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Item C07Co unty of Monr M l� 4C BOARD OF COUNTY COMMISSIONERS Mayor David Rice, District 4 The Florida Keys Y Mayor Pro Tern Sylvia J. Murphy, District 5 Danny L. Kolhage, District 1 George Neugent, District 2 11.1 5 Heather Carruthers, District 3 County Commission Meeting February 21, 2018 Agenda Item Number: C.7 Agenda Item Swnmary #3863 BULK ITEM: Yes DEPARTMENT: Employee Services TIME APPROXIMATE: STAFF CONTACT: Maria Fernandez- Gonzalez (305) 292 -4448 n/a AGENDA ITEM WORDING: Approval to advertise a Request for Proposals for Self Insured Medical Plans through Third Party Administrator (without Pharmacy Benefits), including Claims Administration, Case Management and Utilization Review Services, Disease Management (DM), Network Management, Wellness Programs, and other Related Services. ITEM BACKGROUND: On February 15, 2017, The County Commission requested that in 2017- 2018 staff issue two health insurance Requests for Proposals. The first was an RFP for Fully Insured Medical Plans and the second was an RFP for a Self - Funded Plan through a Third Party Administrator (TPA). Before you today is the approval to advertise an RFP for the TPA - Self - Funded Medical Plan (without Pharmacy Benefits). The Fully Insured Medical Plan was advertised in December after BOCC approval on 12/13/17. This RFP will allow us to compare Self- Funded plan options alongside Fully Insured options. PREVIOUS RELEVANT BOCC ACTION: March 2010 BOCC directed staff to rebid for Fully- Insured and Self- Funded Providers. February 2011 BOCC approved the RPF for services in medical plan administration on a Self - Funded or Fully- Insured basis. March 2011 was bid opening for medical plan administration on a Self- Funded or Fully- Insured basis. No Fully- Insured proposals were received. February 15, 2017 — BOCC directed staff to issue an RFP for a Self- Funded Plan through a Third Party Administrator (TPA), Agenda Item 2642 attached. December 13, 2017 — BOCC approved advertisement of an RFP for a Fully Insured Medical Plan (without pharmacy). CONTRACT /AGREEMENT CHANGES: n/a STAFF RECOMMENDATION: Approve DOCUMENTATION: Agenda Item 2642 - February 15 2017 Fully Insured RFP Agenda Item 12 -13 -17 1. Specifications - Medical TPA 1- 1- 2019.V5 2. ATTACHMENT A - MEDICAL PLAN BOOKLET 2.1 ATTACHMENT B - MEDICAL CLAIMS. LAG. ENROLLMENT BY MONTH 2.2 ATTACHMENT C - LARGE LOSS REPORT (MINUTETRAQ) 2.3. ATTACHMENT D - CENSUS (MINUTETRAQ) 2.4 ATTACHMENT E - RATE EQUIVALENT (MINUTETRAQ) 3. EXHIBIT A - SCOPE OF SERVICES 3.1 EXHIBIT B - QUESTIONNAIRE 3.2 EXHIBIT C - NETWORK DISRUPTION (MinuteTraq) 3.3 EXHIBIT D - BENEFIT COMPARISON (MinuteTraq) 3.4 EXHIBIT E - CPT CODE WORKSHEET (MinuteTraq) 3.5 EXHIBIT F - PRICING EXHIBIT (MinuteTraq) FINANCIAL IMPACT: Effective Date: N/A Expiration Date: N/A Total Dollar Value of Contract: N/A Total Cost to County: Current Year Portion: Budgeted: Source of Funds: CPI: Indirect Costs: Estimated Ongoing Costs Not Included in above dollar amounts: Revenue Producing: Grant: County Match: Insurance Required: Additional Details: If yes, amount: N/A REVIEWED BY: Bryan Cook Completed 01/30/2018 9:22 AM Assistant County Administrator Christine Hurley 01/30/2018 3:38 PM Cynthia Hall Completed Budget and Finance Completed Maria Slavik Completed Kathy Peters Completed Board of County Commissioners Pending Completed 01/31/2018 7:32 AM 01/31/2018 8:37 AM 01/31/2018 8:47 AM 01/31/2018 2:16 PM 02/21/2018 9:00 AM TIME APPROXIMATE: STAFF CONTACT: glaria Fernandez-Gonzalez (305) 292-4448 N;A ... ..... . . . .x...... ......... ................. ................ .............................................. ... . . . . . . . . ............. ....... . . .. ITEM BACKGROUND: The County Commission requested staff issue a total of four (4) Requests The timing ofthese RFPs must be coordinated with the existing contract term with our current Ph acv vendor. Envision contr act expires 13'31 :2017) and our current Self Insured TPA, Florida lilue (contract expires 113 1 ..:2020) with a $1500000 early termination fee. Attached is a recommended timeline for issuance of these RFPs. Given these dates. County staff is recommending an extension of our agreement with Gallagher Benefirs Services (GBS) through December 30` 301 in order to ensure proper evaluation of tile RFPs, and proper implementation with the new vendors. Further, GBS has dc'k eloped a new process for evaluating pharmacy benefits proposals to assure a comprehensive, proprietary F pricing model that quantitatively evaluates and adjust all proposals for pharmacy benefits by collecting Current PBM usage front the County's existing 1 plan. preparing a financial and non-financial analysis of the proposals. Health Care Analytics (I-ICA) fee for evaluating the pharniacy benefits management (PBM) proposals cost a one-time fee of $25.000. The additional 144 A service will provide real value in e%aluatnul the 1 proposals to the P13 Nil pr grarn. AI .