 ,$561.00 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$242.49 ,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$231.00 ,35% based on GA Medicaid OP CCR Rate,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$246.33 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$134.44 ,$986.63 ,$528.00 
Outpatient Medical Services,CARDIOLOGY,92953,EXTERNAL PACEMAKER,480,"$1,100.00 ",$935.00 ,85% of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$504.64 ,Pays 100% Medicare OPPS,$504.64 ,Pays 100% Medicare OPPS,$672.51 ,Pays 130% Medicare OPPS,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$514.73 ,Pays 102% Medicare OPPS,$990.00 ,90% of total billed charges,$385.00 ,35% based on GA Medicaid OP CCR Rate,$755.70 ,68.7% of total billed charges,$880.00 ,80 percent of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$454.17 ,Pays 90% Medicare OPPS,$638.00 ,58% of total billed charges,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,$517.30 ,Pays 100% Medicare OPPS,$672.51 ,Pays 130% Medicare OPPS,$935.00 ,85% of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$224.07 ,$990.00 ,$880.00 
Outpatient Medical Services,CARDIOLOGY,93017,STRESS TEST (TREADMILL),482,"$1,265.00 ","$1,075.25 ",85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$320.23 ,Pays 130% Medicare OPPS,$257.68 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$242.49 ,Pays 102% Medicare OPPS,"$1,138.50 ",90% of total billed charges,$442.75 ,35% based on GA Medicaid OP CCR Rate,$869.06 ,68.7% of total billed charges,"$1,012.00 ",80 percent of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,Pays 90% Medicare OPPS,$733.70 ,58% of total billed charges,$257.68 ,20.37% based on GA Medicaid OP CCR Rate,$246.33 ,Pays 100% Medicare OPPS,$320.23 ,Pays 130% Medicare OPPS,"$1,075.25 ",85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,"$1,138.50 ","$1,012.00 "
Outpatient Medical Services,CARDIOLOGY,93308,ECHO LIMITED STUDY,483,$465.00 ,$395.25 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$206.70 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$94.72 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$210.83 ,Pays 102% Medicare OPPS,$418.50 ,90% of total billed charges,$162.75 ,35% based on GA Medicaid OP CCR Rate,$319.46 ,68.7% of total billed charges,$372.00 ,80 percent of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$186.03 ,Pays 90% Medicare OPPS,$269.70 ,58% of total billed charges,$94.72 ,20.37% based on GA Medicaid OP CCR Rate,$205.39 ,Pays 100% Medicare OPPS,$267.01 ,Pays 130% Medicare OPPS,$395.25 ,85% of total billed charges,$206.70 ,Pays 100% Medicare OPPS,$94.72 ,$986.63 ,$372.00 
Outpatient Medical Services,CARDIOLOGY,93350,Stress test with echocardiogram,483,"$1,970.00 ","$1,674.50 ",85% of total billed charges,$434.05 ,Pays 100% Medicare OPPS,$434.05 ,Pays 100% Medicare OPPS,$434.05 ,Pays 100% Medicare OPPS,$575.29 ,Pays 130% Medicare OPPS,$401.29 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$442.72 ,Pays 102% Medicare OPPS,"$1,773.00 ",90% of total billed charges,$689.50 ,35% based on GA Medicaid OP CCR Rate,"$1,353.39 ",68.7% of total billed charges,"$1,576.00 ",80 percent of total billed charges,$434.05 ,Pays 100% Medicare OPPS,$390.64 ,Pays 90% Medicare OPPS,"$1,142.60 ",58% of total billed charges,$401.29 ,20.37% based on GA Medicaid OP CCR Rate,$442.54 ,Pays 100% Medicare OPPS,$575.29 ,Pays 130% Medicare OPPS,"$1,674.50 ",85% of total billed charges,$434.05 ,Pays 100% Medicare OPPS,$390.64 ,"$1,773.00 ","$1,576.00 "
Outpatient Medical Services,CARDIOLOGY,93306,"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",483,"$2,825.00 ","$2,401.25 ",85% of total billed charges,$434.05 ,Pays 100% Medicare OPPS,$434.05 ,Pays 100% Medicare OPPS,$434.05 ,Pays 100% Medicare OPPS,$575.29 ,Pays 130% Medicare OPPS,$575.45 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$442.72 ,Pays 102% Medicare OPPS,"$2,542.50 ",90% of total billed charges,$988.75 ,35% based on GA Medicaid OP CCR Rate,"$1,940.78 ",68.7% of total billed charges,"$2,260.00 ",80 percent of total billed charges,$434.05 ,Pays 100% Medicare OPPS,$390.64 ,Pays 90% Medicare OPPS,"$1,638.50 ",58% of total billed charges,$575.45 ,20.37% based on GA Medicaid OP CCR Rate,$442.54 ,Pays 100% Medicare OPPS,$575.29 ,Pays 130% Medicare OPPS,"$2,401.25 ",85% of total billed charges,$434.05 ,Pays 100% Medicare OPPS,$390.64 ,"$2,542.50 ","$2,260.00 "
Outpatient Medical Services,CARDIOLOGY,93041,RHYTHM STRIP CHG W EKG,730,$260.00 ,$221.00 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$52.96 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$51.00 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$91.00 ,35% based on GA Medicaid OP CCR Rate,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$52.96 ,20.37% based on GA Medicaid OP CCR Rate,$50.55 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,$234.00 ,$208.00 
Outpatient Medical Services,CARDIOLOGY,93005,EKG,730,$320.00 ,$272.00 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$65.18 ,20.37% based on GA Medicaid OP CCR Rate,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$180.80 ,56.5 percent of total billed charges,$51.00 ,Pays 102% Medicare OPPS,$288.00 ,90% of total billed charges,$112.00 ,35% based on GA Medicaid OP CCR Rate,$219.84 ,68.7% of total billed charges,$256.00 ,80 percent of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,Pays 90% Medicare OPPS,$185.60 ,58% of total billed charges,$65.18 ,20.37% based on GA Medicaid OP CCR Rate,$50.55 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$272.00 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,$288.00 ,$256.00 
Outpatient Medical Services,CARDIOLOGY,93270,EVENT MONITOR,731,$675.00 ,$573.75 ,85% of total billed charges,$33.45 ,Pays 100% Medicare OPPS,$33.45 ,Pays 100% Medicare OPPS,$33.45 ,Pays 100% Medicare OPPS,$40.02 ,Pays 130% Medicare OPPS,$137.50 ,20.37% based on GA Medicaid OP CCR Rate,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$381.38 ,56.5 percent of total billed charges,$34.11 ,Pays 102% Medicare OPPS,$607.50 ,90% of total billed charges,$236.25 ,35% based on GA Medicaid OP CCR Rate,$463.73 ,68.7% of total billed charges,$540.00 ,80 percent of total billed charges,$33.45 ,Pays 100% Medicare OPPS,$30.10 ,Pays 90% Medicare OPPS,$391.50 ,58% of total billed charges,$137.50 ,20.37% based on GA Medicaid OP CCR Rate,$30.78 ,Pays 100% Medicare OPPS,$40.02 ,Pays 130% Medicare OPPS,$573.75 ,85% of total billed charges,$33.45 ,Pays 100% Medicare OPPS,$30.10 ,$607.50 ,$540.00 
Outpatient Medical Services,CARDIOLOGY,93225,HOLTER HOOK-UP W/SCAN,731,$735.00 ,$624.75 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$415.28 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$661.50 ,90% of total billed charges,$257.25 ,35% based on GA Medicaid OP CCR Rate,$504.95 ,68.7% of total billed charges,$588.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$426.30 ,58% of total billed charges,$149.72 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$624.75 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,$661.50 ,$588.00 
Outpatient Medical Services,CARDIOLOGY,91010,ESOPHAGUS MOTILITY STUDY (MONOMETRY),750,"$1,970.00 ","$1,674.50 ",85% of total billed charges,$438.49 ,Pays 100% Medicare OPPS,$438.49 ,Pays 100% Medicare OPPS,$438.49 ,Pays 100% Medicare OPPS,$552.77 ,Pays 130% Medicare OPPS,$401.29 ,20.37% based on GA Medicaid OP CCR Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$862.48 ,100% of ASC Unlisted Rate,$986.63 ,100% of ASC Unlisted Rate,$447.26 ,Pays 102% Medicare OPPS,"$1,773.00 ",90% of total billed charges,$689.50 ,35% based on GA Medicaid OP CCR Rate,"$1,353.39 ",68.7% of total billed charges,"$1,576.00 ",80 percent of total billed charges,$438.49 ,Pays 100% Medicare OPPS,$394.64 ,Pays 90% Medicare OPPS,"$1,142.60 ",58% of total billed charges,$401.29 ,20.37% based on GA Medicaid OP CCR Rate,$425.21 ,Pays 100% Medicare OPPS,$552.77 ,Pays 130% Medicare OPPS,"$1,674.50 ",85% of total billed charges,$438.49 ,Pays 100% Medicare OPPS,$394.64 ,"$1,773.00 ","$1,576.00 "
Outpatient Medical Services,THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,$100.00 ,$85.00 ,85% of total billed charges,$13.65 ,Pays 100% Medicare OPPS,$13.65 ,Pays 100% Medicare OPPS,$13.65 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$13.92 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$35.00 ,35% based on GA Medicaid OP CCR Rate,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$13.65 ,Pays 100% Medicare OPPS,$12.29 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$13.72 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$13.65 ,Pays 100% Medicare OPPS,$12.29 ,$90.00 ,$80.00 
Outpatient Medical Services,THERAPY,97026,Light-based method to treat pain and inflammation,420,$100.00 ,$85.00 ,85% of total billed charges,$6.03 ,Pays 100% Medicare OPPS,$6.03 ,Pays 100% Medicare OPPS,$6.03 ,Pays 100% Medicare OPPS,$8.13 ,Pays 130% Medicare OPPS,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$6.15 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$35.00 ,35% based on GA Medicaid OP CCR Rate,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$6.03 ,Pays 100% Medicare OPPS,$5.43 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$6.25 ,Pays 100% Medicare OPPS,$8.13 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$6.03 ,Pays 100% Medicare OPPS,$5.43 ,$90.00 ,$80.00 
Outpatient Medical Services,THERAPY,97035,"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",420,$100.00 ,$85.00 ,85% of total billed charges,$13.65 ,Pays 100% Medicare OPPS,$13.65 ,Pays 100% Medicare OPPS,$13.65 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$13.92 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$35.00 ,35% based on GA Medicaid OP CCR Rate,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$13.65 ,Pays 100% Medicare OPPS,$12.29 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$13.72 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$13.65 ,Pays 100% Medicare OPPS,$12.29 ,$90.00 ,$80.00 
Outpatient Medical Services,THERAPY,97124,Use of massage,420,$100.00 ,$85.00 ,85% of total billed charges,$28.22 ,Pays 100% Medicare OPPS,$28.22 ,Pays 100% Medicare OPPS,$28.22 ,Pays 100% Medicare OPPS,$36.82 ,Pays 130% Medicare OPPS,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$56.50 ,56.5 percent of total billed charges,$28.78 ,Pays 102% Medicare OPPS,$90.00 ,90% of total billed charges,$35.00 ,35% based on GA Medicaid OP CCR Rate,$68.70 ,68.7% of total billed charges,$80.00 ,80 percent of total billed charges,$28.22 ,Pays 100% Medicare OPPS,$25.40 ,Pays 90% Medicare OPPS,$58.00 ,58% of total billed charges,$20.37 ,20.37% based on GA Medicaid OP CCR Rate,$28.32 ,Pays 100% Medicare OPPS,$36.82 ,Pays 130% Medicare OPPS,$85.00 ,85% of total billed charges,$28.22 ,Pays 100% Medicare OPPS,$20.37 ,$90.00 ,$80.00 
Outpatient Medical Services,THERAPY,97113,Use of water for therapy/exercises,420,$120.00 ,$102.00 ,85% of total billed charges,$35.16 ,Pays 100% Medicare OPPS,$35.16 ,Pays 100% Medicare OPPS,$35.16 ,Pays 100% Medicare OPPS,$45.27 ,Pays 130% Medicare OPPS,$24.44 ,20.37% based on GA Medicaid OP CCR Rate,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$35.86 ,Pays 102% Medicare OPPS,$108.00 ,90% of total billed charges,$42.00 ,35% based on GA Medicaid OP CCR Rate,$82.44 ,68.7% of total billed charges,$96.00 ,80 percent of total billed charges,$35.16 ,Pays 100% Medicare OPPS,$31.64 ,Pays 90% Medicare OPPS,$69.60 ,58% of total billed charges,$24.44 ,20.37% based on GA Medicaid OP CCR Rate,$34.82 ,Pays 100% Medicare OPPS,$45.27 ,Pays 130% Medicare OPPS,$102.00 ,85% of total billed charges,$35.16 ,Pays 100% Medicare OPPS,$24.44 ,$108.00 ,$96.00 
Outpatient Medical Services,THERAPY,97018,PT MOD-PARAFFIN BATH (PER SESSION),420,$120.00 ,$102.00 ,85% of total billed charges,$5.42 ,Pays 100% Medicare OPPS,$5.42 ,Pays 100% Medicare OPPS,$5.42 ,Pays 100% Medicare OPPS,$6.97 ,Pays 130% Medicare OPPS,$24.44 ,20.37% based on GA Medicaid OP CCR Rate,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$5.53 ,Pays 102% Medicare OPPS,$108.00 ,90% of total billed charges,$42.00 ,35% based on GA Medicaid OP CCR Rate,$82.44 ,68.7% of total billed charges,$96.00 ,80 percent of total billed charges,$5.42 ,Pays 100% Medicare OPPS,$4.88 ,Pays 90% Medicare OPPS,$69.60 ,58% of total billed charges,$24.44 ,20.37% based on GA Medicaid OP CCR Rate,$5.36 ,Pays 100% Medicare OPPS,$6.97 ,Pays 130% Medicare OPPS,$102.00 ,85% of total billed charges,$5.42 ,Pays 100% Medicare OPPS,$4.88 ,$108.00 ,$96.00 
Outpatient Medical Services,THERAPY,97113,Use of water for therapy/exercises,420,$120.00 ,$102.00 ,85% of total billed charges,$35.16 ,Pays 100% Medicare OPPS,$35.16 ,Pays 100% Medicare OPPS,$35.16 ,Pays 100% Medicare OPPS,$45.27 ,Pays 130% Medicare OPPS,$24.44 ,20.37% based on GA Medicaid OP CCR Rate,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$67.80 ,56.5 percent of total billed charges,$35.86 ,Pays 102% Medicare OPPS,$108.00 ,90% of total billed charges,$42.00 ,35% based on GA Medicaid OP CCR Rate,$82.44 ,68.7% of total billed charges,$96.00 ,80 percent of total billed charges,$35.16 ,Pays 100% Medicare OPPS,$31.64 ,Pays 90% Medicare OPPS,$69.60 ,58% of total billed charges,$24.44 ,20.37% based on GA Medicaid OP CCR Rate,$34.82 ,Pays 100% Medicare OPPS,$45.27 ,Pays 130% Medicare OPPS,$102.00 ,85% of total billed charges,$35.16 ,Pays 100% Medicare OPPS,$24.44 ,$108.00 ,$96.00 
Outpatient Medical Services,THERAPY,97012,Form of decompression therapy of the spine,420,$165.00 ,$140.25 ,85% of total billed charges,$13.82 ,Pays 100% Medicare OPPS,$13.82 ,Pays 100% Medicare OPPS,$13.82 ,Pays 100% Medicare OPPS,$18.06 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$14.10 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$13.82 ,Pays 100% Medicare OPPS,$12.44 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$13.89 ,Pays 100% Medicare OPPS,$18.06 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$13.82 ,Pays 100% Medicare OPPS,$12.44 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97014,One time use unattended,420,$165.00 ,$140.25 ,85% of total billed charges,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$148.50 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$33.61 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,420,$165.00 ,$140.25 ,85% of total billed charges,$18.72 ,Pays 100% Medicare OPPS,$18.72 ,Pays 100% Medicare OPPS,$18.72 ,Pays 100% Medicare OPPS,$24.31 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$19.09 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$18.72 ,Pays 100% Medicare OPPS,$16.85 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$18.70 ,Pays 100% Medicare OPPS,$24.31 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$18.72 ,Pays 100% Medicare OPPS,$16.85 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,G0283,PT UNATTEN ELECT STIMULA(PER SESSION),420,$165.00 ,$140.25 ,85% of total billed charges,$11.70 ,Pays 100% Medicare OPPS,$11.70 ,Pays 100% Medicare OPPS,$11.70 ,Pays 100% Medicare OPPS,$14.96 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$11.93 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$11.70 ,Pays 100% Medicare OPPS,$10.53 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$11.51 ,Pays 100% Medicare OPPS,$14.96 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$11.70 ,Pays 100% Medicare OPPS,$10.53 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,64550,PT TENS FITTING APPLIC (PER SESSION),420,$165.00 ,$140.25 ,85% of total billed charges,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$148.50 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$33.61 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,95851,PT ROM EXTREMITY NOT HAND,420,$165.00 ,$140.25 ,85% of total billed charges,$19.21 ,Pays 100% Medicare OPPS,$19.21 ,Pays 100% Medicare OPPS,$19.21 ,Pays 100% Medicare OPPS,$9.82 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$19.59 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$19.21 ,Pays 100% Medicare OPPS,$17.29 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$7.55 ,Pays 100% Medicare OPPS,$9.82 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$19.21 ,Pays 100% Medicare OPPS,$7.55 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97012,Form of decompression therapy of the spine,420,$165.00 ,$140.25 ,85% of total billed charges,$13.82 ,Pays 100% Medicare OPPS,$13.82 ,Pays 100% Medicare OPPS,$13.82 ,Pays 100% Medicare OPPS,$18.06 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$14.10 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$13.82 ,Pays 100% Medicare OPPS,$12.44 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$13.89 ,Pays 100% Medicare OPPS,$18.06 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$13.82 ,Pays 100% Medicare OPPS,$12.44 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97014,One time use unattended,420,$165.00 ,$140.25 ,85% of total billed charges,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,$41.25 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$148.50 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$33.61 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97016,"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",420,$165.00 ,$140.25 ,85% of total billed charges,$11.40 ,Pays 100% Medicare OPPS,$11.40 ,Pays 100% Medicare OPPS,$11.40 ,Pays 100% Medicare OPPS,$14.59 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$11.63 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$11.40 ,Pays 100% Medicare OPPS,$10.26 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$11.22 ,Pays 100% Medicare OPPS,$14.59 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$11.40 ,Pays 100% Medicare OPPS,$10.26 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97022,PT WHIRLPOOL (PER SESSION),420,$165.00 ,$140.25 ,85% of total billed charges,$16.22 ,Pays 100% Medicare OPPS,$16.22 ,Pays 100% Medicare OPPS,$16.22 ,Pays 100% Medicare OPPS,$20.74 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$16.54 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$16.22 ,Pays 100% Medicare OPPS,$14.60 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$15.95 ,Pays 100% Medicare OPPS,$20.74 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$16.22 ,Pays 100% Medicare OPPS,$14.60 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97032,Repeated application to one or more parts of the body,420,$165.00 ,$140.25 ,85% of total billed charges,$14.12 ,Pays 100% Medicare OPPS,$14.12 ,Pays 100% Medicare OPPS,$14.12 ,Pays 100% Medicare OPPS,$18.06 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$14.40 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$14.12 ,Pays 100% Medicare OPPS,$12.71 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$13.89 ,Pays 100% Medicare OPPS,$18.06 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$14.12 ,Pays 100% Medicare OPPS,$12.71 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97033,Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,420,$165.00 ,$140.25 ,85% of total billed charges,$18.72 ,Pays 100% Medicare OPPS,$18.72 ,Pays 100% Medicare OPPS,$18.72 ,Pays 100% Medicare OPPS,$24.31 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$19.09 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$18.72 ,Pays 100% Medicare OPPS,$16.85 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$18.70 ,Pays 100% Medicare OPPS,$24.31 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$18.72 ,Pays 100% Medicare OPPS,$16.85 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97034,PT CONTRAST BATH (PER 15 MINS),420,$165.00 ,$140.25 ,85% of total billed charges,$13.96 ,Pays 100% Medicare OPPS,$13.96 ,Pays 100% Medicare OPPS,$13.96 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$14.24 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$13.96 ,Pays 100% Medicare OPPS,$12.56 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$13.72 ,Pays 100% Medicare OPPS,$17.84 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$13.96 ,Pays 100% Medicare OPPS,$12.56 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97039,PT MECHAN MODALITY (PER 15 MINS),420,$165.00 ,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$33.61 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97150,PT GROUP THER PROC (PER SESSION),420,$165.00 ,$140.25 ,85% of total billed charges,$17.03 ,Pays 100% Medicare OPPS,$17.03 ,Pays 100% Medicare OPPS,$17.03 ,Pays 100% Medicare OPPS,$22.14 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$17.37 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$17.03 ,Pays 100% Medicare OPPS,$15.33 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$17.03 ,Pays 100% Medicare OPPS,$22.14 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$17.03 ,Pays 100% Medicare OPPS,$15.33 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97750,PT PHY PERFM TEST (PER 15 MINS),420,$165.00 ,$140.25 ,85% of total billed charges,$31.99 ,Pays 100% Medicare OPPS,$31.99 ,Pays 100% Medicare OPPS,$31.99 ,Pays 100% Medicare OPPS,$41.61 ,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$32.63 ,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,$31.99 ,Pays 100% Medicare OPPS,$28.79 ,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$32.01 ,Pays 100% Medicare OPPS,$41.61 ,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,$31.99 ,Pays 100% Medicare OPPS,$28.79 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97762,PT PROST/ORTHOT CK (PER 15 MINS),420,$165.00 ,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,$93.23 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$148.50 ,90% of total billed charges,$57.75 ,35% based on GA Medicaid OP CCR Rate,$113.36 ,68.7% of total billed charges,$132.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$95.70 ,58% of total billed charges,$33.61 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$140.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$33.61 ,$148.50 ,$132.00 
Outpatient Medical Services,THERAPY,97533,PT SENSORY INTEGRAT(PER 15 MINS),420,$170.00 ,$144.50 ,85% of total billed charges,$60.07 ,Pays 100% Medicare OPPS,$60.07 ,Pays 100% Medicare OPPS,$60.07 ,Pays 100% Medicare OPPS,$76.31 ,Pays 130% Medicare OPPS,$34.63 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$61.27 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$59.50 ,35% based on GA Medicaid OP CCR Rate,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$60.07 ,Pays 100% Medicare OPPS,$54.06 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$34.63 ,20.37% based on GA Medicaid OP CCR Rate,$58.70 ,Pays 100% Medicare OPPS,$76.31 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$60.07 ,Pays 100% Medicare OPPS,$34.63 ,$153.00 ,$136.00 
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,$175.00 ,$148.75 ,85% of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$32.81 ,Pays 100% Medicare OPPS,$32.81 ,Pays 100% Medicare OPPS,$41.87 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$33.47 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$61.25 ,35% based on GA Medicaid OP CCR Rate,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$29.53 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$32.21 ,Pays 100% Medicare OPPS,$41.87 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$29.53 ,$157.50 ,$140.00 
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,$175.00 ,$148.75 ,85% of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$28.35 ,Pays 100% Medicare OPPS,$28.35 ,Pays 100% Medicare OPPS,$36.57 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$28.92 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$61.25 ,35% based on GA Medicaid OP CCR Rate,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$25.52 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$28.13 ,Pays 100% Medicare OPPS,$36.57 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$25.52 ,$157.50 ,$140.00 
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,$175.00 ,$148.75 ,85% of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$32.81 ,Pays 100% Medicare OPPS,$32.81 ,Pays 100% Medicare OPPS,$41.87 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$33.47 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$61.25 ,35% based on GA Medicaid OP CCR Rate,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$29.53 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$32.21 ,Pays 100% Medicare OPPS,$41.87 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$29.53 ,$157.50 ,$140.00 
Outpatient Medical Services,THERAPY,97116,A type of physical therapy,420,$175.00 ,$148.75 ,85% of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$28.35 ,Pays 100% Medicare OPPS,$28.35 ,Pays 100% Medicare OPPS,$36.57 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$28.92 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$61.25 ,35% based on GA Medicaid OP CCR Rate,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$25.52 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$28.13 ,Pays 100% Medicare OPPS,$36.57 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$25.52 ,$157.50 ,$140.00 
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,$175.00 ,$148.75 ,85% of total billed charges,$26.14 ,Pays 100% Medicare OPPS,$26.14 ,Pays 100% Medicare OPPS,$26.14 ,Pays 100% Medicare OPPS,$33.75 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$26.66 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$61.25 ,35% based on GA Medicaid OP CCR Rate,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$26.14 ,Pays 100% Medicare OPPS,$23.53 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$25.96 ,Pays 100% Medicare OPPS,$33.75 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$26.14 ,Pays 100% Medicare OPPS,$23.53 ,$157.50 ,$140.00 
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,$175.00 ,$148.75 ,85% of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$32.81 ,Pays 100% Medicare OPPS,$32.81 ,Pays 100% Medicare OPPS,$41.87 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$33.47 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$61.25 ,35% based on GA Medicaid OP CCR Rate,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$29.53 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$32.21 ,Pays 100% Medicare OPPS,$41.87 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$29.53 ,$157.50 ,$140.00 
Outpatient Medical Services,THERAPY,97110,"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",420,$175.00 ,$148.75 ,85% of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$28.35 ,Pays 100% Medicare OPPS,$28.35 ,Pays 100% Medicare OPPS,$36.57 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$28.92 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$61.25 ,35% based on GA Medicaid OP CCR Rate,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$25.52 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$28.13 ,Pays 100% Medicare OPPS,$36.57 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$25.52 ,$157.50 ,$140.00 
Outpatient Medical Services,THERAPY,97112,A technique used by physical therapists to restore normal body movement patterns,420,$175.00 ,$148.75 ,85% of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$32.81 ,Pays 100% Medicare OPPS,$32.81 ,Pays 100% Medicare OPPS,$41.87 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$33.47 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$61.25 ,35% based on GA Medicaid OP CCR Rate,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$29.53 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$32.21 ,Pays 100% Medicare OPPS,$41.87 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$32.81 ,Pays 100% Medicare OPPS,$29.53 ,$157.50 ,$140.00 
Outpatient Medical Services,THERAPY,97116,A type of physical therapy,420,$175.00 ,$148.75 ,85% of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$28.35 ,Pays 100% Medicare OPPS,$28.35 ,Pays 100% Medicare OPPS,$36.57 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$28.92 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$61.25 ,35% based on GA Medicaid OP CCR Rate,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$25.52 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$28.13 ,Pays 100% Medicare OPPS,$36.57 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$28.35 ,Pays 100% Medicare OPPS,$25.52 ,$157.50 ,$140.00 
Outpatient Medical Services,THERAPY,97140,Manipulation of 1 or more regions of the body,420,$175.00 ,$148.75 ,85% of total billed charges,$26.14 ,Pays 100% Medicare OPPS,$26.14 ,Pays 100% Medicare OPPS,$26.14 ,Pays 100% Medicare OPPS,$33.75 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$26.66 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$61.25 ,35% based on GA Medicaid OP CCR Rate,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$26.14 ,Pays 100% Medicare OPPS,$23.53 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$25.96 ,Pays 100% Medicare OPPS,$33.75 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$26.14 ,Pays 100% Medicare OPPS,$23.53 ,$157.50 ,$140.00 
Outpatient Medical Services,THERAPY,97542,PT WHEELCHAIR MNGT TRAINI (PER 15 MINS),420,$175.00 ,$148.75 ,85% of total billed charges,$30.60 ,Pays 100% Medicare OPPS,$30.60 ,Pays 100% Medicare OPPS,$30.60 ,Pays 100% Medicare OPPS,$39.44 ,Pays 130% Medicare OPPS,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$98.88 ,56.5 percent of total billed charges,$31.21 ,Pays 102% Medicare OPPS,$157.50 ,90% of total billed charges,$61.25 ,35% based on GA Medicaid OP CCR Rate,$120.23 ,68.7% of total billed charges,$140.00 ,80 percent of total billed charges,$30.60 ,Pays 100% Medicare OPPS,$27.54 ,Pays 90% Medicare OPPS,$101.50 ,58% of total billed charges,$35.65 ,20.37% based on GA Medicaid OP CCR Rate,$30.34 ,Pays 100% Medicare OPPS,$39.44 ,Pays 130% Medicare OPPS,$148.75 ,85% of total billed charges,$30.60 ,Pays 100% Medicare OPPS,$27.54 ,$157.50 ,$140.00 
Outpatient Medical Services,THERAPY,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",420,$190.00 ,$161.50 ,85% of total billed charges,$35.29 ,Pays 100% Medicare OPPS,$35.29 ,Pays 100% Medicare OPPS,$35.29 ,Pays 100% Medicare OPPS,$45.44 ,Pays 130% Medicare OPPS,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$36.00 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$66.50 ,35% based on GA Medicaid OP CCR Rate,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$35.29 ,Pays 100% Medicare OPPS,$31.76 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$34.95 ,Pays 100% Medicare OPPS,$45.44 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$35.29 ,Pays 100% Medicare OPPS,$31.76 ,$171.00 ,$152.00 
Outpatient Medical Services,THERAPY,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",420,$190.00 ,$161.50 ,85% of total billed charges,$35.29 ,Pays 100% Medicare OPPS,$35.29 ,Pays 100% Medicare OPPS,$35.29 ,Pays 100% Medicare OPPS,$45.44 ,Pays 130% Medicare OPPS,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$36.00 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$66.50 ,35% based on GA Medicaid OP CCR Rate,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$35.29 ,Pays 100% Medicare OPPS,$31.76 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$34.95 ,Pays 100% Medicare OPPS,$45.44 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$35.29 ,Pays 100% Medicare OPPS,$31.76 ,$171.00 ,$152.00 
Outpatient Medical Services,THERAPY,97535,Occupational therapy,420,$190.00 ,$161.50 ,85% of total billed charges,$31.39 ,Pays 100% Medicare OPPS,$31.39 ,Pays 100% Medicare OPPS,$31.39 ,Pays 100% Medicare OPPS,$40.44 ,Pays 130% Medicare OPPS,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$32.02 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$66.50 ,35% based on GA Medicaid OP CCR Rate,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$31.39 ,Pays 100% Medicare OPPS,$28.25 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$31.11 ,Pays 100% Medicare OPPS,$40.44 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$31.39 ,Pays 100% Medicare OPPS,$28.25 ,$171.00 ,$152.00 
Outpatient Medical Services,THERAPY,97530,"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",420,$190.00 ,$161.50 ,85% of total billed charges,$35.29 ,Pays 100% Medicare OPPS,$35.29 ,Pays 100% Medicare OPPS,$35.29 ,Pays 100% Medicare OPPS,$45.44 ,Pays 130% Medicare OPPS,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$107.35 ,56.5 percent of total billed charges,$36.00 ,Pays 102% Medicare OPPS,$171.00 ,90% of total billed charges,$66.50 ,35% based on GA Medicaid OP CCR Rate,$130.53 ,68.7% of total billed charges,$152.00 ,80 percent of total billed charges,$35.29 ,Pays 100% Medicare OPPS,$31.76 ,Pays 90% Medicare OPPS,$110.20 ,58% of total billed charges,$38.70 ,20.37% based on GA Medicaid OP CCR Rate,$34.95 ,Pays 100% Medicare OPPS,$45.44 ,Pays 130% Medicare OPPS,$161.50 ,85% of total billed charges,$35.29 ,Pays 100% Medicare OPPS,$31.76 ,$171.00 ,$152.00 
Outpatient Medical Services,THERAPY,97761,PT PROSTHETIC TRAINING(PER 15 MINS),420,$195.00 ,$165.75 ,85% of total billed charges,$39.50 ,Pays 100% Medicare OPPS,$39.50 ,Pays 100% Medicare OPPS,$39.50 ,Pays 100% Medicare OPPS,$51.18 ,Pays 130% Medicare OPPS,$39.72 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$40.29 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$68.25 ,35% based on GA Medicaid OP CCR Rate,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$39.50 ,Pays 100% Medicare OPPS,$35.55 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$39.72 ,20.37% based on GA Medicaid OP CCR Rate,$39.37 ,Pays 100% Medicare OPPS,$51.18 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$39.50 ,Pays 100% Medicare OPPS,$35.55 ,$175.50 ,$156.00 
Outpatient Medical Services,THERAPY,97760,PT ORTHOTIC TRAINING (PER SESSION),420,$195.00 ,$165.75 ,85% of total billed charges,$45.88 ,Pays 100% Medicare OPPS,$45.88 ,Pays 100% Medicare OPPS,$45.88 ,Pays 100% Medicare OPPS,$58.96 ,Pays 130% Medicare OPPS,$39.72 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$46.80 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$68.25 ,35% based on GA Medicaid OP CCR Rate,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$45.88 ,Pays 100% Medicare OPPS,$41.29 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$39.72 ,20.37% based on GA Medicaid OP CCR Rate,$45.35 ,Pays 100% Medicare OPPS,$58.96 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$45.88 ,Pays 100% Medicare OPPS,$39.72 ,$175.50 ,$156.00 
Outpatient Medical Services,THERAPY,97761,PT PROSTHETIC TRAINING(PER 15 MINS),420,$195.00 ,$165.75 ,85% of total billed charges,$39.50 ,Pays 100% Medicare OPPS,$39.50 ,Pays 100% Medicare OPPS,$39.50 ,Pays 100% Medicare OPPS,$51.18 ,Pays 130% Medicare OPPS,$39.72 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$40.29 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$68.25 ,35% based on GA Medicaid OP CCR Rate,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$39.50 ,Pays 100% Medicare OPPS,$35.55 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$39.72 ,20.37% based on GA Medicaid OP CCR Rate,$39.37 ,Pays 100% Medicare OPPS,$51.18 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$39.50 ,Pays 100% Medicare OPPS,$35.55 ,$175.50 ,$156.00 
Outpatient Medical Services,THERAPY,97546,PT WORK HARDENING ADDON,420,$200.00 ,$170.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$40.74 ,20.37% based on GA Medicaid OP CCR Rate,$113.00 ,56.5 percent of total billed charges,$113.00 ,56.5 percent of total billed charges,$113.00 ,56.5 percent of total billed charges,$113.00 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$180.00 ,90% of total billed charges,$70.00 ,35% based on GA Medicaid OP CCR Rate,$137.40 ,68.7% of total billed charges,$160.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$116.00 ,58% of total billed charges,$40.74 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$170.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$40.74 ,$180.00 ,$160.00 
Outpatient Medical Services,THERAPY,95992,PT CANALITH REPOSITIONING PROCEDURE,420,$235.00 ,$199.75 ,85% of total billed charges,$42.09 ,Pays 100% Medicare OPPS,$42.09 ,Pays 100% Medicare OPPS,$42.09 ,Pays 100% Medicare OPPS,$45.70 ,Pays 130% Medicare OPPS,$47.87 ,20.37% based on GA Medicaid OP CCR Rate,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,$42.93 ,Pays 102% Medicare OPPS,$211.50 ,90% of total billed charges,$82.25 ,35% based on GA Medicaid OP CCR Rate,$161.45 ,68.7% of total billed charges,$188.00 ,80 percent of total billed charges,$42.09 ,Pays 100% Medicare OPPS,$37.88 ,Pays 90% Medicare OPPS,$136.30 ,58% of total billed charges,$47.87 ,20.37% based on GA Medicaid OP CCR Rate,$35.15 ,Pays 100% Medicare OPPS,$45.70 ,Pays 130% Medicare OPPS,$199.75 ,85% of total billed charges,$42.09 ,Pays 100% Medicare OPPS,$35.15 ,$211.50 ,$188.00 
Outpatient Medical Services,THERAPY,99211,Outpatient visit of established patient not requiring a physician,420,$335.00 ,$284.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$68.24 ,20.37% based on GA Medicaid OP CCR Rate,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,$189.28 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$301.50 ,90% of total billed charges,$117.25 ,35% based on GA Medicaid OP CCR Rate,$230.15 ,68.7% of total billed charges,$268.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$194.30 ,58% of total billed charges,$68.24 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$284.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$68.24 ,$301.50 ,$268.00 
Outpatient Medical Services,THERAPY,29580,PT UNNA BOOT APPLICATION (PER SESSION),420,$395.00 ,$335.75 ,85% of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$126.91 ,Pays 100% Medicare OPPS,$126.91 ,Pays 100% Medicare OPPS,$166.66 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$129.44 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$114.22 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$128.19 ,Pays 100% Medicare OPPS,$166.66 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,THERAPY,97545,PT WORK HARDENING 1 2HR,420,$400.00 ,$340.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$81.48 ,20.37% based on GA Medicaid OP CCR Rate,$226.00 ,56.5 percent of total billed charges,$226.00 ,56.5 percent of total billed charges,$226.00 ,56.5 percent of total billed charges,$226.00 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$360.00 ,90% of total billed charges,$140.00 ,35% based on GA Medicaid OP CCR Rate,$274.80 ,68.7% of total billed charges,$320.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$232.00 ,58% of total billed charges,$81.48 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$340.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$81.48 ,$360.00 ,$320.00 
Outpatient Medical Services,THERAPY,97598,PT WOUND CARE SEL GR 20SQCM (PER SESSION,420,$500.00 ,$425.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$101.85 ,20.37% based on GA Medicaid OP CCR Rate,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$450.00 ,90% of total billed charges,$175.00 ,35% based on GA Medicaid OP CCR Rate,$343.50 ,68.7% of total billed charges,$400.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$290.00 ,58% of total billed charges,$101.85 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$425.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$101.85 ,$450.00 ,$400.00 
Outpatient Medical Services,THERAPY,97597,"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",420,$585.00 ,$497.25 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$119.16 ,20.37% based on GA Medicaid OP CCR Rate,$330.53 ,56.5 percent of total billed charges,$330.53 ,56.5 percent of total billed charges,$330.53 ,56.5 percent of total billed charges,$330.53 ,56.5 percent of total billed charges,$164.53 ,Pays 102% Medicare OPPS,$526.50 ,90% of total billed charges,$204.75 ,35% based on GA Medicaid OP CCR Rate,$401.90 ,68.7% of total billed charges,$468.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$339.30 ,58% of total billed charges,$119.16 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$497.25 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$119.16 ,$526.50 ,$468.00 
Outpatient Medical Services,THERAPY,424,PT STUDENT-TEACHER CONFERENCE,424,$60.00 ,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,$33.90 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$54.00 ,90% of total billed charges,$21.00 ,35% based on GA Medicaid OP CCR Rate,$41.22 ,68.7% of total billed charges,$48.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$34.80 ,58% of total billed charges,$12.22 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$51.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$12.22 ,$54.00 ,$48.00 
Outpatient Medical Services,THERAPY,424,PT REGULAR VISIT,424,$145.00 ,$123.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$29.54 ,20.37% based on GA Medicaid OP CCR Rate,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,$81.93 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$130.50 ,90% of total billed charges,$50.75 ,35% based on GA Medicaid OP CCR Rate,$99.62 ,68.7% of total billed charges,$116.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$84.10 ,58% of total billed charges,$29.54 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$123.25 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$29.54 ,$130.50 ,$116.00 
Outpatient Medical Services,THERAPY,97002,PT RE EVALUATION (OLD CHARGE) OLD,424,$260.00 ,$221.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$52.96 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$91.00 ,35% based on GA Medicaid OP CCR Rate,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$52.96 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$52.96 ,$234.00 ,$208.00 
Outpatient Medical Services,THERAPY,97164,PT RE EVALUATION (PER SESSION),424,$260.00 ,$221.00 ,85% of total billed charges,$66.07 ,Pays 100% Medicare OPPS,$66.07 ,Pays 100% Medicare OPPS,$66.07 ,Pays 100% Medicare OPPS,$86.00 ,Pays 130% Medicare OPPS,$52.96 ,20.37% based on GA Medicaid OP CCR Rate,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$146.90 ,56.5 percent of total billed charges,$67.39 ,Pays 102% Medicare OPPS,$234.00 ,90% of total billed charges,$91.00 ,35% based on GA Medicaid OP CCR Rate,$178.62 ,68.7% of total billed charges,$208.00 ,80 percent of total billed charges,$66.07 ,Pays 100% Medicare OPPS,$59.46 ,Pays 90% Medicare OPPS,$150.80 ,58% of total billed charges,$52.96 ,20.37% based on GA Medicaid OP CCR Rate,$66.15 ,Pays 100% Medicare OPPS,$86.00 ,Pays 130% Medicare OPPS,$221.00 ,85% of total billed charges,$66.07 ,Pays 100% Medicare OPPS,$52.96 ,$234.00 ,$208.00 
Outpatient Medical Services,THERAPY,97001,PT MOD-EVALUATION (PER SESSION),424,$395.00 ,$335.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,THERAPY,97161,PT EVAL LOW COMPLEXITY,424,$395.00 ,$335.75 ,85% of total billed charges,$96.50 ,Pays 100% Medicare OPPS,$96.50 ,Pays 100% Medicare OPPS,$96.50 ,Pays 100% Medicare OPPS,$124.74 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$98.43 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$96.50 ,Pays 100% Medicare OPPS,$86.85 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$95.95 ,Pays 100% Medicare OPPS,$124.74 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$96.50 ,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,THERAPY,97162,PT EVAL MODERATE COMPLEXITY,424,$395.00 ,$335.75 ,85% of total billed charges,$96.50 ,Pays 100% Medicare OPPS,$96.50 ,Pays 100% Medicare OPPS,$96.50 ,Pays 100% Medicare OPPS,$124.74 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$98.43 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$96.50 ,Pays 100% Medicare OPPS,$86.85 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$95.95 ,Pays 100% Medicare OPPS,$124.74 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$96.50 ,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,THERAPY,97163,PT EVAL HIGH COMPLEXITY,424,$395.00 ,$335.75 ,85% of total billed charges,$96.50 ,Pays 100% Medicare OPPS,$96.50 ,Pays 100% Medicare OPPS,$96.50 ,Pays 100% Medicare OPPS,$124.74 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$98.43 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$96.50 ,Pays 100% Medicare OPPS,$86.85 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$95.95 ,Pays 100% Medicare OPPS,$124.74 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$96.50 ,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,EMERGENCY ROOM,31500,"INTUBATION, ENDOTRACHEAL EMERGENCY",450,"$2,600.00 ","$2,210.00 ",85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,$529.62 ,20.37% based on GA Medicaid OP CCR Rate,"$1,469.00 ",56.5 percent of total billed charges,"$1,469.00 ",56.5 percent of total billed charges,"$1,469.00 ",56.5 percent of total billed charges,"$1,469.00 ",56.5 percent of total billed charges,$193.85 ,Pays 102% Medicare OPPS,"$2,340.00 ",90% of total billed charges,$910.00 ,35% based on GA Medicaid OP CCR Rate,"$1,786.20 ",68.7% of total billed charges,"$2,080.00 ",80 percent of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$171.04 ,Pays 90% Medicare OPPS,"$1,508.00 ",58% of total billed charges,$529.62 ,20.37% based on GA Medicaid OP CCR Rate,$182.80 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,"$2,210.00 ",85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$171.04 ,"$2,340.00 ","$2,080.00 "
Outpatient Medical Services,EMERGENCY ROOM,51701,IN & OUT CATHETERIZATION,450,$410.00 ,$348.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$143.50 ,35% based on GA Medicaid OP CCR Rate,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$83.52 ,$369.00 ,$328.00 
Outpatient Medical Services,EMERGENCY ROOM,92960,CARDIOVERSION,450,"$1,100.00 ",$935.00 ,85% of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$504.64 ,Pays 100% Medicare OPPS,$504.64 ,Pays 100% Medicare OPPS,$672.51 ,Pays 130% Medicare OPPS,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$514.73 ,Pays 102% Medicare OPPS,$990.00 ,90% of total billed charges,$385.00 ,35% based on GA Medicaid OP CCR Rate,$755.70 ,68.7% of total billed charges,$880.00 ,80 percent of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$454.17 ,Pays 90% Medicare OPPS,$638.00 ,58% of total billed charges,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,$517.30 ,Pays 100% Medicare OPPS,$672.51 ,Pays 130% Medicare OPPS,$935.00 ,85% of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$224.07 ,$990.00 ,$880.00 
Outpatient Medical Services,EMERGENCY ROOM,96368,IV CONCURRENT INFUSION,450,$135.00 ,$114.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$47.25 ,35% based on GA Medicaid OP CCR Rate,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$27.50 ,$121.50 ,$108.00 
Outpatient Medical Services,EMERGENCY ROOM,10060,Incision and drainage of abscess; simple or single and complex or multiple,450,$490.00 ,$416.50 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$99.81 ,20.37% based on GA Medicaid OP CCR Rate,$276.85 ,56.5 percent of total billed charges,$276.85 ,56.5 percent of total billed charges,$276.85 ,56.5 percent of total billed charges,$276.85 ,56.5 percent of total billed charges,$164.53 ,Pays 102% Medicare OPPS,$441.00 ,90% of total billed charges,$171.50 ,35% based on GA Medicaid OP CCR Rate,$336.63 ,68.7% of total billed charges,$392.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$284.20 ,58% of total billed charges,$99.81 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$416.50 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$99.81 ,$441.00 ,$392.00 
Outpatient Medical Services,EMERGENCY ROOM,99284,"Emergency department visit, problem of high severity",450,"$4,100.00 ","$3,485.00 ",85% of total billed charges,$326.77 ,Pays 100% Medicare OPPS,$326.77 ,Pays 100% Medicare OPPS,$326.77 ,Pays 100% Medicare OPPS,$436.35 ,Pays 130% Medicare OPPS,$835.17 ,20.37% based on GA Medicaid OP CCR Rate,"$4,100.00 ",ER Level 4 Case Rate,"$4,100.00 ",ER Level 4 Case Rate,"$4,100.00 ",ER Level 4 Case Rate,"$4,100.00 ",ER Level 4 Case Rate,$333.31 ,Pays 102% Medicare OPPS,"$3,690.00 ",90% of total billed charges,"$1,435.00 ",35% based on GA Medicaid OP CCR Rate,"$2,816.70 ",68.7% of total billed charges,"$3,280.00 ",80 percent of total billed charges,$326.77 ,Pays 100% Medicare OPPS,$294.08 ,Pays 90% Medicare OPPS,"$2,378.00 ",58% of total billed charges,$835.17 ,20.37% based on GA Medicaid OP CCR Rate,$335.65 ,Pays 100% Medicare OPPS,$436.35 ,Pays 130% Medicare OPPS,"$3,485.00 ",85% of total billed charges,$326.77 ,Pays 100% Medicare OPPS,$294.08 ,"$4,100.00 ","$3,280.00 "
Outpatient Medical Services,EMERGENCY ROOM,99281,TRIAGE,450,$135.00 ,$114.75 ,85% of total billed charges,$65.16 ,Pays 100% Medicare OPPS,$65.16 ,Pays 100% Medicare OPPS,$65.16 ,Pays 100% Medicare OPPS,$85.85 ,Pays 130% Medicare OPPS,$50.00 ,20.37% based on GA Medicaid OP CCR Rate,$135.00 ,ER Level 1 Case Rate,$135.00 ,ER Level 1 Case Rate,$135.00 ,ER Level 1 Case Rate,$135.00 ,ER Level 1 Case Rate,$66.45 ,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$47.25 ,35% based on GA Medicaid OP CCR Rate,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,$65.16 ,Pays 100% Medicare OPPS,$58.64 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$66.04 ,Pays 100% Medicare OPPS,$85.85 ,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,$65.16 ,Pays 100% Medicare OPPS,$27.50 ,$135.00 ,$108.00 
Outpatient Medical Services,EMERGENCY ROOM,10140,"Incision and drainage of hematoma, seroma or fluid collection",450,$920.00 ,$782.00 ,85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$187.40 ,20.37% based on GA Medicaid OP CCR Rate,$519.80 ,56.5 percent of total billed charges,$519.80 ,56.5 percent of total billed charges,$519.80 ,56.5 percent of total billed charges,$519.80 ,56.5 percent of total billed charges,"$1,289.21 ",Pays 102% Medicare OPPS,$828.00 ,90% of total billed charges,$322.00 ,35% based on GA Medicaid OP CCR Rate,$632.04 ,68.7% of total billed charges,$736.00 ,80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,$533.60 ,58% of total billed charges,$187.40 ,20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$782.00 ,85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,$187.40 ,"$1,714.66 ",$736.00 
Outpatient Medical Services,EMERGENCY ROOM,99281,ER NON-URGENT EMC,450,$265.00 ,$225.25 ,85% of total billed charges,$65.16 ,Pays 100% Medicare OPPS,$65.16 ,Pays 100% Medicare OPPS,$65.16 ,Pays 100% Medicare OPPS,$85.85 ,Pays 130% Medicare OPPS,$50.00 ,20.37% based on GA Medicaid OP CCR Rate,$265.00 ,ER Level 1 Case Rate,$265.00 ,ER Level 1 Case Rate,$265.00 ,ER Level 1 Case Rate,$265.00 ,ER Level 1 Case Rate,$66.45 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$92.75 ,35% based on GA Medicaid OP CCR Rate,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$65.16 ,Pays 100% Medicare OPPS,$58.64 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$53.98 ,20.37% based on GA Medicaid OP CCR Rate,$66.04 ,Pays 100% Medicare OPPS,$85.85 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$65.16 ,Pays 100% Medicare OPPS,$50.00 ,$265.00 ,$212.00 
Outpatient Medical Services,EMERGENCY ROOM,10021,Fine Needle Aspiration Biopsy without imaging,450,"$1,290.00 ","$1,096.50 ",85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$262.77 ,20.37% based on GA Medicaid OP CCR Rate,$728.85 ,56.5 percent of total billed charges,$728.85 ,56.5 percent of total billed charges,$728.85 ,56.5 percent of total billed charges,$728.85 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,"$1,161.00 ",90% of total billed charges,$451.50 ,35% based on GA Medicaid OP CCR Rate,$886.23 ,68.7% of total billed charges,"$1,032.00 ",80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$748.20 ,58% of total billed charges,$262.77 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,"$1,096.50 ",85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$262.77 ,"$1,161.00 ","$1,032.00 "
Outpatient Medical Services,EMERGENCY ROOM,10060,Incision and drainage of abscess; simple or single and complex or multiple,450,$695.00 ,$590.75 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$141.57 ,20.37% based on GA Medicaid OP CCR Rate,$392.68 ,56.5 percent of total billed charges,$392.68 ,56.5 percent of total billed charges,$392.68 ,56.5 percent of total billed charges,$392.68 ,56.5 percent of total billed charges,$164.53 ,Pays 102% Medicare OPPS,$625.50 ,90% of total billed charges,$243.25 ,35% based on GA Medicaid OP CCR Rate,$477.47 ,68.7% of total billed charges,$556.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$403.10 ,58% of total billed charges,$141.57 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$590.75 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$141.57 ,$625.50 ,$556.00 
Outpatient Medical Services,EMERGENCY ROOM,10140,"Incision and drainage of hematoma, seroma or fluid collection",450,"$2,760.00 ","$2,346.00 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$562.21 ,20.37% based on GA Medicaid OP CCR Rate,"$1,559.40 ",56.5 percent of total billed charges,"$1,559.40 ",56.5 percent of total billed charges,"$1,559.40 ",56.5 percent of total billed charges,"$1,559.40 ",56.5 percent of total billed charges,"$1,289.21 ",Pays 102% Medicare OPPS,"$2,484.00 ",90% of total billed charges,$966.00 ,35% based on GA Medicaid OP CCR Rate,"$1,896.12 ",68.7% of total billed charges,"$2,208.00 ",80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,"$1,600.80 ",58% of total billed charges,$562.21 ,20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$2,346.00 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,$562.21 ,"$2,484.00 ","$2,208.00 "
Outpatient Medical Services,EMERGENCY ROOM,10160,"Puncture aspiration of abscess, hematoma, bulla, or cyst",450,$500.00 ,$425.00 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$101.85 ,20.37% based on GA Medicaid OP CCR Rate,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$282.50 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$450.00 ,90% of total billed charges,$175.00 ,35% based on GA Medicaid OP CCR Rate,$343.50 ,68.7% of total billed charges,$400.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$290.00 ,58% of total billed charges,$101.85 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$425.00 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$101.85 ,$450.00 ,$400.00 
Outpatient Medical Services,EMERGENCY ROOM,11042,DEBRID SKIN PRTL SUBCUTAN,450,$920.00 ,$782.00 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$187.40 ,20.37% based on GA Medicaid OP CCR Rate,$519.80 ,56.5 percent of total billed charges,$519.80 ,56.5 percent of total billed charges,$519.80 ,56.5 percent of total billed charges,$519.80 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$828.00 ,90% of total billed charges,$322.00 ,35% based on GA Medicaid OP CCR Rate,$632.04 ,68.7% of total billed charges,$736.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$533.60 ,58% of total billed charges,$187.40 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$782.00 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$187.40 ,$828.00 ,$736.00 
Outpatient Medical Services,EMERGENCY ROOM,11305,SHAVING OF EPIDERMAL/DERMAL LESION,450,$440.00 ,$374.00 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$89.63 ,20.37% based on GA Medicaid OP CCR Rate,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,$248.60 ,56.5 percent of total billed charges,$164.54 ,Pays 102% Medicare OPPS,$396.00 ,90% of total billed charges,$154.00 ,35% based on GA Medicaid OP CCR Rate,$302.28 ,68.7% of total billed charges,$352.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$255.20 ,58% of total billed charges,$89.63 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$374.00 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$89.63 ,$396.00 ,$352.00 
Outpatient Medical Services,EMERGENCY ROOM,11420,EXCISION BENIGN LESION .5CM OR LESS,450,"$3,315.00 ","$2,817.75 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$675.27 ,20.37% based on GA Medicaid OP CCR Rate,"$1,872.98 ",56.5 percent of total billed charges,"$1,872.98 ",56.5 percent of total billed charges,"$1,872.98 ",56.5 percent of total billed charges,"$1,872.98 ",56.5 percent of total billed charges,"$1,289.21 ",Pays 102% Medicare OPPS,"$2,983.50 ",90% of total billed charges,"$1,160.25 ",35% based on GA Medicaid OP CCR Rate,"$2,277.41 ",68.7% of total billed charges,"$2,652.00 ",80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,"$1,922.70 ",58% of total billed charges,$675.27 ,20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$2,817.75 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,$675.27 ,"$2,983.50 ","$2,652.00 "
Outpatient Medical Services,EMERGENCY ROOM,11730,Separation and removal of the entire nail plate or a portion of nail plate,450,$625.00 ,$531.25 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$127.31 ,20.37% based on GA Medicaid OP CCR Rate,$353.13 ,56.5 percent of total billed charges,$353.13 ,56.5 percent of total billed charges,$353.13 ,56.5 percent of total billed charges,$353.13 ,56.5 percent of total billed charges,$164.54 ,Pays 102% Medicare OPPS,$562.50 ,90% of total billed charges,$218.75 ,35% based on GA Medicaid OP CCR Rate,$429.38 ,68.7% of total billed charges,$500.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$362.50 ,58% of total billed charges,$127.31 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$531.25 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$127.31 ,$562.50 ,$500.00 
Outpatient Medical Services,EMERGENCY ROOM,11740,NAIL DECOMPRESSION,450,$245.00 ,$208.25 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$49.91 ,20.37% based on GA Medicaid OP CCR Rate,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$220.50 ,90% of total billed charges,$85.75 ,35% based on GA Medicaid OP CCR Rate,$168.32 ,68.7% of total billed charges,$196.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$142.10 ,58% of total billed charges,$49.91 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$208.25 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$49.91 ,$220.50 ,$196.00 
Outpatient Medical Services,EMERGENCY ROOM,11750,NAIL REMOVAL,450,$995.00 ,$845.75 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$202.68 ,20.37% based on GA Medicaid OP CCR Rate,$562.18 ,56.5 percent of total billed charges,$562.18 ,56.5 percent of total billed charges,$562.18 ,56.5 percent of total billed charges,$562.18 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$895.50 ,90% of total billed charges,$348.25 ,35% based on GA Medicaid OP CCR Rate,$683.57 ,68.7% of total billed charges,$796.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$577.10 ,58% of total billed charges,$202.68 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$845.75 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$202.68 ,$895.50 ,$796.00 
Outpatient Medical Services,EMERGENCY ROOM,11765,REMOVAL OF INGROWN TOENAIL,450,$710.00 ,$603.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$639.00 ,90% of total billed charges,$248.50 ,35% based on GA Medicaid OP CCR Rate,$487.77 ,68.7% of total billed charges,$568.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$411.80 ,58% of total billed charges,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$603.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$144.63 ,$639.00 ,$568.00 
Outpatient Medical Services,EMERGENCY ROOM,12001,"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",450,$595.00 ,$505.75 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$121.20 ,20.37% based on GA Medicaid OP CCR Rate,$336.18 ,56.5 percent of total billed charges,$336.18 ,56.5 percent of total billed charges,$336.18 ,56.5 percent of total billed charges,$336.18 ,56.5 percent of total billed charges,$164.54 ,Pays 102% Medicare OPPS,$535.50 ,90% of total billed charges,$208.25 ,35% based on GA Medicaid OP CCR Rate,$408.77 ,68.7% of total billed charges,$476.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$345.10 ,58% of total billed charges,$121.20 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$505.75 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$121.20 ,$535.50 ,$476.00 
Outpatient Medical Services,EMERGENCY ROOM,12005,LAC SIMPLE 12.6-20.0CM,450,$790.00 ,$671.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$160.92 ,20.37% based on GA Medicaid OP CCR Rate,$446.35 ,56.5 percent of total billed charges,$446.35 ,56.5 percent of total billed charges,$446.35 ,56.5 percent of total billed charges,$446.35 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$711.00 ,90% of total billed charges,$276.50 ,35% based on GA Medicaid OP CCR Rate,$542.73 ,68.7% of total billed charges,$632.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$458.20 ,58% of total billed charges,$160.92 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$671.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$160.92 ,$711.00 ,$632.00 
Outpatient Medical Services,EMERGENCY ROOM,12006,LAC SIMPLE 20.1-30CM,450,$990.00 ,$841.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$201.66 ,20.37% based on GA Medicaid OP CCR Rate,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$891.00 ,90% of total billed charges,$346.50 ,35% based on GA Medicaid OP CCR Rate,$680.13 ,68.7% of total billed charges,$792.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$574.20 ,58% of total billed charges,$201.66 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$841.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$201.66 ,$891.00 ,$792.00 
Outpatient Medical Services,EMERGENCY ROOM,12007,LAC SIMPLE >30 CM,450,$920.00 ,$782.00 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$187.40 ,20.37% based on GA Medicaid OP CCR Rate,$519.80 ,56.5 percent of total billed charges,$519.80 ,56.5 percent of total billed charges,$519.80 ,56.5 percent of total billed charges,$519.80 ,56.5 percent of total billed charges,$164.53 ,Pays 102% Medicare OPPS,$828.00 ,90% of total billed charges,$322.00 ,35% based on GA Medicaid OP CCR Rate,$632.04 ,68.7% of total billed charges,$736.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$533.60 ,58% of total billed charges,$187.40 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$782.00 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,$828.00 ,$736.00 
Outpatient Medical Services,EMERGENCY ROOM,12014,FACIAL LAC SIMPLE 5.1-7.5,450,$635.00 ,$539.75 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$129.35 ,20.37% based on GA Medicaid OP CCR Rate,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$358.78 ,56.5 percent of total billed charges,$164.54 ,Pays 102% Medicare OPPS,$571.50 ,90% of total billed charges,$222.25 ,35% based on GA Medicaid OP CCR Rate,$436.25 ,68.7% of total billed charges,$508.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$368.30 ,58% of total billed charges,$129.35 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$539.75 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$129.35 ,$571.50 ,$508.00 
Outpatient Medical Services,EMERGENCY ROOM,12015,FACIAL LAC SIMPLE 7.6-12.5,450,$700.00 ,$595.00 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$142.59 ,20.37% based on GA Medicaid OP CCR Rate,$395.50 ,56.5 percent of total billed charges,$395.50 ,56.5 percent of total billed charges,$395.50 ,56.5 percent of total billed charges,$395.50 ,56.5 percent of total billed charges,$164.54 ,Pays 102% Medicare OPPS,$630.00 ,90% of total billed charges,$245.00 ,35% based on GA Medicaid OP CCR Rate,$480.90 ,68.7% of total billed charges,$560.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$406.00 ,58% of total billed charges,$142.59 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$595.00 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$142.59 ,$630.00 ,$560.00 
Outpatient Medical Services,EMERGENCY ROOM,12016,LAC REPAIR SIMPLE 12.6 CM TO 20.0 CM,450,$965.00 ,$820.25 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$196.57 ,20.37% based on GA Medicaid OP CCR Rate,$545.23 ,56.5 percent of total billed charges,$545.23 ,56.5 percent of total billed charges,$545.23 ,56.5 percent of total billed charges,$545.23 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$868.50 ,90% of total billed charges,$337.75 ,35% based on GA Medicaid OP CCR Rate,$662.96 ,68.7% of total billed charges,$772.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$559.70 ,58% of total billed charges,$196.57 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$820.25 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$196.57 ,$868.50 ,$772.00 
Outpatient Medical Services,EMERGENCY ROOM,12031,LAC INTRM < 2.5 CM,450,$550.00 ,$467.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$112.04 ,20.37% based on GA Medicaid OP CCR Rate,$310.75 ,56.5 percent of total billed charges,$310.75 ,56.5 percent of total billed charges,$310.75 ,56.5 percent of total billed charges,$310.75 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$495.00 ,90% of total billed charges,$192.50 ,35% based on GA Medicaid OP CCR Rate,$377.85 ,68.7% of total billed charges,$440.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$319.00 ,58% of total billed charges,$112.04 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$467.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$112.04 ,$495.00 ,$440.00 
Outpatient Medical Services,EMERGENCY ROOM,12036,LAC INTER 20.1 CM - 30.0 CM,450,$965.00 ,$820.25 ,85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,$196.57 ,20.37% based on GA Medicaid OP CCR Rate,$545.23 ,56.5 percent of total billed charges,$545.23 ,56.5 percent of total billed charges,$545.23 ,56.5 percent of total billed charges,$545.23 ,56.5 percent of total billed charges,$479.88 ,Pays 102% Medicare OPPS,$868.50 ,90% of total billed charges,$337.75 ,35% based on GA Medicaid OP CCR Rate,$662.96 ,68.7% of total billed charges,$772.00 ,80 percent of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$423.42 ,Pays 90% Medicare OPPS,$559.70 ,58% of total billed charges,$196.57 ,20.37% based on GA Medicaid OP CCR Rate,$510.99 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,$820.25 ,85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$196.57 ,$868.50 ,$772.00 
Outpatient Medical Services,EMERGENCY ROOM,12041,LAC INTRM HAND/FEET <2.5 OR LESS,450,$610.00 ,$518.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$124.26 ,20.37% based on GA Medicaid OP CCR Rate,$344.65 ,56.5 percent of total billed charges,$344.65 ,56.5 percent of total billed charges,$344.65 ,56.5 percent of total billed charges,$344.65 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$549.00 ,90% of total billed charges,$213.50 ,35% based on GA Medicaid OP CCR Rate,$419.07 ,68.7% of total billed charges,$488.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$353.80 ,58% of total billed charges,$124.26 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$518.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$124.26 ,$549.00 ,$488.00 
Outpatient Medical Services,EMERGENCY ROOM,12051,FACIAL LAC INTRM <2.5CM,450,$660.00 ,$561.00 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$231.00 ,35% based on GA Medicaid OP CCR Rate,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$134.44 ,$594.00 ,$528.00 
Outpatient Medical Services,EMERGENCY ROOM,12052,FACIAL LAC INTRM 2.6 - 5.0CM,450,$710.00 ,$603.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$639.00 ,90% of total billed charges,$248.50 ,35% based on GA Medicaid OP CCR Rate,$487.77 ,68.7% of total billed charges,$568.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$411.80 ,58% of total billed charges,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$603.50 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$144.63 ,$639.00 ,$568.00 
Outpatient Medical Services,EMERGENCY ROOM,12054,ITMD WOUND REPAIR FACE 7.6-12.5CM,450,$865.00 ,$735.25 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$176.20 ,20.37% based on GA Medicaid OP CCR Rate,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$778.50 ,90% of total billed charges,$302.75 ,35% based on GA Medicaid OP CCR Rate,$594.26 ,68.7% of total billed charges,$692.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$501.70 ,58% of total billed charges,$176.20 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$735.25 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$176.20 ,$778.50 ,$692.00 
Outpatient Medical Services,EMERGENCY ROOM,13101,C REP TRUNK 2.6-7.5 CM,450,"$3,315.00 ","$2,817.75 ",85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,$675.27 ,20.37% based on GA Medicaid OP CCR Rate,"$1,872.98 ",56.5 percent of total billed charges,"$1,872.98 ",56.5 percent of total billed charges,"$1,872.98 ",56.5 percent of total billed charges,"$1,872.98 ",56.5 percent of total billed charges,$479.88 ,Pays 102% Medicare OPPS,"$2,983.50 ",90% of total billed charges,"$1,160.25 ",35% based on GA Medicaid OP CCR Rate,"$2,277.41 ",68.7% of total billed charges,"$2,652.00 ",80 percent of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$423.42 ,Pays 90% Medicare OPPS,"$1,922.70 ",58% of total billed charges,$675.27 ,20.37% based on GA Medicaid OP CCR Rate,$510.99 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,"$2,817.75 ",85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$423.42 ,"$2,983.50 ","$2,652.00 "
Outpatient Medical Services,EMERGENCY ROOM,13102,C REP TRUNK EA ADTL 5CM,450,$420.00 ,$357.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$85.55 ,$378.00 ,$336.00 
Outpatient Medical Services,EMERGENCY ROOM,13121,LAC RPR CMPLX 2.6-7.5 CM,450,$865.00 ,$735.25 ,85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,$176.20 ,20.37% based on GA Medicaid OP CCR Rate,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$488.73 ,56.5 percent of total billed charges,$479.88 ,Pays 102% Medicare OPPS,$778.50 ,90% of total billed charges,$302.75 ,35% based on GA Medicaid OP CCR Rate,$594.26 ,68.7% of total billed charges,$692.00 ,80 percent of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$423.42 ,Pays 90% Medicare OPPS,$501.70 ,58% of total billed charges,$176.20 ,20.37% based on GA Medicaid OP CCR Rate,$510.99 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,$735.25 ,85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$176.20 ,$778.50 ,$692.00 
Outpatient Medical Services,EMERGENCY ROOM,13122,LAC CMPLX EA ADDTL 5 CMS,450,$790.00 ,$671.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$160.92 ,20.37% based on GA Medicaid OP CCR Rate,$446.35 ,56.5 percent of total billed charges,$446.35 ,56.5 percent of total billed charges,$446.35 ,56.5 percent of total billed charges,$446.35 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$711.00 ,90% of total billed charges,$276.50 ,35% based on GA Medicaid OP CCR Rate,$542.73 ,68.7% of total billed charges,$632.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$458.20 ,58% of total billed charges,$160.92 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$671.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$160.92 ,$711.00 ,$632.00 
Outpatient Medical Services,EMERGENCY ROOM,13133,CREP H/A/5 CM OR LESS,450,$660.00 ,$561.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,$372.90 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$594.00 ,90% of total billed charges,$231.00 ,35% based on GA Medicaid OP CCR Rate,$453.42 ,68.7% of total billed charges,$528.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$382.80 ,58% of total billed charges,$134.44 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$561.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$134.44 ,$594.00 ,$528.00 
Outpatient Medical Services,EMERGENCY ROOM,13151,REPAIR COMPLEX E/N/E/L 1.1-2.5 CM,450,"$1,990.00 ","$1,691.50 ",85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,$405.36 ,20.37% based on GA Medicaid OP CCR Rate,"$1,124.35 ",56.5 percent of total billed charges,"$1,124.35 ",56.5 percent of total billed charges,"$1,124.35 ",56.5 percent of total billed charges,"$1,124.35 ",56.5 percent of total billed charges,$479.88 ,Pays 102% Medicare OPPS,"$1,791.00 ",90% of total billed charges,$696.50 ,35% based on GA Medicaid OP CCR Rate,"$1,367.13 ",68.7% of total billed charges,"$1,592.00 ",80 percent of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$423.42 ,Pays 90% Medicare OPPS,"$1,154.20 ",58% of total billed charges,$405.36 ,20.37% based on GA Medicaid OP CCR Rate,$510.99 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,"$1,691.50 ",85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$405.36 ,"$1,791.00 ","$1,592.00 "
Outpatient Medical Services,EMERGENCY ROOM,13152,REPAIR COMPLEX 2.6CM-7.5CM,450,"$1,990.00 ","$1,691.50 ",85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$470.47 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,$405.36 ,20.37% based on GA Medicaid OP CCR Rate,"$1,124.35 ",56.5 percent of total billed charges,"$1,124.35 ",56.5 percent of total billed charges,"$1,124.35 ",56.5 percent of total billed charges,"$1,124.35 ",56.5 percent of total billed charges,$479.88 ,Pays 102% Medicare OPPS,"$1,791.00 ",90% of total billed charges,$696.50 ,35% based on GA Medicaid OP CCR Rate,"$1,367.13 ",68.7% of total billed charges,"$1,592.00 ",80 percent of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$423.42 ,Pays 90% Medicare OPPS,"$1,154.20 ",58% of total billed charges,$405.36 ,20.37% based on GA Medicaid OP CCR Rate,$510.99 ,Pays 100% Medicare OPPS,$664.28 ,Pays 130% Medicare OPPS,"$1,691.50 ",85% of total billed charges,$470.47 ,Pays 100% Medicare OPPS,$405.36 ,"$1,791.00 ","$1,592.00 "
Outpatient Medical Services,EMERGENCY ROOM,16000,BURNS 1 DEGREE LOCAL TX,450,$435.00 ,$369.75 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$164.54 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$88.61 ,$391.50 ,$348.00 
Outpatient Medical Services,EMERGENCY ROOM,16020,BURN SMALL DSG/DEBRIDMENT,450,$460.00 ,$391.00 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$93.70 ,20.37% based on GA Medicaid OP CCR Rate,$259.90 ,56.5 percent of total billed charges,$259.90 ,56.5 percent of total billed charges,$259.90 ,56.5 percent of total billed charges,$259.90 ,56.5 percent of total billed charges,$164.54 ,Pays 102% Medicare OPPS,$414.00 ,90% of total billed charges,$161.00 ,35% based on GA Medicaid OP CCR Rate,$316.02 ,68.7% of total billed charges,$368.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$266.80 ,58% of total billed charges,$93.70 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$391.00 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$93.70 ,$414.00 ,$368.00 
Outpatient Medical Services,EMERGENCY ROOM,16025,BURN MED FACE/1 EXTREM,450,$490.00 ,$416.50 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$99.81 ,20.37% based on GA Medicaid OP CCR Rate,$276.85 ,56.5 percent of total billed charges,$276.85 ,56.5 percent of total billed charges,$276.85 ,56.5 percent of total billed charges,$276.85 ,56.5 percent of total billed charges,$164.53 ,Pays 102% Medicare OPPS,$441.00 ,90% of total billed charges,$171.50 ,35% based on GA Medicaid OP CCR Rate,$336.63 ,68.7% of total billed charges,$392.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$284.20 ,58% of total billed charges,$99.81 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$416.50 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$99.81 ,$441.00 ,$392.00 
Outpatient Medical Services,EMERGENCY ROOM,16030,BURN LARGE >1 EXTREMETY,450,$525.00 ,$446.25 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$310.49 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$106.94 ,20.37% based on GA Medicaid OP CCR Rate,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$296.63 ,56.5 percent of total billed charges,$316.70 ,Pays 102% Medicare OPPS,$472.50 ,90% of total billed charges,$183.75 ,35% based on GA Medicaid OP CCR Rate,$360.68 ,68.7% of total billed charges,$420.00 ,80 percent of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$279.44 ,Pays 90% Medicare OPPS,$304.50 ,58% of total billed charges,$106.94 ,20.37% based on GA Medicaid OP CCR Rate,$328.14 ,Pays 100% Medicare OPPS,$426.58 ,Pays 130% Medicare OPPS,$446.25 ,85% of total billed charges,$310.49 ,Pays 100% Medicare OPPS,$106.94 ,$472.50 ,$420.00 
Outpatient Medical Services,EMERGENCY ROOM,20103,EXPLORATION WOUND EXTREMITY,450,$450.00 ,$382.50 ,85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$91.67 ,20.37% based on GA Medicaid OP CCR Rate,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$254.25 ,56.5 percent of total billed charges,$570.17 ,Pays 102% Medicare OPPS,$405.00 ,90% of total billed charges,$157.50 ,35% based on GA Medicaid OP CCR Rate,$309.15 ,68.7% of total billed charges,$360.00 ,80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,$261.00 ,58% of total billed charges,$91.67 ,20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$382.50 ,85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$91.67 ,"$1,714.66 ",$360.00 
Outpatient Medical Services,EMERGENCY ROOM,20520,FB REMOVAL MUSCLE,450,$995.00 ,$845.75 ,85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$202.68 ,20.37% based on GA Medicaid OP CCR Rate,$562.18 ,56.5 percent of total billed charges,$562.18 ,56.5 percent of total billed charges,$562.18 ,56.5 percent of total billed charges,$562.18 ,56.5 percent of total billed charges,"$1,289.21 ",Pays 102% Medicare OPPS,$895.50 ,90% of total billed charges,$348.25 ,35% based on GA Medicaid OP CCR Rate,$683.57 ,68.7% of total billed charges,$796.00 ,80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,$577.10 ,58% of total billed charges,$202.68 ,20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$845.75 ,85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,$202.68 ,"$1,714.66 ",$796.00 
Outpatient Medical Services,EMERGENCY ROOM,20600,Draining or injecting medication into a small joint/bursa without ultrasound,450,$620.00 ,$527.00 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$126.29 ,20.37% based on GA Medicaid OP CCR Rate,$350.30 ,56.5 percent of total billed charges,$350.30 ,56.5 percent of total billed charges,$350.30 ,56.5 percent of total billed charges,$350.30 ,56.5 percent of total billed charges,$239.38 ,Pays 102% Medicare OPPS,$558.00 ,90% of total billed charges,$217.00 ,35% based on GA Medicaid OP CCR Rate,$425.94 ,68.7% of total billed charges,$496.00 ,80 percent of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$211.22 ,Pays 90% Medicare OPPS,$359.60 ,58% of total billed charges,$126.29 ,20.37% based on GA Medicaid OP CCR Rate,$239.14 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$527.00 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$126.29 ,$558.00 ,$496.00 
Outpatient Medical Services,EMERGENCY ROOM,20610,Draining or injecting medication into a major joint/bursa without ultrasound,450,$785.00 ,$667.25 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$239.38 ,Pays 102% Medicare OPPS,$706.50 ,90% of total billed charges,$274.75 ,35% based on GA Medicaid OP CCR Rate,$539.30 ,68.7% of total billed charges,$628.00 ,80 percent of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$211.22 ,Pays 90% Medicare OPPS,$455.30 ,58% of total billed charges,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$239.14 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$667.25 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$159.90 ,$706.50 ,$628.00 
Outpatient Medical Services,EMERGENCY ROOM,21310,FX NOSE CLOSED,450,$235.00 ,$199.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$47.87 ,20.37% based on GA Medicaid OP CCR Rate,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$211.50 ,90% of total billed charges,$82.25 ,35% based on GA Medicaid OP CCR Rate,$161.45 ,68.7% of total billed charges,$188.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,N/A,Pays 90% Medicare OPPS,$136.30 ,58% of total billed charges,$47.87 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$199.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$47.87 ,$211.50 ,$188.00 
Outpatient Medical Services,EMERGENCY ROOM,21337,CL TX NASAL SEPTAL FX,450,"$5,375.00 ","$4,568.75 ",85% of total billed charges,"$2,457.53 ",Pays 100% Medicare OPPS,"$2,457.53 ",Pays 100% Medicare OPPS,"$2,457.53 ",Pays 100% Medicare OPPS,"$3,253.15 ",Pays 130% Medicare OPPS,"$1,094.89 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,506.67 ",Pays 102% Medicare OPPS,"$4,837.50 ",90% of total billed charges,"$1,881.25 ",35% based on GA Medicaid OP CCR Rate,"$3,692.63 ",68.7% of total billed charges,"$4,300.00 ",80 percent of total billed charges,"$2,457.53 ",Pays 100% Medicare OPPS,"$2,211.77 ",Pays 90% Medicare OPPS,"$3,117.50 ",58% of total billed charges,"$1,094.89 ",20.37% based on GA Medicaid OP CCR Rate,"$2,502.42 ",Pays 100% Medicare OPPS,"$3,253.15 ",Pays 130% Medicare OPPS,"$4,568.75 ",85% of total billed charges,"$2,457.53 ",Pays 100% Medicare OPPS,"$1,094.89 ","$4,837.50 ","$4,300.00 "
Outpatient Medical Services,EMERGENCY ROOM,21480,DISLOC JAW TX,450,$640.00 ,$544.00 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$130.37 ,20.37% based on GA Medicaid OP CCR Rate,$361.60 ,56.5 percent of total billed charges,$361.60 ,56.5 percent of total billed charges,$361.60 ,56.5 percent of total billed charges,$361.60 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$576.00 ,90% of total billed charges,$224.00 ,35% based on GA Medicaid OP CCR Rate,$439.68 ,68.7% of total billed charges,$512.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$371.20 ,58% of total billed charges,$130.37 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$544.00 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$130.37 ,$576.00 ,$512.00 
Outpatient Medical Services,EMERGENCY ROOM,23545,CLOSE TREATMENT SHOULDER DISL W MANIPULA,450,$685.00 ,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$616.50 ,90% of total billed charges,$239.75 ,35% based on GA Medicaid OP CCR Rate,$470.60 ,68.7% of total billed charges,$548.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$397.30 ,58% of total billed charges,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$139.53 ,$616.50 ,$548.00 
Outpatient Medical Services,EMERGENCY ROOM,23650,DISLOC SHOULDER WO ANESTH,450,$685.00 ,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$616.50 ,90% of total billed charges,$239.75 ,35% based on GA Medicaid OP CCR Rate,$470.60 ,68.7% of total billed charges,$548.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$397.30 ,58% of total billed charges,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$139.53 ,$616.50 ,$548.00 
Outpatient Medical Services,EMERGENCY ROOM,23655,DISLOC SHOULDER W ANES,450,"$4,815.00 ","$4,092.75 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,$980.82 ,20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,276.23 ",Pays 102% Medicare OPPS,"$4,333.50 ",90% of total billed charges,"$1,685.25 ",35% based on GA Medicaid OP CCR Rate,"$3,307.91 ",68.7% of total billed charges,"$3,852.00 ",80 percent of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ",Pays 90% Medicare OPPS,"$2,792.70 ",58% of total billed charges,$980.82 ,20.37% based on GA Medicaid OP CCR Rate,"$1,261.77 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$4,092.75 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,$980.82 ,"$4,333.50 ","$3,852.00 "
Outpatient Medical Services,EMERGENCY ROOM,24600,DISLOC ELBOW TX,450,$685.00 ,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$616.50 ,90% of total billed charges,$239.75 ,35% based on GA Medicaid OP CCR Rate,$470.60 ,68.7% of total billed charges,$548.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$397.30 ,58% of total billed charges,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$139.53 ,$616.50 ,$548.00 
Outpatient Medical Services,EMERGENCY ROOM,24605,DISLOC ELBOW TX W ANEST,450,"$4,965.00 ","$4,220.25 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$1,011.37 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,276.23 ",Pays 102% Medicare OPPS,"$4,468.50 ",90% of total billed charges,"$1,737.75 ",35% based on GA Medicaid OP CCR Rate,"$3,410.96 ",68.7% of total billed charges,"$3,972.00 ",80 percent of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ",Pays 90% Medicare OPPS,"$2,879.70 ",58% of total billed charges,"$1,011.37 ",20.37% based on GA Medicaid OP CCR Rate,"$1,261.77 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$4,220.25 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,011.37 ","$4,468.50 ","$3,972.00 "
Outpatient Medical Services,EMERGENCY ROOM,24640,DISLOC ELBOW CHILD(NURSEMAIDS),450,$685.00 ,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$616.50 ,90% of total billed charges,$239.75 ,35% based on GA Medicaid OP CCR Rate,$470.60 ,68.7% of total billed charges,$548.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$397.30 ,58% of total billed charges,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$139.53 ,$616.50 ,$548.00 
Outpatient Medical Services,EMERGENCY ROOM,12001,"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",450,"$1,560.00 ","$1,326.00 ",85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$317.77 ,20.37% based on GA Medicaid OP CCR Rate,$881.40 ,56.5 percent of total billed charges,$881.40 ,56.5 percent of total billed charges,$881.40 ,56.5 percent of total billed charges,$881.40 ,56.5 percent of total billed charges,$164.54 ,Pays 102% Medicare OPPS,"$1,404.00 ",90% of total billed charges,$546.00 ,35% based on GA Medicaid OP CCR Rate,"$1,071.72 ",68.7% of total billed charges,"$1,248.00 ",80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$904.80 ,58% of total billed charges,$317.77 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,"$1,326.00 ",85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,"$1,404.00 ","$1,248.00 "
Outpatient Medical Services,EMERGENCY ROOM,25530,FX ULNAR CLOSED,450,$685.00 ,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$616.50 ,90% of total billed charges,$239.75 ,35% based on GA Medicaid OP CCR Rate,$470.60 ,68.7% of total billed charges,$548.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$397.30 ,58% of total billed charges,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$139.53 ,$616.50 ,$548.00 
Outpatient Medical Services,EMERGENCY ROOM,25535,CL TX ULNAR SHFT W/ MANIPULATION,450,$990.00 ,$841.50 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$201.66 ,20.37% based on GA Medicaid OP CCR Rate,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$559.35 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$891.00 ,90% of total billed charges,$346.50 ,35% based on GA Medicaid OP CCR Rate,$680.13 ,68.7% of total billed charges,$792.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$574.20 ,58% of total billed charges,$201.66 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$841.50 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,$891.00 ,$792.00 
Outpatient Medical Services,EMERGENCY ROOM,25605,CLTX RDL FX/EPIIP,450,"$3,795.00 ","$3,225.75 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,$773.04 ,20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,276.23 ",Pays 102% Medicare OPPS,"$3,415.50 ",90% of total billed charges,"$1,328.25 ",35% based on GA Medicaid OP CCR Rate,"$2,607.17 ",68.7% of total billed charges,"$3,036.00 ",80 percent of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ",Pays 90% Medicare OPPS,"$2,201.10 ",58% of total billed charges,$773.04 ,20.37% based on GA Medicaid OP CCR Rate,"$1,261.77 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$3,225.75 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,$773.04 ,"$3,415.50 ","$3,036.00 "
Outpatient Medical Services,EMERGENCY ROOM,26010,DRAIN FINGER ABSESS SIMPLE,450,$750.00 ,$637.50 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$161.31 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$164.53 ,Pays 102% Medicare OPPS,$675.00 ,90% of total billed charges,$262.50 ,35% based on GA Medicaid OP CCR Rate,$515.25 ,68.7% of total billed charges,$600.00 ,80 percent of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,Pays 90% Medicare OPPS,$435.00 ,58% of total billed charges,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$158.83 ,Pays 100% Medicare OPPS,$206.48 ,Pays 130% Medicare OPPS,$637.50 ,85% of total billed charges,$161.31 ,Pays 100% Medicare OPPS,$145.18 ,$675.00 ,$600.00 
Outpatient Medical Services,EMERGENCY ROOM,26011,DRAIN FINGER ABSC COMPLICATED,450,"$2,900.00 ","$2,465.00 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$590.73 ,20.37% based on GA Medicaid OP CCR Rate,"$1,638.50 ",56.5 percent of total billed charges,"$1,638.50 ",56.5 percent of total billed charges,"$1,638.50 ",56.5 percent of total billed charges,"$1,638.50 ",56.5 percent of total billed charges,"$1,289.21 ",Pays 102% Medicare OPPS,"$2,610.00 ",90% of total billed charges,"$1,015.00 ",35% based on GA Medicaid OP CCR Rate,"$1,992.30 ",68.7% of total billed charges,"$2,320.00 ",80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,"$1,682.00 ",58% of total billed charges,$590.73 ,20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$2,465.00 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,$590.73 ,"$2,610.00 ","$2,320.00 "
Outpatient Medical Services,EMERGENCY ROOM,26418,EXTENSOR TENDON REPAIR,450,"$7,160.00 ","$6,086.00 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$1,458.49 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,276.23 ",Pays 102% Medicare OPPS,"$6,444.00 ",90% of total billed charges,"$2,506.00 ",35% based on GA Medicaid OP CCR Rate,"$4,918.92 ",68.7% of total billed charges,"$5,728.00 ",80 percent of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ",Pays 90% Medicare OPPS,"$4,152.80 ",58% of total billed charges,"$1,458.49 ",20.37% based on GA Medicaid OP CCR Rate,"$1,261.77 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$6,086.00 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ","$6,444.00 ","$5,728.00 "
Outpatient Medical Services,EMERGENCY ROOM,26600,CL TX MC FX SGL MANIP EA BONE,450,$785.00 ,$667.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$706.50 ,90% of total billed charges,$274.75 ,35% based on GA Medicaid OP CCR Rate,$539.30 ,68.7% of total billed charges,$628.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$455.30 ,58% of total billed charges,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$667.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$159.90 ,$706.50 ,$628.00 
Outpatient Medical Services,EMERGENCY ROOM,26641,DISLOC THUMB TX,450,$685.00 ,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$616.50 ,90% of total billed charges,$239.75 ,35% based on GA Medicaid OP CCR Rate,$470.60 ,68.7% of total billed charges,$548.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$397.30 ,58% of total billed charges,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$139.53 ,$616.50 ,$548.00 
Outpatient Medical Services,EMERGENCY ROOM,26742,CL TREATMENT ARTICULAR FRACTURE,450,"$5,795.00 ","$4,925.75 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$1,180.44 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,276.23 ",Pays 102% Medicare OPPS,"$5,215.50 ",90% of total billed charges,"$2,028.25 ",35% based on GA Medicaid OP CCR Rate,"$3,981.17 ",68.7% of total billed charges,"$4,636.00 ",80 percent of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ",Pays 90% Medicare OPPS,"$3,361.10 ",58% of total billed charges,"$1,180.44 ",20.37% based on GA Medicaid OP CCR Rate,"$1,261.77 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$4,925.75 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ","$5,215.50 ","$4,636.00 "
Outpatient Medical Services,EMERGENCY ROOM,26775,CL TX IP JT WITH MANIPULATION,450,$750.00 ,$637.50 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$221.03 ,Pays 102% Medicare OPPS,$675.00 ,90% of total billed charges,$262.50 ,35% based on GA Medicaid OP CCR Rate,$515.25 ,68.7% of total billed charges,$600.00 ,80 percent of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$195.03 ,Pays 90% Medicare OPPS,$435.00 ,58% of total billed charges,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$211.02 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$637.50 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$152.78 ,$675.00 ,$600.00 
Outpatient Medical Services,EMERGENCY ROOM,27086,REMOVAL OF FOREIGN BODY PELVIS OR HIP,450,"$3,725.00 ","$3,166.25 ",85% of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,129.94 ",Pays 100% Medicare OPPS,"$2,953.82 ",Pays 130% Medicare OPPS,$758.78 ,20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,172.54 ",Pays 102% Medicare OPPS,"$3,352.50 ",90% of total billed charges,"$1,303.75 ",35% based on GA Medicaid OP CCR Rate,"$2,559.08 ",68.7% of total billed charges,"$2,980.00 ",80 percent of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,"$1,916.94 ",Pays 90% Medicare OPPS,"$2,160.50 ",58% of total billed charges,$758.78 ,20.37% based on GA Medicaid OP CCR Rate,"$2,272.17 ",Pays 100% Medicare OPPS,"$2,953.82 ",Pays 130% Medicare OPPS,"$3,166.25 ",85% of total billed charges,"$2,129.94 ",Pays 100% Medicare OPPS,$758.78 ,"$3,352.50 ","$2,980.00 "
Outpatient Medical Services,EMERGENCY ROOM,27250,CLOSED TREATMENT OF HIP,450,"$1,375.00 ","$1,168.75 ",85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$280.09 ,20.37% based on GA Medicaid OP CCR Rate,$776.88 ,56.5 percent of total billed charges,$776.88 ,56.5 percent of total billed charges,$776.88 ,56.5 percent of total billed charges,$776.88 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,"$1,237.50 ",90% of total billed charges,$481.25 ,35% based on GA Medicaid OP CCR Rate,$944.63 ,68.7% of total billed charges,"$1,100.00 ",80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$797.50 ,58% of total billed charges,$280.09 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,"$1,168.75 ",85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,"$1,237.50 ","$1,100.00 "
Outpatient Medical Services,EMERGENCY ROOM,27252,DISLOCATED HIP CLOSED,450,$685.00 ,$582.25 ,85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,"$1,276.23 ",Pays 102% Medicare OPPS,$616.50 ,90% of total billed charges,$239.75 ,35% based on GA Medicaid OP CCR Rate,$470.60 ,68.7% of total billed charges,$548.00 ,80 percent of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ",Pays 90% Medicare OPPS,$397.30 ,58% of total billed charges,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,"$1,261.77 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,$582.25 ,85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,$139.53 ,"$1,640.30 ",$548.00 
Outpatient Medical Services,EMERGENCY ROOM,27265,CL TX POST HIP DL WO ANESTHESIA,450,"$1,040.00 ",$884.00 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$211.85 ,20.37% based on GA Medicaid OP CCR Rate,$587.60 ,56.5 percent of total billed charges,$587.60 ,56.5 percent of total billed charges,$587.60 ,56.5 percent of total billed charges,$587.60 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$936.00 ,90% of total billed charges,$364.00 ,35% based on GA Medicaid OP CCR Rate,$714.48 ,68.7% of total billed charges,$832.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$603.20 ,58% of total billed charges,$211.85 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$884.00 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,$936.00 ,$832.00 
Outpatient Medical Services,EMERGENCY ROOM,27510,CL TX FEMUR FX OR EPIPHYS SEP,450,"$3,795.00 ","$3,225.75 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,$773.04 ,20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,276.23 ",Pays 102% Medicare OPPS,"$3,415.50 ",90% of total billed charges,"$1,328.25 ",35% based on GA Medicaid OP CCR Rate,"$2,607.17 ",68.7% of total billed charges,"$3,036.00 ",80 percent of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ",Pays 90% Medicare OPPS,"$2,201.10 ",58% of total billed charges,$773.04 ,20.37% based on GA Medicaid OP CCR Rate,"$1,261.77 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$3,225.75 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,$773.04 ,"$3,415.50 ","$3,036.00 "
Outpatient Medical Services,EMERGENCY ROOM,27550,DISLOC KNEE TX,450,$685.00 ,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$616.50 ,90% of total billed charges,$239.75 ,35% based on GA Medicaid OP CCR Rate,$470.60 ,68.7% of total billed charges,$548.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$397.30 ,58% of total billed charges,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$582.25 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$139.53 ,$616.50 ,$548.00 
Outpatient Medical Services,EMERGENCY ROOM,27562,CLOSED TREATMENT OF PATELLAR DISLOCATION,450,"$2,900.00 ","$2,465.00 ",85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$590.73 ,20.37% based on GA Medicaid OP CCR Rate,"$1,638.50 ",56.5 percent of total billed charges,"$1,638.50 ",56.5 percent of total billed charges,"$1,638.50 ",56.5 percent of total billed charges,"$1,638.50 ",56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,"$2,610.00 ",90% of total billed charges,"$1,015.00 ",35% based on GA Medicaid OP CCR Rate,"$1,992.30 ",68.7% of total billed charges,"$2,320.00 ",80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,"$1,682.00 ",58% of total billed charges,$590.73 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,"$2,465.00 ",85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,"$2,610.00 ","$2,320.00 "
Outpatient Medical Services,EMERGENCY ROOM,27818,CL TX TRIMALL ANKLE FX W MANIP,450,"$2,985.00 ","$2,537.25 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,$608.04 ,20.37% based on GA Medicaid OP CCR Rate,"$1,686.53 ",56.5 percent of total billed charges,"$1,686.53 ",56.5 percent of total billed charges,"$1,686.53 ",56.5 percent of total billed charges,"$1,686.53 ",56.5 percent of total billed charges,"$1,276.23 ",Pays 102% Medicare OPPS,"$2,686.50 ",90% of total billed charges,"$1,044.75 ",35% based on GA Medicaid OP CCR Rate,"$2,050.70 ",68.7% of total billed charges,"$2,388.00 ",80 percent of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ",Pays 90% Medicare OPPS,"$1,731.30 ",58% of total billed charges,$608.04 ,20.37% based on GA Medicaid OP CCR Rate,"$1,261.77 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$2,537.25 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,$608.04 ,"$2,686.50 ","$2,388.00 "
Outpatient Medical Services,EMERGENCY ROOM,27825,CL TX WB DSTL TIB FX W MANIP,450,"$3,940.00 ","$3,349.00 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,$802.58 ,20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,276.23 ",Pays 102% Medicare OPPS,"$3,546.00 ",90% of total billed charges,"$1,379.00 ",35% based on GA Medicaid OP CCR Rate,"$2,706.78 ",68.7% of total billed charges,"$3,152.00 ",80 percent of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ",Pays 90% Medicare OPPS,"$2,285.20 ",58% of total billed charges,$802.58 ,20.37% based on GA Medicaid OP CCR Rate,"$1,261.77 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$3,349.00 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,$802.58 ,"$3,546.00 ","$3,152.00 "
Outpatient Medical Services,EMERGENCY ROOM,27840,DISLOC ANKLE TX,450,$460.00 ,$391.00 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$93.70 ,20.37% based on GA Medicaid OP CCR Rate,$259.90 ,56.5 percent of total billed charges,$259.90 ,56.5 percent of total billed charges,$259.90 ,56.5 percent of total billed charges,$259.90 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$414.00 ,90% of total billed charges,$161.00 ,35% based on GA Medicaid OP CCR Rate,$316.02 ,68.7% of total billed charges,$368.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$266.80 ,58% of total billed charges,$93.70 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$391.00 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$93.70 ,$414.00 ,$368.00 
Outpatient Medical Services,EMERGENCY ROOM,27842,CLOSED TX OF ANKLE DISLOCATION W ANETH,450,"$6,620.00 ","$5,627.00 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$1,348.49 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$1,276.23 ",Pays 102% Medicare OPPS,"$5,958.00 ",90% of total billed charges,"$2,317.00 ",35% based on GA Medicaid OP CCR Rate,"$4,547.94 ",68.7% of total billed charges,"$5,296.00 ",80 percent of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ",Pays 90% Medicare OPPS,"$3,839.60 ",58% of total billed charges,"$1,348.49 ",20.37% based on GA Medicaid OP CCR Rate,"$1,261.77 ",Pays 100% Medicare OPPS,"$1,640.30 ",Pays 130% Medicare OPPS,"$5,627.00 ",85% of total billed charges,"$1,251.21 ",Pays 100% Medicare OPPS,"$1,126.08 ","$5,958.00 ","$5,296.00 "
Outpatient Medical Services,EMERGENCY ROOM,28190,FB REMOVAL FOOT SUBCUT,450,$790.00 ,$671.50 ,85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$160.92 ,20.37% based on GA Medicaid OP CCR Rate,$446.35 ,56.5 percent of total billed charges,$446.35 ,56.5 percent of total billed charges,$446.35 ,56.5 percent of total billed charges,$446.35 ,56.5 percent of total billed charges,$570.17 ,Pays 102% Medicare OPPS,$711.00 ,90% of total billed charges,$276.50 ,35% based on GA Medicaid OP CCR Rate,$542.73 ,68.7% of total billed charges,$632.00 ,80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,$458.20 ,58% of total billed charges,$160.92 ,20.37% based on GA Medicaid OP CCR Rate,$570.82 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$671.50 ,85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$160.92 ,$742.06 ,$632.00 
Outpatient Medical Services,EMERGENCY ROOM,28400,FX CALCANEAL CLOSED,450,$395.00 ,$335.75 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$185.15 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$188.85 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$166.63 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$182.08 ,Pays 100% Medicare OPPS,$236.70 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$185.15 ,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,EMERGENCY ROOM,29065,CAST LONG ARM QK C,450,$540.00 ,$459.00 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$221.03 ,Pays 102% Medicare OPPS,$486.00 ,90% of total billed charges,$189.00 ,35% based on GA Medicaid OP CCR Rate,$370.98 ,68.7% of total billed charges,$432.00 ,80 percent of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$195.03 ,Pays 90% Medicare OPPS,$313.20 ,58% of total billed charges,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$211.02 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$459.00 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$110.00 ,$486.00 ,$432.00 
Outpatient Medical Services,EMERGENCY ROOM,29085,APPLY GAUNTLET CAST,450,$750.00 ,$637.50 ,85% of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$126.91 ,Pays 100% Medicare OPPS,$126.91 ,Pays 100% Medicare OPPS,$166.66 ,Pays 130% Medicare OPPS,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$129.44 ,Pays 102% Medicare OPPS,$675.00 ,90% of total billed charges,$262.50 ,35% based on GA Medicaid OP CCR Rate,$515.25 ,68.7% of total billed charges,$600.00 ,80 percent of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$114.22 ,Pays 90% Medicare OPPS,$435.00 ,58% of total billed charges,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$128.19 ,Pays 100% Medicare OPPS,$166.66 ,Pays 130% Medicare OPPS,$637.50 ,85% of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$114.22 ,$675.00 ,$600.00 
Outpatient Medical Services,EMERGENCY ROOM,29125,SPLINT APPLICATION ARM SHORT,450,$395.00 ,$335.75 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,EMERGENCY ROOM,29130,SPLINT APP FINGER,450,$310.00 ,$263.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$63.15 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$108.50 ,35% based on GA Medicaid OP CCR Rate,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$63.15 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$63.15 ,$279.00 ,$248.00 
Outpatient Medical Services,EMERGENCY ROOM,29260,STRAPPING ELBOW OR WRIST,450,$245.00 ,$208.25 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$49.91 ,20.37% based on GA Medicaid OP CCR Rate,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$51.00 ,Pays 102% Medicare OPPS,$220.50 ,90% of total billed charges,$85.75 ,35% based on GA Medicaid OP CCR Rate,$168.32 ,68.7% of total billed charges,$196.00 ,80 percent of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,Pays 90% Medicare OPPS,$142.10 ,58% of total billed charges,$49.91 ,20.37% based on GA Medicaid OP CCR Rate,$50.55 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$208.25 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,$220.50 ,$196.00 
Outpatient Medical Services,EMERGENCY ROOM,29345,CAST LONG LEG QK C,450,$860.00 ,$731.00 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$175.18 ,20.37% based on GA Medicaid OP CCR Rate,$485.90 ,56.5 percent of total billed charges,$485.90 ,56.5 percent of total billed charges,$485.90 ,56.5 percent of total billed charges,$485.90 ,56.5 percent of total billed charges,$221.03 ,Pays 102% Medicare OPPS,$774.00 ,90% of total billed charges,$301.00 ,35% based on GA Medicaid OP CCR Rate,$590.82 ,68.7% of total billed charges,$688.00 ,80 percent of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$195.03 ,Pays 90% Medicare OPPS,$498.80 ,58% of total billed charges,$175.18 ,20.37% based on GA Medicaid OP CCR Rate,$211.02 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$731.00 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$175.18 ,$774.00 ,$688.00 
Outpatient Medical Services,EMERGENCY ROOM,29405,CAST SHORT LEG QK C,450,$540.00 ,$459.00 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$305.10 ,56.5 percent of total billed charges,$221.03 ,Pays 102% Medicare OPPS,$486.00 ,90% of total billed charges,$189.00 ,35% based on GA Medicaid OP CCR Rate,$370.98 ,68.7% of total billed charges,$432.00 ,80 percent of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$195.03 ,Pays 90% Medicare OPPS,$313.20 ,58% of total billed charges,$110.00 ,20.37% based on GA Medicaid OP CCR Rate,$211.02 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$459.00 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$110.00 ,$486.00 ,$432.00 
Outpatient Medical Services,EMERGENCY ROOM,29505,SPLINT APP LEG,450,$395.00 ,$335.75 ,85% of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$126.91 ,Pays 100% Medicare OPPS,$126.91 ,Pays 100% Medicare OPPS,$166.66 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$129.44 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$114.22 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$128.19 ,Pays 100% Medicare OPPS,$166.66 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,EMERGENCY ROOM,29515,SPLINT APP LOWER LEG,450,$395.00 ,$335.75 ,85% of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$126.91 ,Pays 100% Medicare OPPS,$126.91 ,Pays 100% Medicare OPPS,$166.66 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$129.44 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$114.22 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$128.19 ,Pays 100% Medicare OPPS,$166.66 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,EMERGENCY ROOM,29550,STRAPPING OF TOES,450,$245.00 ,$208.25 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$49.91 ,20.37% based on GA Medicaid OP CCR Rate,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$138.43 ,56.5 percent of total billed charges,$51.00 ,Pays 102% Medicare OPPS,$220.50 ,90% of total billed charges,$85.75 ,35% based on GA Medicaid OP CCR Rate,$168.32 ,68.7% of total billed charges,$196.00 ,80 percent of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,Pays 90% Medicare OPPS,$142.10 ,58% of total billed charges,$49.91 ,20.37% based on GA Medicaid OP CCR Rate,$50.55 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$208.25 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,$220.50 ,$196.00 
Outpatient Medical Services,EMERGENCY ROOM,29700,REMOVAL REVISION OF CAST,450,$750.00 ,$637.50 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$221.03 ,Pays 102% Medicare OPPS,$675.00 ,90% of total billed charges,$262.50 ,35% based on GA Medicaid OP CCR Rate,$515.25 ,68.7% of total billed charges,$600.00 ,80 percent of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$195.03 ,Pays 90% Medicare OPPS,$435.00 ,58% of total billed charges,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$211.02 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$637.50 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$152.78 ,$675.00 ,$600.00 
Outpatient Medical Services,EMERGENCY ROOM,29705,CAST REMOVAL,450,$40.00 ,$34.00 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$216.71 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$221.03 ,Pays 102% Medicare OPPS,$36.00 ,90% of total billed charges,$14.00 ,35% based on GA Medicaid OP CCR Rate,$27.48 ,68.7% of total billed charges,$32.00 ,80 percent of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$195.03 ,Pays 90% Medicare OPPS,$23.20 ,58% of total billed charges,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,$211.02 ,Pays 100% Medicare OPPS,$274.32 ,Pays 130% Medicare OPPS,$34.00 ,85% of total billed charges,$216.71 ,Pays 100% Medicare OPPS,$8.15 ,$274.32 ,$32.00 
Outpatient Medical Services,EMERGENCY ROOM,29799,CASTING STRAPPING PROCEDU,450,$395.00 ,$335.75 ,85% of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$126.91 ,Pays 100% Medicare OPPS,$126.91 ,Pays 100% Medicare OPPS,$166.66 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$129.44 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$114.22 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$128.19 ,Pays 100% Medicare OPPS,$166.66 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$126.91 ,Pays 100% Medicare OPPS,$80.46 ,$355.50 ,$316.00 
Outpatient Medical Services,EMERGENCY ROOM,30300,FB REMOVAL NASAL,450,$650.00 ,$552.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$132.41 ,20.37% based on GA Medicaid OP CCR Rate,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$585.00 ,90% of total billed charges,$227.50 ,35% based on GA Medicaid OP CCR Rate,$446.55 ,68.7% of total billed charges,$520.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$377.00 ,58% of total billed charges,$132.41 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$552.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,$585.00 ,$520.00 
Outpatient Medical Services,EMERGENCY ROOM,30905,CONTROL NASAL HEMORRAHAGE,450,$475.00 ,$403.75 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$96.76 ,20.37% based on GA Medicaid OP CCR Rate,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$268.38 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$427.50 ,90% of total billed charges,$166.25 ,35% based on GA Medicaid OP CCR Rate,$326.33 ,68.7% of total billed charges,$380.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$275.50 ,58% of total billed charges,$96.76 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$403.75 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,$427.50 ,$380.00 
Outpatient Medical Services,EMERGENCY ROOM,31500,INTUBATION EMERGENCY,450,"$1,020.00 ",$867.00 ,85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,$207.77 ,20.37% based on GA Medicaid OP CCR Rate,$576.30 ,56.5 percent of total billed charges,$576.30 ,56.5 percent of total billed charges,$576.30 ,56.5 percent of total billed charges,$576.30 ,56.5 percent of total billed charges,$193.85 ,Pays 102% Medicare OPPS,$918.00 ,90% of total billed charges,$357.00 ,35% based on GA Medicaid OP CCR Rate,$700.74 ,68.7% of total billed charges,$816.00 ,80 percent of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$171.04 ,Pays 90% Medicare OPPS,$591.60 ,58% of total billed charges,$207.77 ,20.37% based on GA Medicaid OP CCR Rate,$182.80 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,$867.00 ,85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$171.04 ,$918.00 ,$816.00 
Outpatient Medical Services,EMERGENCY ROOM,31502,REPLACE TRACEOTOMY TUBE,450,$770.00 ,$654.50 ,85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,$156.85 ,20.37% based on GA Medicaid OP CCR Rate,$435.05 ,56.5 percent of total billed charges,$435.05 ,56.5 percent of total billed charges,$435.05 ,56.5 percent of total billed charges,$435.05 ,56.5 percent of total billed charges,$193.85 ,Pays 102% Medicare OPPS,$693.00 ,90% of total billed charges,$269.50 ,35% based on GA Medicaid OP CCR Rate,$528.99 ,68.7% of total billed charges,$616.00 ,80 percent of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$171.04 ,Pays 90% Medicare OPPS,$446.60 ,58% of total billed charges,$156.85 ,20.37% based on GA Medicaid OP CCR Rate,$182.80 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,$654.50 ,85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$156.85 ,$693.00 ,$616.00 
Outpatient Medical Services,EMERGENCY ROOM,32421,THORACENTESIS DRAIN CHEST,450,$910.00 ,$773.50 ,85% of total billed charges,$227.50 ,Pays 100% Medicare OPPS,$227.50 ,Pays 100% Medicare OPPS,$227.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$185.37 ,20.37% based on GA Medicaid OP CCR Rate,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$819.00 ,90% of total billed charges,$318.50 ,35% based on GA Medicaid OP CCR Rate,$625.17 ,68.7% of total billed charges,$728.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$819.00 ,Pays 90% Medicare OPPS,$527.80 ,58% of total billed charges,$185.37 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$773.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$185.37 ,$819.00 ,$728.00 
Outpatient Medical Services,EMERGENCY ROOM,32421,THORACENTESIS INSERT TUBE,450,$910.00 ,$773.50 ,85% of total billed charges,$227.50 ,Pays 100% Medicare OPPS,$227.50 ,Pays 100% Medicare OPPS,$227.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$185.37 ,20.37% based on GA Medicaid OP CCR Rate,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,$514.15 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$819.00 ,90% of total billed charges,$318.50 ,35% based on GA Medicaid OP CCR Rate,$625.17 ,68.7% of total billed charges,$728.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$819.00 ,Pays 90% Medicare OPPS,$527.80 ,58% of total billed charges,$185.37 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$773.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$185.37 ,$819.00 ,$728.00 
Outpatient Medical Services,EMERGENCY ROOM,32551,INSERTION OF CHEST TUBE,450,"$3,215.00 ","$2,732.75 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,816.48 ",56.5 percent of total billed charges,"$1,288.48 ",Pays 102% Medicare OPPS,"$2,893.50 ",90% of total billed charges,"$1,125.25 ",35% based on GA Medicaid OP CCR Rate,"$2,208.71 ",68.7% of total billed charges,"$2,572.00 ",80 percent of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,"$1,136.89 ",Pays 90% Medicare OPPS,"$1,864.70 ",58% of total billed charges,$654.90 ,20.37% based on GA Medicaid OP CCR Rate,"$1,308.68 ",Pays 100% Medicare OPPS,"$1,701.28 ",Pays 130% Medicare OPPS,"$2,732.75 ",85% of total billed charges,"$1,263.21 ",Pays 100% Medicare OPPS,$654.90 ,"$2,893.50 ","$2,572.00 "
Outpatient Medical Services,EMERGENCY ROOM,35226,REPAIR BLOOD VESSEL DIRECT LOW EXT,450,"$4,140.00 ","$3,519.00 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$843.32 ,20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,$570.17 ,Pays 102% Medicare OPPS,"$3,726.00 ",90% of total billed charges,"$1,449.00 ",35% based on GA Medicaid OP CCR Rate,"$2,844.18 ",68.7% of total billed charges,"$3,312.00 ",80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,"$2,401.20 ",58% of total billed charges,$843.32 ,20.37% based on GA Medicaid OP CCR Rate,$570.82 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,"$3,519.00 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,"$3,726.00 ","$3,312.00 "
Outpatient Medical Services,EMERGENCY ROOM,36000,INTRO OF NEEDLE OR ENTRACATHETER,450,$215.00 ,$182.75 ,85% of total billed charges,$53.75 ,Pays 100% Medicare OPPS,$53.75 ,Pays 100% Medicare OPPS,$53.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$43.80 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$75.25 ,35% based on GA Medicaid OP CCR Rate,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$193.50 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$43.80 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$43.80 ,$193.50 ,$172.00 
Outpatient Medical Services,EMERGENCY ROOM,36555,CUT DOWN INFANT,450,"$1,315.00 ","$1,117.75 ",85% of total billed charges,"$2,571.56 ",Pays 100% Medicare OPPS,"$2,571.56 ",Pays 100% Medicare OPPS,"$2,571.56 ",Pays 100% Medicare OPPS,"$3,406.31 ",Pays 130% Medicare OPPS,$267.87 ,20.37% based on GA Medicaid OP CCR Rate,$742.98 ,56.5 percent of total billed charges,$742.98 ,56.5 percent of total billed charges,$742.98 ,56.5 percent of total billed charges,$742.98 ,56.5 percent of total billed charges,"$2,622.99 ",Pays 102% Medicare OPPS,"$1,183.50 ",90% of total billed charges,$460.25 ,35% based on GA Medicaid OP CCR Rate,$903.41 ,68.7% of total billed charges,"$1,052.00 ",80 percent of total billed charges,"$2,571.56 ",Pays 100% Medicare OPPS,"$2,314.40 ",Pays 90% Medicare OPPS,$762.70 ,58% of total billed charges,$267.87 ,20.37% based on GA Medicaid OP CCR Rate,"$2,620.23 ",Pays 100% Medicare OPPS,"$3,406.31 ",Pays 130% Medicare OPPS,"$1,117.75 ",85% of total billed charges,"$2,571.56 ",Pays 100% Medicare OPPS,$267.87 ,"$3,406.31 ","$1,052.00 "
Outpatient Medical Services,EMERGENCY ROOM,36556,CENTRAL LINE PLACEMENT,450,"$1,970.00 ","$1,674.50 ",85% of total billed charges,"$2,571.56 ",Pays 100% Medicare OPPS,"$2,571.56 ",Pays 100% Medicare OPPS,"$2,571.56 ",Pays 100% Medicare OPPS,"$3,406.31 ",Pays 130% Medicare OPPS,$401.29 ,20.37% based on GA Medicaid OP CCR Rate,"$1,113.05 ",56.5 percent of total billed charges,"$1,113.05 ",56.5 percent of total billed charges,"$1,113.05 ",56.5 percent of total billed charges,"$1,113.05 ",56.5 percent of total billed charges,"$2,622.99 ",Pays 102% Medicare OPPS,"$1,773.00 ",90% of total billed charges,$689.50 ,35% based on GA Medicaid OP CCR Rate,"$1,353.39 ",68.7% of total billed charges,"$1,576.00 ",80 percent of total billed charges,"$2,571.56 ",Pays 100% Medicare OPPS,"$2,314.40 ",Pays 90% Medicare OPPS,"$1,142.60 ",58% of total billed charges,$401.29 ,20.37% based on GA Medicaid OP CCR Rate,"$2,620.23 ",Pays 100% Medicare OPPS,"$3,406.31 ",Pays 130% Medicare OPPS,"$1,674.50 ",85% of total billed charges,"$2,571.56 ",Pays 100% Medicare OPPS,$401.29 ,"$3,406.31 ","$1,576.00 "
Outpatient Medical Services,EMERGENCY ROOM,40804,FB REMOVAL MOUTH,450,$235.00 ,$199.75 ,85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$726.87 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$47.87 ,20.37% based on GA Medicaid OP CCR Rate,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,$741.41 ,Pays 102% Medicare OPPS,$211.50 ,90% of total billed charges,$82.25 ,35% based on GA Medicaid OP CCR Rate,$161.45 ,68.7% of total billed charges,$188.00 ,80 percent of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$654.18 ,Pays 90% Medicare OPPS,$136.30 ,58% of total billed charges,$47.87 ,20.37% based on GA Medicaid OP CCR Rate,$726.10 ,Pays 100% Medicare OPPS,$943.93 ,Pays 130% Medicare OPPS,$199.75 ,85% of total billed charges,$726.87 ,Pays 100% Medicare OPPS,$47.87 ,$943.93 ,$188.00 
Outpatient Medical Services,EMERGENCY ROOM,40812,EXCISION OF LESSION MOUTH W/SIMPLE REPAI,450,"$1,245.00 ","$1,058.25 ",85% of total billed charges,"$1,215.17 ",Pays 100% Medicare OPPS,"$1,215.17 ",Pays 100% Medicare OPPS,"$1,215.17 ",Pays 100% Medicare OPPS,"$1,587.27 ",Pays 130% Medicare OPPS,$253.61 ,20.37% based on GA Medicaid OP CCR Rate,$703.43 ,56.5 percent of total billed charges,$703.43 ,56.5 percent of total billed charges,$703.43 ,56.5 percent of total billed charges,$703.43 ,56.5 percent of total billed charges,"$1,239.47 ",Pays 102% Medicare OPPS,"$1,120.50 ",90% of total billed charges,$435.75 ,35% based on GA Medicaid OP CCR Rate,$855.32 ,68.7% of total billed charges,$996.00 ,80 percent of total billed charges,"$1,215.17 ",Pays 100% Medicare OPPS,"$1,093.65 ",Pays 90% Medicare OPPS,$722.10 ,58% of total billed charges,$253.61 ,20.37% based on GA Medicaid OP CCR Rate,"$1,220.98 ",Pays 100% Medicare OPPS,"$1,587.27 ",Pays 130% Medicare OPPS,"$1,058.25 ",85% of total billed charges,"$1,215.17 ",Pays 100% Medicare OPPS,$253.61 ,"$1,587.27 ",$996.00 
Outpatient Medical Services,EMERGENCY ROOM,41250,REPAIR LACERATION <2.5 CM MOUTH,450,$860.00 ,$731.00 ,85% of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$243.80 ,Pays 100% Medicare OPPS,$243.80 ,Pays 100% Medicare OPPS,$431.73 ,Pays 130% Medicare OPPS,$175.18 ,20.37% based on GA Medicaid OP CCR Rate,$485.90 ,56.5 percent of total billed charges,$485.90 ,56.5 percent of total billed charges,$485.90 ,56.5 percent of total billed charges,$485.90 ,56.5 percent of total billed charges,$248.67 ,Pays 102% Medicare OPPS,$774.00 ,90% of total billed charges,$301.00 ,35% based on GA Medicaid OP CCR Rate,$590.82 ,68.7% of total billed charges,$688.00 ,80 percent of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$219.42 ,Pays 90% Medicare OPPS,$498.80 ,58% of total billed charges,$175.18 ,20.37% based on GA Medicaid OP CCR Rate,$332.10 ,Pays 100% Medicare OPPS,$431.73 ,Pays 130% Medicare OPPS,$731.00 ,85% of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$175.18 ,$774.00 ,$688.00 
Outpatient Medical Services,EMERGENCY ROOM,41252,REPAIR LACERATION TONGUE MOUTH OVER 2.6,450,"$2,070.00 ","$1,759.50 ",85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,$421.66 ,20.37% based on GA Medicaid OP CCR Rate,"$1,169.55 ",56.5 percent of total billed charges,"$1,169.55 ",56.5 percent of total billed charges,"$1,169.55 ",56.5 percent of total billed charges,"$1,169.55 ",56.5 percent of total billed charges,$193.85 ,Pays 102% Medicare OPPS,"$1,863.00 ",90% of total billed charges,$724.50 ,35% based on GA Medicaid OP CCR Rate,"$1,422.09 ",68.7% of total billed charges,"$1,656.00 ",80 percent of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$171.04 ,Pays 90% Medicare OPPS,"$1,200.60 ",58% of total billed charges,$421.66 ,20.37% based on GA Medicaid OP CCR Rate,$182.80 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,"$1,759.50 ",85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$171.04 ,"$1,863.00 ","$1,656.00 "
Outpatient Medical Services,EMERGENCY ROOM,41800,DRAINAGE OF ABSCESS CYST,450,$710.00 ,$603.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$401.15 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$639.00 ,90% of total billed charges,$248.50 ,35% based on GA Medicaid OP CCR Rate,$487.77 ,68.7% of total billed charges,$568.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$411.80 ,58% of total billed charges,$144.63 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$603.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,$639.00 ,$568.00 
Outpatient Medical Services,EMERGENCY ROOM,43752,NASOGASTRIC TUBE PLACEMEN,450,$395.00 ,$335.75 ,85% of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$243.80 ,Pays 100% Medicare OPPS,$243.80 ,Pays 100% Medicare OPPS,$431.73 ,Pays 130% Medicare OPPS,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$223.18 ,56.5 percent of total billed charges,$248.67 ,Pays 102% Medicare OPPS,$355.50 ,90% of total billed charges,$138.25 ,35% based on GA Medicaid OP CCR Rate,$271.37 ,68.7% of total billed charges,$316.00 ,80 percent of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$219.42 ,Pays 90% Medicare OPPS,$229.10 ,58% of total billed charges,$80.46 ,20.37% based on GA Medicaid OP CCR Rate,$332.10 ,Pays 100% Medicare OPPS,$431.73 ,Pays 130% Medicare OPPS,$335.75 ,85% of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$80.46 ,$431.73 ,$316.00 
Outpatient Medical Services,EMERGENCY ROOM,43752,OROGRASTRIC TUBE PLACEMEN,450,$345.00 ,$293.25 ,85% of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$243.80 ,Pays 100% Medicare OPPS,$243.80 ,Pays 100% Medicare OPPS,$431.73 ,Pays 130% Medicare OPPS,$70.28 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$248.67 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$120.75 ,35% based on GA Medicaid OP CCR Rate,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$219.42 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$70.28 ,20.37% based on GA Medicaid OP CCR Rate,$332.10 ,Pays 100% Medicare OPPS,$431.73 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$70.28 ,$431.73 ,$276.00 
Outpatient Medical Services,EMERGENCY ROOM,43762,GASTROSTOMY TUBE REPLACE,450,$810.00 ,$688.50 ,85% of total billed charges,$239.04 ,Pays 100% Medicare OPPS,$239.04 ,Pays 100% Medicare OPPS,$239.04 ,Pays 100% Medicare OPPS,$245.69 ,Pays 130% Medicare OPPS,$165.00 ,20.37% based on GA Medicaid OP CCR Rate,$457.65 ,56.5 percent of total billed charges,$457.65 ,56.5 percent of total billed charges,$457.65 ,56.5 percent of total billed charges,$457.65 ,56.5 percent of total billed charges,$243.81 ,Pays 102% Medicare OPPS,$729.00 ,90% of total billed charges,$283.50 ,35% based on GA Medicaid OP CCR Rate,$556.47 ,68.7% of total billed charges,$648.00 ,80 percent of total billed charges,$239.04 ,Pays 100% Medicare OPPS,$215.13 ,Pays 90% Medicare OPPS,$469.80 ,58% of total billed charges,$165.00 ,20.37% based on GA Medicaid OP CCR Rate,$188.99 ,Pays 100% Medicare OPPS,$245.69 ,Pays 130% Medicare OPPS,$688.50 ,85% of total billed charges,$239.04 ,Pays 100% Medicare OPPS,$165.00 ,$729.00 ,$648.00 
Outpatient Medical Services,EMERGENCY ROOM,46040,I&D PERIRECTAL OR ISCHIAL ABSCESS,450,$685.00 ,$582.25 ,85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,$931.52 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$387.03 ,56.5 percent of total billed charges,$950.15 ,Pays 102% Medicare OPPS,$616.50 ,90% of total billed charges,$239.75 ,35% based on GA Medicaid OP CCR Rate,$470.60 ,68.7% of total billed charges,$548.00 ,80 percent of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$838.37 ,Pays 90% Medicare OPPS,$397.30 ,58% of total billed charges,$139.53 ,20.37% based on GA Medicaid OP CCR Rate,$952.50 ,Pays 100% Medicare OPPS,"$1,238.25 ",Pays 130% Medicare OPPS,$582.25 ,85% of total billed charges,$931.52 ,Pays 100% Medicare OPPS,$139.53 ,"$1,238.25 ",$548.00 
Outpatient Medical Services,EMERGENCY ROOM,46050,I & D PERIANAL ABSCESS,450,"$2,485.00 ","$2,112.25 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$712.88 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,$506.19 ,20.37% based on GA Medicaid OP CCR Rate,"$1,404.03 ",56.5 percent of total billed charges,"$1,404.03 ",56.5 percent of total billed charges,"$1,404.03 ",56.5 percent of total billed charges,"$1,404.03 ",56.5 percent of total billed charges,$727.13 ,Pays 102% Medicare OPPS,"$2,236.50 ",90% of total billed charges,$869.75 ,35% based on GA Medicaid OP CCR Rate,"$1,707.20 ",68.7% of total billed charges,"$1,988.00 ",80 percent of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$641.59 ,Pays 90% Medicare OPPS,"$1,441.30 ",58% of total billed charges,$506.19 ,20.37% based on GA Medicaid OP CCR Rate,$730.96 ,Pays 100% Medicare OPPS,$950.25 ,Pays 130% Medicare OPPS,"$2,112.25 ",85% of total billed charges,$712.88 ,Pays 100% Medicare OPPS,$506.19 ,"$2,236.50 ","$1,988.00 "
Outpatient Medical Services,EMERGENCY ROOM,49080,PARACENTESIS,450,$835.00 ,$709.75 ,85% of total billed charges,$208.75 ,Pays 100% Medicare OPPS,$208.75 ,Pays 100% Medicare OPPS,$208.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$170.09 ,20.37% based on GA Medicaid OP CCR Rate,$471.78 ,56.5 percent of total billed charges,$471.78 ,56.5 percent of total billed charges,$471.78 ,56.5 percent of total billed charges,$471.78 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$751.50 ,90% of total billed charges,$292.25 ,35% based on GA Medicaid OP CCR Rate,$573.65 ,68.7% of total billed charges,$668.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$751.50 ,Pays 90% Medicare OPPS,$484.30 ,58% of total billed charges,$170.09 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$709.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$170.09 ,$751.50 ,$668.00 
Outpatient Medical Services,EMERGENCY ROOM,51700,BLADDER IRRIG SIMPLE,450,$435.00 ,$369.75 ,85% of total billed charges,$239.04 ,Pays 100% Medicare OPPS,$239.04 ,Pays 100% Medicare OPPS,$239.04 ,Pays 100% Medicare OPPS,$245.69 ,Pays 130% Medicare OPPS,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$245.78 ,56.5 percent of total billed charges,$243.81 ,Pays 102% Medicare OPPS,$391.50 ,90% of total billed charges,$152.25 ,35% based on GA Medicaid OP CCR Rate,$298.85 ,68.7% of total billed charges,$348.00 ,80 percent of total billed charges,$239.04 ,Pays 100% Medicare OPPS,$215.13 ,Pays 90% Medicare OPPS,$252.30 ,58% of total billed charges,$88.61 ,20.37% based on GA Medicaid OP CCR Rate,$188.99 ,Pays 100% Medicare OPPS,$245.69 ,Pays 130% Medicare OPPS,$369.75 ,85% of total billed charges,$239.04 ,Pays 100% Medicare OPPS,$88.61 ,$391.50 ,$348.00 
Outpatient Medical Services,EMERGENCY ROOM,51701,IN & OUT CATHETERIZATION,450,$410.00 ,$348.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$231.65 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$369.00 ,90% of total billed charges,$143.50 ,35% based on GA Medicaid OP CCR Rate,$281.67 ,68.7% of total billed charges,$328.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$237.80 ,58% of total billed charges,$83.52 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$348.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$83.52 ,$369.00 ,$328.00 
Outpatient Medical Services,EMERGENCY ROOM,51702,FOLEY CATH INSERTION SIMP,450,$815.00 ,$692.75 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$166.02 ,20.37% based on GA Medicaid OP CCR Rate,$460.48 ,56.5 percent of total billed charges,$460.48 ,56.5 percent of total billed charges,$460.48 ,56.5 percent of total billed charges,$460.48 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$733.50 ,90% of total billed charges,$285.25 ,35% based on GA Medicaid OP CCR Rate,$559.91 ,68.7% of total billed charges,$652.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$472.70 ,58% of total billed charges,$166.02 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$692.75 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,$733.50 ,$652.00 
Outpatient Medical Services,EMERGENCY ROOM,51703,FOLEY CATH INSERTION DIFF,450,$545.00 ,$463.25 ,85% of total billed charges,$125.42 ,Pays 100% Medicare OPPS,$125.42 ,Pays 100% Medicare OPPS,$125.42 ,Pays 100% Medicare OPPS,$166.28 ,Pays 130% Medicare OPPS,$111.02 ,20.37% based on GA Medicaid OP CCR Rate,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$307.93 ,56.5 percent of total billed charges,$127.92 ,Pays 102% Medicare OPPS,$490.50 ,90% of total billed charges,$190.75 ,35% based on GA Medicaid OP CCR Rate,$374.42 ,68.7% of total billed charges,$436.00 ,80 percent of total billed charges,$125.42 ,Pays 100% Medicare OPPS,$112.87 ,Pays 90% Medicare OPPS,$316.10 ,58% of total billed charges,$111.02 ,20.37% based on GA Medicaid OP CCR Rate,$127.91 ,Pays 100% Medicare OPPS,$166.28 ,Pays 130% Medicare OPPS,$463.25 ,85% of total billed charges,$125.42 ,Pays 100% Medicare OPPS,$111.02 ,$490.50 ,$436.00 
Outpatient Medical Services,EMERGENCY ROOM,51702,INS TEMP BLADDER CATH,450,$750.00 ,$637.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$675.00 ,90% of total billed charges,$262.50 ,35% based on GA Medicaid OP CCR Rate,$515.25 ,68.7% of total billed charges,$600.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$435.00 ,58% of total billed charges,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$637.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,$675.00 ,$600.00 
Outpatient Medical Services,EMERGENCY ROOM,54235,INJ CORPORA CAVERNOSA,450,"$1,195.00 ","$1,015.75 ",85% of total billed charges,$239.04 ,Pays 100% Medicare OPPS,$239.04 ,Pays 100% Medicare OPPS,$239.04 ,Pays 100% Medicare OPPS,$245.69 ,Pays 130% Medicare OPPS,$243.42 ,20.37% based on GA Medicaid OP CCR Rate,$675.18 ,56.5 percent of total billed charges,$675.18 ,56.5 percent of total billed charges,$675.18 ,56.5 percent of total billed charges,$675.18 ,56.5 percent of total billed charges,$243.81 ,Pays 102% Medicare OPPS,"$1,075.50 ",90% of total billed charges,$418.25 ,35% based on GA Medicaid OP CCR Rate,$820.97 ,68.7% of total billed charges,$956.00 ,80 percent of total billed charges,$239.04 ,Pays 100% Medicare OPPS,$215.13 ,Pays 90% Medicare OPPS,$693.10 ,58% of total billed charges,$243.42 ,20.37% based on GA Medicaid OP CCR Rate,$188.99 ,Pays 100% Medicare OPPS,$245.69 ,Pays 130% Medicare OPPS,"$1,015.75 ",85% of total billed charges,$239.04 ,Pays 100% Medicare OPPS,$188.99 ,"$1,075.50 ",$956.00 
Outpatient Medical Services,EMERGENCY ROOM,55100,DRAINAGE OF SCROTAL WALL ABSCESS,450,"$3,315.00 ","$2,817.75 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,$675.27 ,20.37% based on GA Medicaid OP CCR Rate,"$1,872.98 ",56.5 percent of total billed charges,"$1,872.98 ",56.5 percent of total billed charges,"$1,872.98 ",56.5 percent of total billed charges,"$1,872.98 ",56.5 percent of total billed charges,"$1,289.21 ",Pays 102% Medicare OPPS,"$2,983.50 ",90% of total billed charges,"$1,160.25 ",35% based on GA Medicaid OP CCR Rate,"$2,277.41 ",68.7% of total billed charges,"$2,652.00 ",80 percent of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,"$1,137.55 ",Pays 90% Medicare OPPS,"$1,922.70 ",58% of total billed charges,$675.27 ,20.37% based on GA Medicaid OP CCR Rate,"$1,318.97 ",Pays 100% Medicare OPPS,"$1,714.66 ",Pays 130% Medicare OPPS,"$2,817.75 ",85% of total billed charges,"$1,263.94 ",Pays 100% Medicare OPPS,$675.27 ,"$2,983.50 ","$2,652.00 "
Outpatient Medical Services,EMERGENCY ROOM,56405,I&D VULVA PERINEAL ABSCESS,450,$585.00 ,$497.25 ,85% of total billed charges,$253.35 ,Pays 100% Medicare OPPS,$253.35 ,Pays 100% Medicare OPPS,$253.35 ,Pays 100% Medicare OPPS,$333.83 ,Pays 130% Medicare OPPS,$119.16 ,20.37% based on GA Medicaid OP CCR Rate,$330.53 ,56.5 percent of total billed charges,$330.53 ,56.5 percent of total billed charges,$330.53 ,56.5 percent of total billed charges,$330.53 ,56.5 percent of total billed charges,$258.42 ,Pays 102% Medicare OPPS,$526.50 ,90% of total billed charges,$204.75 ,35% based on GA Medicaid OP CCR Rate,$401.90 ,68.7% of total billed charges,$468.00 ,80 percent of total billed charges,$253.35 ,Pays 100% Medicare OPPS,$228.01 ,Pays 90% Medicare OPPS,$339.30 ,58% of total billed charges,$119.16 ,20.37% based on GA Medicaid OP CCR Rate,$256.79 ,Pays 100% Medicare OPPS,$333.83 ,Pays 130% Medicare OPPS,$497.25 ,85% of total billed charges,$253.35 ,Pays 100% Medicare OPPS,$119.16 ,$526.50 ,$468.00 
Outpatient Medical Services,EMERGENCY ROOM,56420,I&D BARTHOLINS GLAND ABSCESS,450,$750.00 ,$637.50 ,85% of total billed charges,$153.03 ,Pays 100% Medicare OPPS,$153.03 ,Pays 100% Medicare OPPS,$153.03 ,Pays 100% Medicare OPPS,$203.67 ,Pays 130% Medicare OPPS,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$156.09 ,Pays 102% Medicare OPPS,$675.00 ,90% of total billed charges,$262.50 ,35% based on GA Medicaid OP CCR Rate,$515.25 ,68.7% of total billed charges,$600.00 ,80 percent of total billed charges,$153.03 ,Pays 100% Medicare OPPS,$137.72 ,Pays 90% Medicare OPPS,$435.00 ,58% of total billed charges,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$156.68 ,Pays 100% Medicare OPPS,$203.67 ,Pays 130% Medicare OPPS,$637.50 ,85% of total billed charges,$153.03 ,Pays 100% Medicare OPPS,$137.72 ,$675.00 ,$600.00 
Outpatient Medical Services,EMERGENCY ROOM,57200,COLPORRHAPHY,450,"$7,035.00 ","$5,979.75 ",85% of total billed charges,"$2,356.88 ",Pays 100% Medicare OPPS,"$2,356.88 ",Pays 100% Medicare OPPS,"$2,356.88 ",Pays 100% Medicare OPPS,"$3,233.04 ",Pays 130% Medicare OPPS,"$1,433.03 ",20.37% based on GA Medicaid OP CCR Rate,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,000.00 ",56.5 percent of total billed charges,"$2,404.02 ",Pays 102% Medicare OPPS,"$6,331.50 ",90% of total billed charges,"$2,462.25 ",35% based on GA Medicaid OP CCR Rate,"$4,833.05 ",68.7% of total billed charges,"$5,628.00 ",80 percent of total billed charges,"$2,356.88 ",Pays 100% Medicare OPPS,"$2,121.19 ",Pays 90% Medicare OPPS,"$4,080.30 ",58% of total billed charges,"$1,433.03 ",20.37% based on GA Medicaid OP CCR Rate,"$2,486.96 ",Pays 100% Medicare OPPS,"$3,233.04 ",Pays 130% Medicare OPPS,"$5,979.75 ",85% of total billed charges,"$2,356.88 ",Pays 100% Medicare OPPS,"$1,433.03 ","$6,331.50 ","$5,628.00 "
Outpatient Medical Services,EMERGENCY ROOM,59050,FETAL MONITOR,450,$300.00 ,$255.00 ,85% of total billed charges,$75.00 ,Pays 100% Medicare OPPS,$75.00 ,Pays 100% Medicare OPPS,$75.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,$169.50 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$270.00 ,90% of total billed charges,$105.00 ,35% based on GA Medicaid OP CCR Rate,$206.10 ,68.7% of total billed charges,$240.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$270.00 ,Pays 90% Medicare OPPS,$174.00 ,58% of total billed charges,$61.11 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$255.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$61.11 ,$270.00 ,$240.00 
Outpatient Medical Services,EMERGENCY ROOM,59300,EPISIOTOMY/VAGINAL REPAIR,450,"$3,200.00 ","$2,720.00 ",85% of total billed charges,"$2,356.88 ",Pays 100% Medicare OPPS,"$2,356.88 ",Pays 100% Medicare OPPS,"$2,356.88 ",Pays 100% Medicare OPPS,"$3,233.04 ",Pays 130% Medicare OPPS,$651.84 ,20.37% based on GA Medicaid OP CCR Rate,"$1,808.00 ",56.5 percent of total billed charges,"$1,808.00 ",56.5 percent of total billed charges,"$1,808.00 ",56.5 percent of total billed charges,"$1,808.00 ",56.5 percent of total billed charges,"$2,404.02 ",Pays 102% Medicare OPPS,"$2,880.00 ",90% of total billed charges,"$1,120.00 ",35% based on GA Medicaid OP CCR Rate,"$2,198.40 ",68.7% of total billed charges,"$2,560.00 ",80 percent of total billed charges,"$2,356.88 ",Pays 100% Medicare OPPS,"$2,121.19 ",Pays 90% Medicare OPPS,"$1,856.00 ",58% of total billed charges,$651.84 ,20.37% based on GA Medicaid OP CCR Rate,"$2,486.96 ",Pays 100% Medicare OPPS,"$3,233.04 ",Pays 130% Medicare OPPS,"$2,720.00 ",85% of total billed charges,"$2,356.88 ",Pays 100% Medicare OPPS,$651.84 ,"$3,233.04 ","$2,560.00 "
Outpatient Medical Services,EMERGENCY ROOM,64400,NERVE BLK INJ TRIGEMINAL,450,$785.00 ,$667.25 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$239.38 ,Pays 102% Medicare OPPS,$706.50 ,90% of total billed charges,$274.75 ,35% based on GA Medicaid OP CCR Rate,$539.30 ,68.7% of total billed charges,$628.00 ,80 percent of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$211.22 ,Pays 90% Medicare OPPS,$455.30 ,58% of total billed charges,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$239.14 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$667.25 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$159.90 ,$706.50 ,$628.00 
Outpatient Medical Services,EMERGENCY ROOM,64420,N BLOCK INJ INTERCOST SNG,450,"$1,925.00 ","$1,636.25 ",85% of total billed charges,$570.41 ,Pays 100% Medicare OPPS,$570.41 ,Pays 100% Medicare OPPS,$570.41 ,Pays 100% Medicare OPPS,$736.77 ,Pays 130% Medicare OPPS,$392.12 ,20.37% based on GA Medicaid OP CCR Rate,"$1,087.63 ",56.5 percent of total billed charges,"$1,087.63 ",56.5 percent of total billed charges,"$1,087.63 ",56.5 percent of total billed charges,"$1,087.63 ",56.5 percent of total billed charges,$581.83 ,Pays 102% Medicare OPPS,"$1,732.50 ",90% of total billed charges,$673.75 ,35% based on GA Medicaid OP CCR Rate,"$1,322.48 ",68.7% of total billed charges,"$1,540.00 ",80 percent of total billed charges,$570.41 ,Pays 100% Medicare OPPS,$513.37 ,Pays 90% Medicare OPPS,"$1,116.50 ",58% of total billed charges,$392.12 ,20.37% based on GA Medicaid OP CCR Rate,$566.74 ,Pays 100% Medicare OPPS,$736.77 ,Pays 130% Medicare OPPS,"$1,636.25 ",85% of total billed charges,$570.41 ,Pays 100% Medicare OPPS,$392.12 ,"$1,732.50 ","$1,540.00 "
Outpatient Medical Services,EMERGENCY ROOM,64450,NERVE BLOCK OTHER PERIPHE,450,$785.00 ,$667.25 ,85% of total billed charges,$570.41 ,Pays 100% Medicare OPPS,$570.41 ,Pays 100% Medicare OPPS,$570.41 ,Pays 100% Medicare OPPS,$736.77 ,Pays 130% Medicare OPPS,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$443.53 ,56.5 percent of total billed charges,$581.83 ,Pays 102% Medicare OPPS,$706.50 ,90% of total billed charges,$274.75 ,35% based on GA Medicaid OP CCR Rate,$539.30 ,68.7% of total billed charges,$628.00 ,80 percent of total billed charges,$570.41 ,Pays 100% Medicare OPPS,$513.37 ,Pays 90% Medicare OPPS,$455.30 ,58% of total billed charges,$159.90 ,20.37% based on GA Medicaid OP CCR Rate,$566.74 ,Pays 100% Medicare OPPS,$736.77 ,Pays 130% Medicare OPPS,$667.25 ,85% of total billed charges,$570.41 ,Pays 100% Medicare OPPS,$159.90 ,$736.77 ,$628.00 
Outpatient Medical Services,EMERGENCY ROOM,64455,N BLOCK INJ PLANTAR DIGIT,450,$915.00 ,$777.75 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$234.69 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$186.39 ,20.37% based on GA Medicaid OP CCR Rate,$516.98 ,56.5 percent of total billed charges,$516.98 ,56.5 percent of total billed charges,$516.98 ,56.5 percent of total billed charges,$516.98 ,56.5 percent of total billed charges,$239.38 ,Pays 102% Medicare OPPS,$823.50 ,90% of total billed charges,$320.25 ,35% based on GA Medicaid OP CCR Rate,$628.61 ,68.7% of total billed charges,$732.00 ,80 percent of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$211.22 ,Pays 90% Medicare OPPS,$530.70 ,58% of total billed charges,$186.39 ,20.37% based on GA Medicaid OP CCR Rate,$239.14 ,Pays 100% Medicare OPPS,$310.88 ,Pays 130% Medicare OPPS,$777.75 ,85% of total billed charges,$234.69 ,Pays 100% Medicare OPPS,$186.39 ,$823.50 ,$732.00 
Outpatient Medical Services,EMERGENCY ROOM,64520,INJ ANES LUMBAR/THORACIC,450,$925.00 ,$786.25 ,85% of total billed charges,$739.49 ,Pays 100% Medicare OPPS,$739.49 ,Pays 100% Medicare OPPS,$739.49 ,Pays 100% Medicare OPPS,$974.42 ,Pays 130% Medicare OPPS,$188.42 ,20.37% based on GA Medicaid OP CCR Rate,$522.63 ,56.5 percent of total billed charges,$522.63 ,56.5 percent of total billed charges,$522.63 ,56.5 percent of total billed charges,$522.63 ,56.5 percent of total billed charges,$754.27 ,Pays 102% Medicare OPPS,$832.50 ,90% of total billed charges,$323.75 ,35% based on GA Medicaid OP CCR Rate,$635.48 ,68.7% of total billed charges,$740.00 ,80 percent of total billed charges,$739.49 ,Pays 100% Medicare OPPS,$665.53 ,Pays 90% Medicare OPPS,$536.50 ,58% of total billed charges,$188.42 ,20.37% based on GA Medicaid OP CCR Rate,$749.56 ,Pays 100% Medicare OPPS,$974.42 ,Pays 130% Medicare OPPS,$786.25 ,85% of total billed charges,$739.49 ,Pays 100% Medicare OPPS,$188.42 ,$974.42 ,$740.00 
Outpatient Medical Services,EMERGENCY ROOM,65205,FB REMOVAL EYE,450,$650.00 ,$552.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$132.41 ,20.37% based on GA Medicaid OP CCR Rate,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$367.25 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$585.00 ,90% of total billed charges,$227.50 ,35% based on GA Medicaid OP CCR Rate,$446.55 ,68.7% of total billed charges,$520.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$377.00 ,58% of total billed charges,$132.41 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$552.50 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,$585.00 ,$520.00 
Outpatient Medical Services,EMERGENCY ROOM,65220,REM FB EXT EYE,450,"$1,120.00 ",$952.00 ,85% of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$243.80 ,Pays 100% Medicare OPPS,$243.80 ,Pays 100% Medicare OPPS,$431.73 ,Pays 130% Medicare OPPS,$228.14 ,20.37% based on GA Medicaid OP CCR Rate,$632.80 ,56.5 percent of total billed charges,$632.80 ,56.5 percent of total billed charges,$632.80 ,56.5 percent of total billed charges,$632.80 ,56.5 percent of total billed charges,$248.67 ,Pays 102% Medicare OPPS,"$1,008.00 ",90% of total billed charges,$392.00 ,35% based on GA Medicaid OP CCR Rate,$769.44 ,68.7% of total billed charges,$896.00 ,80 percent of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$219.42 ,Pays 90% Medicare OPPS,$649.60 ,58% of total billed charges,$228.14 ,20.37% based on GA Medicaid OP CCR Rate,$332.10 ,Pays 100% Medicare OPPS,$431.73 ,Pays 130% Medicare OPPS,$952.00 ,85% of total billed charges,$243.80 ,Pays 100% Medicare OPPS,$219.42 ,"$1,008.00 ",$896.00 
Outpatient Medical Services,EMERGENCY ROOM,65222,REM FB CONEAL W SLIT LAMP,450,$420.00 ,$357.00 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$237.30 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$378.00 ,90% of total billed charges,$147.00 ,35% based on GA Medicaid OP CCR Rate,$288.54 ,68.7% of total billed charges,$336.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$243.60 ,58% of total billed charges,$85.55 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$357.00 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$85.55 ,$378.00 ,$336.00 
Outpatient Medical Services,EMERGENCY ROOM,67700,BLEPHAROTOMY DRAIN ABSC EYELID,450,"$1,040.00 ",$884.00 ,85% of total billed charges,$234.98 ,Pays 100% Medicare OPPS,$234.98 ,Pays 100% Medicare OPPS,$234.98 ,Pays 100% Medicare OPPS,$302.68 ,Pays 130% Medicare OPPS,$211.85 ,20.37% based on GA Medicaid OP CCR Rate,$587.60 ,56.5 percent of total billed charges,$587.60 ,56.5 percent of total billed charges,$587.60 ,56.5 percent of total billed charges,$587.60 ,56.5 percent of total billed charges,$239.68 ,Pays 102% Medicare OPPS,$936.00 ,90% of total billed charges,$364.00 ,35% based on GA Medicaid OP CCR Rate,$714.48 ,68.7% of total billed charges,$832.00 ,80 percent of total billed charges,$234.98 ,Pays 100% Medicare OPPS,$211.48 ,Pays 90% Medicare OPPS,$603.20 ,58% of total billed charges,$211.85 ,20.37% based on GA Medicaid OP CCR Rate,$232.82 ,Pays 100% Medicare OPPS,$302.68 ,Pays 130% Medicare OPPS,$884.00 ,85% of total billed charges,$234.98 ,Pays 100% Medicare OPPS,$211.48 ,$936.00 ,$832.00 
Outpatient Medical Services,EMERGENCY ROOM,67938,REMOVE EMBEDDED FB EYELID,450,"$1,245.00 ","$1,058.25 ",85% of total billed charges,$234.98 ,Pays 100% Medicare OPPS,$234.98 ,Pays 100% Medicare OPPS,$234.98 ,Pays 100% Medicare OPPS,$302.68 ,Pays 130% Medicare OPPS,$253.61 ,20.37% based on GA Medicaid OP CCR Rate,$703.43 ,56.5 percent of total billed charges,$703.43 ,56.5 percent of total billed charges,$703.43 ,56.5 percent of total billed charges,$703.43 ,56.5 percent of total billed charges,$239.68 ,Pays 102% Medicare OPPS,"$1,120.50 ",90% of total billed charges,$435.75 ,35% based on GA Medicaid OP CCR Rate,$855.32 ,68.7% of total billed charges,$996.00 ,80 percent of total billed charges,$234.98 ,Pays 100% Medicare OPPS,$211.48 ,Pays 90% Medicare OPPS,$722.10 ,58% of total billed charges,$253.61 ,20.37% based on GA Medicaid OP CCR Rate,$232.82 ,Pays 100% Medicare OPPS,$302.68 ,Pays 130% Medicare OPPS,"$1,058.25 ",85% of total billed charges,$234.98 ,Pays 100% Medicare OPPS,$211.48 ,"$1,120.50 ",$996.00 
Outpatient Medical Services,EMERGENCY ROOM,69000,DRAIN EXTERNAL EAR LESION,450,"$1,750.00 ","$1,487.50 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$559.00 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,$356.48 ,20.37% based on GA Medicaid OP CCR Rate,$988.75 ,56.5 percent of total billed charges,$988.75 ,56.5 percent of total billed charges,$988.75 ,56.5 percent of total billed charges,$988.75 ,56.5 percent of total billed charges,$570.17 ,Pays 102% Medicare OPPS,"$1,575.00 ",90% of total billed charges,$612.50 ,35% based on GA Medicaid OP CCR Rate,"$1,202.25 ",68.7% of total billed charges,"$1,400.00 ",80 percent of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$503.10 ,Pays 90% Medicare OPPS,"$1,015.00 ",58% of total billed charges,$356.48 ,20.37% based on GA Medicaid OP CCR Rate,$570.82 ,Pays 100% Medicare OPPS,$742.06 ,Pays 130% Medicare OPPS,"$1,487.50 ",85% of total billed charges,$559.00 ,Pays 100% Medicare OPPS,$356.48 ,"$1,575.00 ","$1,400.00 "
Outpatient Medical Services,EMERGENCY ROOM,69200,REMOVAL FOREIGN BODY FM EXTERNAL AUDITOR,450,$360.00 ,$306.00 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$73.33 ,20.37% based on GA Medicaid OP CCR Rate,$203.40 ,56.5 percent of total billed charges,$203.40 ,56.5 percent of total billed charges,$203.40 ,56.5 percent of total billed charges,$203.40 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$324.00 ,90% of total billed charges,$126.00 ,35% based on GA Medicaid OP CCR Rate,$247.32 ,68.7% of total billed charges,$288.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$208.80 ,58% of total billed charges,$73.33 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$306.00 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$73.33 ,$324.00 ,$288.00 
Outpatient Medical Services,EMERGENCY ROOM,69209,REMOVE INPACTED EAR WAX UNI,450,$315.00 ,$267.75 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$64.17 ,20.37% based on GA Medicaid OP CCR Rate,$177.98 ,56.5 percent of total billed charges,$177.98 ,56.5 percent of total billed charges,$177.98 ,56.5 percent of total billed charges,$177.98 ,56.5 percent of total billed charges,$51.00 ,Pays 102% Medicare OPPS,$283.50 ,90% of total billed charges,$110.25 ,35% based on GA Medicaid OP CCR Rate,$216.41 ,68.7% of total billed charges,$252.00 ,80 percent of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,Pays 90% Medicare OPPS,$182.70 ,58% of total billed charges,$64.17 ,20.37% based on GA Medicaid OP CCR Rate,$50.55 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$267.75 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,$283.50 ,$252.00 
Outpatient Medical Services,EMERGENCY ROOM,69399,UNLISTED PROCEDURE EXTERNAL EAR,450,$750.00 ,$637.50 ,85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$190.05 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$423.75 ,56.5 percent of total billed charges,$193.85 ,Pays 102% Medicare OPPS,$675.00 ,90% of total billed charges,$262.50 ,35% based on GA Medicaid OP CCR Rate,$515.25 ,68.7% of total billed charges,$600.00 ,80 percent of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$171.04 ,Pays 90% Medicare OPPS,$435.00 ,58% of total billed charges,$152.78 ,20.37% based on GA Medicaid OP CCR Rate,$182.80 ,Pays 100% Medicare OPPS,$237.63 ,Pays 130% Medicare OPPS,$637.50 ,85% of total billed charges,$190.05 ,Pays 100% Medicare OPPS,$152.78 ,$675.00 ,$600.00 
Outpatient Medical Services,EMERGENCY ROOM,90281,IM INJECTION IMMUNE GLOBULIN,450,$240.00 ,$204.00 ,85% of total billed charges,$60.00 ,Pays 100% Medicare OPPS,$60.00 ,Pays 100% Medicare OPPS,$60.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$84.00 ,35% based on GA Medicaid OP CCR Rate,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$216.00 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$48.89 ,$216.00 ,$192.00 
Outpatient Medical Services,EMERGENCY ROOM,96372,IM INJECTION VACCINE,450,$240.00 ,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$56.80 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$84.00 ,35% based on GA Medicaid OP CCR Rate,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$50.12 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$59.34 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$48.89 ,$216.00 ,$192.00 
Outpatient Medical Services,EMERGENCY ROOM,96360,IV HYDRATION INITIAL,450,$615.00 ,$522.75 ,85% of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$183.77 ,Pays 100% Medicare OPPS,$183.77 ,Pays 100% Medicare OPPS,$236.20 ,Pays 130% Medicare OPPS,$125.28 ,20.37% based on GA Medicaid OP CCR Rate,$347.48 ,56.5 percent of total billed charges,$347.48 ,56.5 percent of total billed charges,$347.48 ,56.5 percent of total billed charges,$347.48 ,56.5 percent of total billed charges,$187.43 ,Pays 102% Medicare OPPS,$553.50 ,90% of total billed charges,$215.25 ,35% based on GA Medicaid OP CCR Rate,$422.51 ,68.7% of total billed charges,$492.00 ,80 percent of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$165.38 ,Pays 90% Medicare OPPS,$356.70 ,58% of total billed charges,$125.28 ,20.37% based on GA Medicaid OP CCR Rate,$181.69 ,Pays 100% Medicare OPPS,$236.20 ,Pays 130% Medicare OPPS,$522.75 ,85% of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$125.28 ,$553.50 ,$492.00 
Outpatient Medical Services,EMERGENCY ROOM,96361,IV HYDRATION  ADDTL HR,450,$170.00 ,$144.50 ,85% of total billed charges,$35.94 ,Pays 100% Medicare OPPS,$35.94 ,Pays 100% Medicare OPPS,$35.94 ,Pays 100% Medicare OPPS,$48.44 ,Pays 130% Medicare OPPS,$34.63 ,20.37% based on GA Medicaid OP CCR Rate,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$96.05 ,56.5 percent of total billed charges,$36.65 ,Pays 102% Medicare OPPS,$153.00 ,90% of total billed charges,$59.50 ,35% based on GA Medicaid OP CCR Rate,$116.79 ,68.7% of total billed charges,$136.00 ,80 percent of total billed charges,$35.94 ,Pays 100% Medicare OPPS,$32.35 ,Pays 90% Medicare OPPS,$98.60 ,58% of total billed charges,$34.63 ,20.37% based on GA Medicaid OP CCR Rate,$37.26 ,Pays 100% Medicare OPPS,$48.44 ,Pays 130% Medicare OPPS,$144.50 ,85% of total billed charges,$35.94 ,Pays 100% Medicare OPPS,$32.35 ,$153.00 ,$136.00 
Outpatient Medical Services,EMERGENCY ROOM,96365,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",450,$415.00 ,$352.75 ,85% of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$183.77 ,Pays 100% Medicare OPPS,$183.77 ,Pays 100% Medicare OPPS,$236.20 ,Pays 130% Medicare OPPS,$84.54 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$187.43 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$145.25 ,35% based on GA Medicaid OP CCR Rate,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$165.38 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$84.54 ,20.37% based on GA Medicaid OP CCR Rate,$181.69 ,Pays 100% Medicare OPPS,$236.20 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$84.54 ,$373.50 ,$332.00 
Outpatient Medical Services,EMERGENCY ROOM,96366,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",450,$195.00 ,$165.75 ,85% of total billed charges,$35.94 ,Pays 100% Medicare OPPS,$35.94 ,Pays 100% Medicare OPPS,$35.94 ,Pays 100% Medicare OPPS,$48.44 ,Pays 130% Medicare OPPS,$39.72 ,20.37% based on GA Medicaid OP CCR Rate,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$110.18 ,56.5 percent of total billed charges,$36.65 ,Pays 102% Medicare OPPS,$175.50 ,90% of total billed charges,$68.25 ,35% based on GA Medicaid OP CCR Rate,$133.97 ,68.7% of total billed charges,$156.00 ,80 percent of total billed charges,$35.94 ,Pays 100% Medicare OPPS,$32.35 ,Pays 90% Medicare OPPS,$113.10 ,58% of total billed charges,$39.72 ,20.37% based on GA Medicaid OP CCR Rate,$37.26 ,Pays 100% Medicare OPPS,$48.44 ,Pays 130% Medicare OPPS,$165.75 ,85% of total billed charges,$35.94 ,Pays 100% Medicare OPPS,$32.35 ,$175.50 ,$156.00 
Outpatient Medical Services,EMERGENCY ROOM,96367,IV  ADDITIONAL SEQUENTIAL INFUSION,450,$265.00 ,$225.25 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$53.98 ,20.37% based on GA Medicaid OP CCR Rate,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$149.73 ,56.5 percent of total billed charges,$56.80 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$92.75 ,35% based on GA Medicaid OP CCR Rate,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$50.12 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$53.98 ,20.37% based on GA Medicaid OP CCR Rate,$59.34 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$50.12 ,$238.50 ,$212.00 
Outpatient Medical Services,EMERGENCY ROOM,96372,IM INJECTION ANTIBIOTIC,450,$240.00 ,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$56.80 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$84.00 ,35% based on GA Medicaid OP CCR Rate,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$50.12 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$59.34 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$48.89 ,$216.00 ,$192.00 
Outpatient Medical Services,EMERGENCY ROOM,96372,IM INJECTION OR SUBCUTANEOUS,450,$240.00 ,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$56.80 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$84.00 ,35% based on GA Medicaid OP CCR Rate,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$50.12 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$59.34 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$48.89 ,$216.00 ,$192.00 
Outpatient Medical Services,EMERGENCY ROOM,96374,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",450,$285.00 ,$242.25 ,85% of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$183.77 ,Pays 100% Medicare OPPS,$183.77 ,Pays 100% Medicare OPPS,$236.20 ,Pays 130% Medicare OPPS,$58.05 ,20.37% based on GA Medicaid OP CCR Rate,$161.03 ,56.5 percent of total billed charges,$161.03 ,56.5 percent of total billed charges,$161.03 ,56.5 percent of total billed charges,$161.03 ,56.5 percent of total billed charges,$187.43 ,Pays 102% Medicare OPPS,$256.50 ,90% of total billed charges,$99.75 ,35% based on GA Medicaid OP CCR Rate,$195.80 ,68.7% of total billed charges,$228.00 ,80 percent of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$165.38 ,Pays 90% Medicare OPPS,$165.30 ,58% of total billed charges,$58.05 ,20.37% based on GA Medicaid OP CCR Rate,$181.69 ,Pays 100% Medicare OPPS,$236.20 ,Pays 130% Medicare OPPS,$242.25 ,85% of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$58.05 ,$256.50 ,$228.00 
Outpatient Medical Services,EMERGENCY ROOM,96375,"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",450,$235.00 ,$199.75 ,85% of total billed charges,$35.94 ,Pays 100% Medicare OPPS,$35.94 ,Pays 100% Medicare OPPS,$35.94 ,Pays 100% Medicare OPPS,$48.44 ,Pays 130% Medicare OPPS,$47.87 ,20.37% based on GA Medicaid OP CCR Rate,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,$132.78 ,56.5 percent of total billed charges,$36.65 ,Pays 102% Medicare OPPS,$211.50 ,90% of total billed charges,$82.25 ,35% based on GA Medicaid OP CCR Rate,$161.45 ,68.7% of total billed charges,$188.00 ,80 percent of total billed charges,$35.94 ,Pays 100% Medicare OPPS,$32.35 ,Pays 90% Medicare OPPS,$136.30 ,58% of total billed charges,$47.87 ,20.37% based on GA Medicaid OP CCR Rate,$37.26 ,Pays 100% Medicare OPPS,$48.44 ,Pays 130% Medicare OPPS,$199.75 ,85% of total billed charges,$35.94 ,Pays 100% Medicare OPPS,$32.35 ,$211.50 ,$188.00 
Outpatient Medical Services,EMERGENCY ROOM,96376,"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",450,$215.00 ,$182.75 ,85% of total billed charges,$53.75 ,Pays 100% Medicare OPPS,$53.75 ,Pays 100% Medicare OPPS,$53.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$43.80 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$75.25 ,35% based on GA Medicaid OP CCR Rate,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$193.50 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$43.80 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$43.80 ,$193.50 ,$172.00 
Outpatient Medical Services,EMERGENCY ROOM,43753,GASTRIC LAVAGE,450,$345.00 ,$293.25 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$320.23 ,Pays 130% Medicare OPPS,$70.28 ,20.37% based on GA Medicaid OP CCR Rate,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$194.93 ,56.5 percent of total billed charges,$242.49 ,Pays 102% Medicare OPPS,$310.50 ,90% of total billed charges,$120.75 ,35% based on GA Medicaid OP CCR Rate,$237.02 ,68.7% of total billed charges,$276.00 ,80 percent of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,Pays 90% Medicare OPPS,$200.10 ,58% of total billed charges,$70.28 ,20.37% based on GA Medicaid OP CCR Rate,$246.33 ,Pays 100% Medicare OPPS,$320.23 ,Pays 130% Medicare OPPS,$293.25 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$70.28 ,$320.23 ,$276.00 
Outpatient Medical Services,EMERGENCY ROOM,92950,CPR,450,"$1,020.00 ",$867.00 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$237.74 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$207.77 ,20.37% based on GA Medicaid OP CCR Rate,$576.30 ,56.5 percent of total billed charges,$576.30 ,56.5 percent of total billed charges,$576.30 ,56.5 percent of total billed charges,$576.30 ,56.5 percent of total billed charges,$242.49 ,Pays 102% Medicare OPPS,$918.00 ,90% of total billed charges,$357.00 ,35% based on GA Medicaid OP CCR Rate,$700.74 ,68.7% of total billed charges,$816.00 ,80 percent of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$213.96 ,Pays 90% Medicare OPPS,$591.60 ,58% of total billed charges,$207.77 ,20.37% based on GA Medicaid OP CCR Rate,$246.33 ,Pays 100% Medicare OPPS,$320.22 ,Pays 130% Medicare OPPS,$867.00 ,85% of total billed charges,$237.74 ,Pays 100% Medicare OPPS,$207.77 ,$918.00 ,$816.00 
Outpatient Medical Services,EMERGENCY ROOM,92960,CARDIOVERSION ER,450,"$1,100.00 ",$935.00 ,85% of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$504.64 ,Pays 100% Medicare OPPS,$504.64 ,Pays 100% Medicare OPPS,$672.51 ,Pays 130% Medicare OPPS,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$621.50 ,56.5 percent of total billed charges,$514.73 ,Pays 102% Medicare OPPS,$990.00 ,90% of total billed charges,$385.00 ,35% based on GA Medicaid OP CCR Rate,$755.70 ,68.7% of total billed charges,$880.00 ,80 percent of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$454.17 ,Pays 90% Medicare OPPS,$638.00 ,58% of total billed charges,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,$517.30 ,Pays 100% Medicare OPPS,$672.51 ,Pays 130% Medicare OPPS,$935.00 ,85% of total billed charges,$504.64 ,Pays 100% Medicare OPPS,$224.07 ,$990.00 ,$880.00 
Outpatient Medical Services,EMERGENCY ROOM,96365,"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",450,$415.00 ,$352.75 ,85% of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$183.77 ,Pays 100% Medicare OPPS,$183.77 ,Pays 100% Medicare OPPS,$236.20 ,Pays 130% Medicare OPPS,$84.54 ,20.37% based on GA Medicaid OP CCR Rate,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$234.48 ,56.5 percent of total billed charges,$187.43 ,Pays 102% Medicare OPPS,$373.50 ,90% of total billed charges,$145.25 ,35% based on GA Medicaid OP CCR Rate,$285.11 ,68.7% of total billed charges,$332.00 ,80 percent of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$165.38 ,Pays 90% Medicare OPPS,$240.70 ,58% of total billed charges,$84.54 ,20.37% based on GA Medicaid OP CCR Rate,$181.69 ,Pays 100% Medicare OPPS,$236.20 ,Pays 130% Medicare OPPS,$352.75 ,85% of total billed charges,$183.77 ,Pays 100% Medicare OPPS,$84.54 ,$373.50 ,$332.00 
Outpatient Medical Services,EMERGENCY ROOM,96368,IV CONCURRENT INFUSION,450,$135.00 ,$114.75 ,85% of total billed charges,$33.75 ,Pays 100% Medicare OPPS,$33.75 ,Pays 100% Medicare OPPS,$33.75 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,$76.28 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$121.50 ,90% of total billed charges,$47.25 ,35% based on GA Medicaid OP CCR Rate,$92.75 ,68.7% of total billed charges,$108.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$121.50 ,Pays 90% Medicare OPPS,$78.30 ,58% of total billed charges,$27.50 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$114.75 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$27.50 ,$121.50 ,$108.00 
Outpatient Medical Services,EMERGENCY ROOM,96523,IRRIGATION OF IMPLANTED VENOUS ACCESS,450,$215.00 ,$182.75 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$50.00 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$43.80 ,20.37% based on GA Medicaid OP CCR Rate,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$121.48 ,56.5 percent of total billed charges,$51.00 ,Pays 102% Medicare OPPS,$193.50 ,90% of total billed charges,$75.25 ,35% based on GA Medicaid OP CCR Rate,$147.71 ,68.7% of total billed charges,$172.00 ,80 percent of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$45.00 ,Pays 90% Medicare OPPS,$124.70 ,58% of total billed charges,$43.80 ,20.37% based on GA Medicaid OP CCR Rate,$50.55 ,Pays 100% Medicare OPPS,$65.72 ,Pays 130% Medicare OPPS,$182.75 ,85% of total billed charges,$50.00 ,Pays 100% Medicare OPPS,$43.80 ,$193.50 ,$172.00 
Outpatient Medical Services,EMERGENCY ROOM,99203,"New patient office or other outpatient visit, typically 30 min",450,$40.00 ,$34.00 ,85% of total billed charges,$10.00 ,Pays 100% Medicare OPPS,$10.00 ,Pays 100% Medicare OPPS,$10.00 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,$22.60 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$36.00 ,90% of total billed charges,$14.00 ,35% based on GA Medicaid OP CCR Rate,$27.48 ,68.7% of total billed charges,$32.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$36.00 ,Pays 90% Medicare OPPS,$23.20 ,58% of total billed charges,$8.15 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$34.00 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$8.15 ,$36.00 ,$32.00 
Outpatient Medical Services,EMERGENCY ROOM,99205,"New patient office of other outpatient visit, typically 60 min",450,$310.00 ,$263.50 ,85% of total billed charges,$77.50 ,Pays 100% Medicare OPPS,$77.50 ,Pays 100% Medicare OPPS,$77.50 ,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$63.15 ,20.37% based on GA Medicaid OP CCR Rate,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,$175.15 ,56.5 percent of total billed charges,N/A,Pays 102% Medicare OPPS,$279.00 ,90% of total billed charges,$108.50 ,35% based on GA Medicaid OP CCR Rate,$212.97 ,68.7% of total billed charges,$248.00 ,80 percent of total billed charges,N/A,Pays 100% Medicare OPPS,$279.00 ,Pays 90% Medicare OPPS,$179.80 ,58% of total billed charges,$63.15 ,20.37% based on GA Medicaid OP CCR Rate,N/A,Pays 100% Medicare OPPS,N/A,Pays 130% Medicare OPPS,$263.50 ,85% of total billed charges,N/A,Pays 100% Medicare OPPS,$63.15 ,$279.00 ,$248.00 
Outpatient Medical Services,EMERGENCY ROOM,99281,LEVEL I EMERGENCY ROOM,450,$265.00 ,$225.25 ,85% of total billed charges,$65.16 ,Pays 100% Medicare OPPS,$65.16 ,Pays 100% Medicare OPPS,$65.16 ,Pays 100% Medicare OPPS,$85.85 ,Pays 130% Medicare OPPS,$50.00 ,20.37% based on GA Medicaid OP CCR Rate,$265.00 ,ER Level 1 Case Rate,$265.00 ,ER Level 1 Case Rate,$265.00 ,ER Level 1 Case Rate,$265.00 ,ER Level 1 Case Rate,$66.45 ,Pays 102% Medicare OPPS,$238.50 ,90% of total billed charges,$92.75 ,35% based on GA Medicaid OP CCR Rate,$182.06 ,68.7% of total billed charges,$212.00 ,80 percent of total billed charges,$65.16 ,Pays 100% Medicare OPPS,$58.64 ,Pays 90% Medicare OPPS,$153.70 ,58% of total billed charges,$53.98 ,20.37% based on GA Medicaid OP CCR Rate,$66.04 ,Pays 100% Medicare OPPS,$85.85 ,Pays 130% Medicare OPPS,$225.25 ,85% of total billed charges,$65.16 ,Pays 100% Medicare OPPS,$50.00 ,$265.00 ,$212.00 
Outpatient Medical Services,EMERGENCY ROOM,99282,LEVEL II EMERGENCY ROOM,450,$665.00 ,$565.25 ,85% of total billed charges,$117.99 ,Pays 100% Medicare OPPS,$117.99 ,Pays 100% Medicare OPPS,$117.99 ,Pays 100% Medicare OPPS,$159.72 ,Pays 130% Medicare OPPS,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,$665.00 ,ER Level 2 Case Rate,$665.00 ,ER Level 2 Case Rate,$665.00 ,ER Level 2 Case Rate,$665.00 ,ER Level 2 Case Rate,$120.35 ,Pays 102% Medicare OPPS,$598.50 ,90% of total billed charges,$232.75 ,35% based on GA Medicaid OP CCR Rate,$456.86 ,68.7% of total billed charges,$532.00 ,80 percent of total billed charges,$117.99 ,Pays 100% Medicare OPPS,$106.19 ,Pays 90% Medicare OPPS,$385.70 ,58% of total billed charges,$135.46 ,20.37% based on GA Medicaid OP CCR Rate,$122.86 ,Pays 100% Medicare OPPS,$159.72 ,Pays 130% Medicare OPPS,$565.25 ,85% of total billed charges,$117.99 ,Pays 100% Medicare OPPS,$106.19 ,$665.00 ,$532.00 
Outpatient Medical Services,EMERGENCY ROOM,99283,"Emergency department visit, moderately severe problem",450,$850.00 ,$722.50 ,85% of total billed charges,$207.88 ,Pays 100% Medicare OPPS,$207.88 ,Pays 100% Medicare OPPS,$207.88 ,Pays 100% Medicare OPPS,$280.17 ,Pays 130% Medicare OPPS,$173.15 ,20.37% based on GA Medicaid OP CCR Rate,$850.00 ,ER Level 3 Case Rate,$850.00 ,ER Level 3 Case Rate,$850.00 ,ER Level 3 Case Rate,$850.00 ,ER Level 3 Case Rate,$212.04 ,Pays 102% Medicare OPPS,$765.00 ,90% of total billed charges,$297.50 ,35% based on GA Medicaid OP CCR Rate,$583.95 ,68.7% of total billed charges,$680.00 ,80 percent of total billed charges,$207.88 ,Pays 100% Medicare OPPS,$187.09 ,Pays 90% Medicare OPPS,$493.00 ,58% of total billed charges,$173.15 ,20.37% based on GA Medicaid OP CCR Rate,$215.52 ,Pays 100% Medicare OPPS,$280.17 ,Pays 130% Medicare OPPS,$722.50 ,85% of total billed charges,$207.88 ,Pays 100% Medicare OPPS,$173.15 ,$850.00 ,$680.00 
Outpatient Medical Services,EMERGENCY ROOM,99284,"Emergency department visit, problem of high severity",450,"$1,100.00 ",$935.00 ,85% of total billed charges,$326.77 ,Pays 100% Medicare OPPS,$326.77 ,Pays 100% Medicare OPPS,$326.77 ,Pays 100% Medicare OPPS,$436.35 ,Pays 130% Medicare OPPS,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,"$1,100.00 ",ER Level 4 Case Rate,"$1,100.00 ",ER Level 4 Case Rate,"$1,100.00 ",ER Level 4 Case Rate,"$1,100.00 ",ER Level 4 Case Rate,$333.31 ,Pays 102% Medicare OPPS,$990.00 ,90% of total billed charges,$385.00 ,35% based on GA Medicaid OP CCR Rate,$755.70 ,68.7% of total billed charges,$880.00 ,80 percent of total billed charges,$326.77 ,Pays 100% Medicare OPPS,$294.08 ,Pays 90% Medicare OPPS,$638.00 ,58% of total billed charges,$224.07 ,20.37% based on GA Medicaid OP CCR Rate,$335.65 ,Pays 100% Medicare OPPS,$436.35 ,Pays 130% Medicare OPPS,$935.00 ,85% of total billed charges,$326.77 ,Pays 100% Medicare OPPS,$224.07 ,"$1,100.00 ",$880.00 
Outpatient Medical Services,EMERGENCY ROOM,99285,"Emergency department visit, problem with significant threat to life or function",450,"$1,700.00 ","$1,445.00 ",85% of total billed charges,$469.05 ,Pays 100% Medicare OPPS,$469.05 ,Pays 100% Medicare OPPS,$469.05 ,Pays 100% Medicare OPPS,$626.73 ,Pays 130% Medicare OPPS,$346.29 ,20.37% based on GA Medicaid OP CCR Rate,"$1,700.00 ",ER Level 5 Case Rate,"$1,700.00 ",ER Level 5 Case Rate,"$1,700.00 ",ER Level 5 Case Rate,"$1,700.00 ",ER Level 5 Case Rate,$478.43 ,Pays 102% Medicare OPPS,"$1,530.00 ",90% of total billed charges,$595.00 ,35% based on GA Medicaid OP CCR Rate,"$1,167.90 ",68.7% of total billed charges,"$1,360.00 ",80 percent of total billed charges,$469.05 ,Pays 100% Medicare OPPS,$422.14 ,Pays 90% Medicare OPPS,$986.00 ,58% of total billed charges,$346.29 ,20.37% based on GA Medicaid OP CCR Rate,$482.10 ,Pays 100% Medicare OPPS,$626.73 ,Pays 130% Medicare OPPS,"$1,445.00 ",85% of total billed charges,$469.05 ,Pays 100% Medicare OPPS,$346.29 ,"$1,700.00 ","$1,360.00 "
Outpatient Medical Services,EMERGENCY ROOM,99291,LEVEL VI CRITICAL CARE,450,"$2,110.00 ","$1,793.50 ",85% of total billed charges,$669.13 ,Pays 100% Medicare OPPS,$669.13 ,Pays 100% Medicare OPPS,$669.13 ,Pays 100% Medicare OPPS,$877.84 ,Pays 130% Medicare OPPS,$429.81 ,20.37% based on GA Medicaid OP CCR Rate,"$2,110.00 ",Urgent Care Case Rate,"$2,110.00 ",Urgent Care Case Rate,"$2,110.00 ",Urgent Care Case Rate,"$2,110.00 ",Urgent Care Case Rate,$682.51 ,Pays 102% Medicare OPPS,"$1,899.00 ",90% of total billed charges,$738.50 ,35% based on GA Medicaid OP CCR Rate,"$1,449.57 ",68.7% of total billed charges,"$1,688.00 ",80 percent of total billed charges,$669.13 ,Pays 100% Medicare OPPS,$602.21 ,Pays 90% Medicare OPPS,"$1,223.80 ",58% of total billed charges,$429.81 ,20.37% based on GA Medicaid OP CCR Rate,$675.27 ,Pays 100% Medicare OPPS,$877.84 ,Pays 130% Medicare OPPS,"$1,793.50 ",85% of total billed charges,$669.13 ,Pays 100% Medicare OPPS,$429.81 ,"$2,110.00 ","$1,688.00 "
Outpatient Medical Services,EMERGENCY ROOM,M0243,CASIRIVI AND IMDEV INFUSION,450,"$1,550.00 ","$1,317.50 ",85% of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$396.25 ,Pays 100% Medicare OPPS,$396.25 ,Pays 100% Medicare OPPS,$515.12 ,Pays 130% Medicare OPPS,$315.74 ,20.37% based on GA Medicaid OP CCR Rate,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$404.17 ,Pays 102% Medicare OPPS,"$1,395.00 ",90% of total billed charges,$542.50 ,35% based on GA Medicaid OP CCR Rate,"$1,064.85 ",68.7% of total billed charges,"$1,240.00 ",80 percent of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$356.62 ,Pays 90% Medicare OPPS,$899.00 ,58% of total billed charges,$315.74 ,20.37% based on GA Medicaid OP CCR Rate,$396.25 ,Pays 100% Medicare OPPS,$515.12 ,Pays 130% Medicare OPPS,"$1,317.50 ",85% of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$315.74 ,"$1,395.00 ","$1,240.00 "
Outpatient Medical Services,EMERGENCY ROOM,M0247,SOTROVIMAB INFUSION ER,450,"$1,550.00 ","$1,317.50 ",85% of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$396.25 ,Pays 100% Medicare OPPS,$396.25 ,Pays 100% Medicare OPPS,$515.12 ,Pays 130% Medicare OPPS,$315.74 ,20.37% based on GA Medicaid OP CCR Rate,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$875.75 ,56.5 percent of total billed charges,$404.17 ,Pays 102% Medicare OPPS,"$1,395.00 ",90% of total billed charges,$542.50 ,35% based on GA Medicaid OP CCR Rate,"$1,064.85 ",68.7% of total billed charges,"$1,240.00 ",80 percent of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$356.62 ,Pays 90% Medicare OPPS,$899.00 ,58% of total billed charges,$315.74 ,20.37% based on GA Medicaid OP CCR Rate,$396.25 ,Pays 100% Medicare OPPS,$515.12 ,Pays 130% Medicare OPPS,"$1,317.50 ",85% of total billed charges,$396.25 ,Pays 100% Medicare OPPS,$315.74 ,"$1,395.00 ","$1,240.00 "
Outpatient Medical Services,EMERGENCY ROOM,31603,TRACHEOSTOMY,450,"$3,025.00 ","$2,571.25 ",85% of total billed charges,"$1,215.17 ",Pays 100% Medicare OPPS,"$1,215.17 ",Pays 100% Medicare OPPS,"$1,215.17 ",Pays 100% Medicare OPPS,"$1,587.27 ",Pays 130% Medicare OPPS,$616.19 ,20.37% based on GA Medicaid OP CCR Rate,"$1,709.13 ",56.5 percent of total billed charges,"$1,709.13 ",56.5 percent of total billed charges,"$1,709.13 ",56.5 percent of total billed charges,"$1,709.13 ",56.5 percent of total billed charges,"$1,239.47 ",Pays 102% Medicare OPPS,"$2,722.50 ",90% of total billed charges,"$1,058.75 ",35% based on GA Medicaid OP CCR Rate,"$2,078.18 ",68.7% of total billed charges,"$2,420.00 ",80 percent of total billed charges,"$1,215.17 ",Pays 100% Medicare OPPS,"$1,093.65 ",Pays 90% Medicare OPPS,"$1,754.50 ",58% of total billed charges,$616.19 ,20.37% based on GA Medicaid OP CCR Rate,"$1,220.98 ",Pays 100% Medicare OPPS,"$1,587.27 ",Pays 130% Medicare OPPS,"$2,571.25 ",85% of total billed charges,"$1,215.17 ",Pays 100% Medicare OPPS,$616.19 ,"$2,722.50 ","$2,420.00 "
Outpatient Medical Services,EMERGENCY ROOM,51702,FOLEY CATH INSERTION SIMP,450,$325.00 ,$276.25 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$101.29 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$66.20 ,20.37% based on GA Medicaid OP CCR Rate,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$183.63 ,56.5 percent of total billed charges,$103.31 ,Pays 102% Medicare OPPS,$292.50 ,90% of total billed charges,$113.75 ,35% based on GA Medicaid OP CCR Rate,$223.28 ,68.7% of total billed charges,$260.00 ,80 percent of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$91.16 ,Pays 90% Medicare OPPS,$188.50 ,58% of total billed charges,$66.20 ,20.37% based on GA Medicaid OP CCR Rate,$102.12 ,Pays 100% Medicare OPPS,$132.76 ,Pays 130% Medicare OPPS,$276.25 ,85% of total billed charges,$101.29 ,Pays 100% Medicare OPPS,$66.20 ,$292.50 ,$260.00 
Outpatient Medical Services,EMERGENCY ROOM,90471,Immunization administration by a medical assistant or nurse,450,$240.00 ,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$55.69 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$135.60 ,56.5 percent of total billed charges,$56.80 ,Pays 102% Medicare OPPS,$216.00 ,90% of total billed charges,$84.00 ,35% based on GA Medicaid OP CCR Rate,$164.88 ,68.7% of total billed charges,$192.00 ,80 percent of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$50.12 ,Pays 90% Medicare OPPS,$139.20 ,58% of total billed charges,$48.89 ,20.37% based on GA Medicaid OP CCR Rate,$59.34 ,Pays 100% Medicare OPPS,$77.14 ,Pays 130% Medicare OPPS,$204.00 ,85% of total billed charges,$55.69 ,Pays 100% Medicare OPPS,$48.89 ,$216.00 ,$192.00 
Outpatient Medical Services,BEHAVIORAL,90832,"Psychotherapy, 30 minute",900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,BEHAVIORAL,90834,"Psychotherapy, 45 minutes",900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,BEHAVIORAL,90837,"Psychotherapy, 60 minutes",900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,BEHAVIORAL,90846,"Family psychotherapy, not including patient, 50 minutes",900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,BEHAVIORAL,90847,"Family psychotherapy, including patient, 50 min",900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,BEHAVIORAL,90853,Group psychotherapy,900,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99204,"New patient office of other outpatient visit, typically 45 min",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99243,"Patient office consultation, typically 40 min",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99244,"Patient office consultation, typically 60 min",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99385,"Initial new patient preventive medicine evaluation, for those ages 18 to 39",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OFFICE VISIT,99386,"Initial new patient preventive medicine evaluation, for those ages 40 to 64",761,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,LAB,81000,Manual urinalysis test with examination using microscope,300,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,42820,Removal of tonsils and adenoid glands patient younger than age 12,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,55700,Biopsy of prostate gland,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,55866,Surgical removal of prostate and surrounding lymph nodes using an endoscope,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,59400,"Routine obstetric care for vaginal delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,59510,"Routine obstetric care for cesarean delivery, including pre-and post-delivery care",720,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,59610,Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care,720,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,62323,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,62322,Injection of substance into spinal canal of lower back or sacrum using imaging guidanc,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,64483,Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,66821,Removal of recurring cataract in lens capsule using laser,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Outpatient Medical Services,OUTPATIENT SERVICES,66984,Removal of cataract with insertion of lens,360,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,216,Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,460,Spinal fusion except cervical without major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,470,Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,473,Cervical spinal fusion without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A
Inpatient Medical Services,INPATIENT PROCEDURES,743,Uterine and adnexa procedures for non-malignancy without comorbid conditions or major comorbid conditions or complications,100,SERVICE NOT OFFERED,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,Service not offered,N/A,N/A,N/A