(,) i i tided is a Client Corer a kno%N ledu incra and Compen, at ion Di Selo L re Staten ej t f r acceptance bN the BOCC. PREVIOUS RELEVANT BOCC ACTION: • September 15, 201 NWBOCCuttered into an greet ent x ith Gallaither Benefits Services (GRS) to proNide consulting ser\ ices in the area f Group l • April 1 7 . 2013 agreernenro�ith GRS to renev, for one l y e ear and subsequend) renewed at (lie C'ount's option for two (2) additional conseculi \ a one vear terms • October 1. 2016 imreement extended for one (I additional year through September 20. 2017 CONTRACPAGREEMENT CHANGES: Renew agreement until Dec. 30. 2018 no increase in their service fee STAFF RECOMMENDATION: Approval of amendment and approval to utilize the services of I lealth Care Anal tics to evaluate the PMB proposals received in the 2017 RFP. Acceptance of Client Coverage Acknooledgment and Compensation Disclosure Statement. t DOCUMENTATION: .. . . . ... ................................... ......................... .............. . ......... ............... .............. . ... ................... ... ... ... . ..................... . . . . . ......... . . . . ....... . . ....... . . ............. . . . . ........... . . ... ... FINANCIAL IMPACT: Effective Date: February 15, 2017 Expiration Date: December 31, 2018 Total Dollar Value of Contract: S150,00010 ear plus a one time additional $25,000 for additional services being added (Pharmacy Benefit Manager Proposals) Total Cost to County: $325,000 Current Year Portion: 5125,000 Budgeted: YES Source of Funds: Health Insurance Fund CPI: Indirect Costs.- Estimated Ongoing Costs Not Included in above dollar amounts: Revenue Producing: If yes, amount: Grant: County Match: .5 Insurance Required: Addidonal Details 02 15''17 502-08001 , GROUP IN ADMIN increase to coNer I IC A serN ice for PPM RIT anaINsis $2-5.000.00 Completed Completed Completed Completed Completed Pending 5 z 0 OL 4:58 PM 02 O 1 '2 017 8:23 AM 2,'O `?017 12:53 PM 01V; 2017 12:55 PM 02 . 2017 12:59 PM [17:°15°2017 9:00 AM 5 $150,D00 Early Termination Fee per the Amendment (Vd.L e q6nout4l Held leopow pepwal-Ilas e aslIJOApe 01 1BAoiddV) 1 1 Z 9 l, Aienjqo - ZlP9Z wall epua6V :weLw4oejjV q Health Insurance and Prescription Benefit Request for Proposals (RFPs) Recommended Timellnes Selection Finallet Recommendation - Termination DOCC ApWanl of Analysis to Committee presentations (only Agenda Item Notice to Vendor Drafts from GAS am Publish Date Fire Opening MMCC Meeting H handed) Deadline ROCC AymAl "most date) implementation Oates I 1111612011 ""'par 1 91—ft" 11'.113 1 � 1 1 3 12011 124) 1 1c 111 f117 NJA 7 W/111' 111/115 $150,D00 Early Termination Fee per the Amendment Co unty of M onroe r BOARD OF COUNTY COMMISSIONERS l� Mayor David Rice, District 4 The Flofid Keys F ' Mayor Pro Tern Sylvia J. Murphy, District 5 ' z Danny L. Kolha e District 1 George Neugent, District 2 Heather Carruthers, District 3 County Commission Meeting December 13, 2017 Agenda Item Number: C.19 Agenda Item Summary #3678 BULK ITEM: Yes DEPARTMENT: Employee Services TIME APPROXIMATE: STAFF CONTACT: Maria Fernandez - Gonzalez (305) 292 -4448 n/a AGENDA ITEM WORDING: Approval to advertise a Request for Proposals for Fully Insured Medical Plans (without Pharmacy Benefits), including Claims Administration, Case Management and Utilization Review Services, Disease Management (DM), Network Management, Wellness Programs, and other Related Services. ITEM BACKGROUND: On February 15, 2017, The County Commission requested that in 2017- 2018 staff issue two health insurance Requests for Proposals. The first was an RFP for Fully Insured Medical Plans and the second was an RFP for a Self- Funded Plan. Before you today is the approval to advertise the Fully Insured Medical Plan (without Pharmacy Benefits). PREVIOUS RELEVANT BOCC ACTION: March 2010 BOCC directed staff to rebid for Fully- Insured and Self - Funded Providers. February 2011 BOCC approved the RPF for services in medical plan administration on a Self - Funded or Fully- Insured basis. March 2011 was bid opening for medical plan administration on a Self- Funded or Fully- Insured basis. No Fully- Insured proposals were received. February 15, 2017 — BOCC directed staff to issue the Fully insured health insurance program RFP, Agenda Item 2642 attached. CONTRACT /AGREEMENT CHANGES: n/a STAFF RECOMMENDATION: Approve DOCUMENTATION: MCBCC Fully Insured Medical RFP Draft 2018 ch 11.20.2018 without comment.._ EXHIBIT A - SCOPE OF SERVICES EXHIBIT B - MEDICAL QUESTIONNAIRE EXHIBIT C - NETWORK DISRUPTION EXHIBIT D - BENEFIT COMPARISON EXHIBIT E - RATE EQUIVALENTS EXHIBIT F - PRICING EXHIBIT ATTACHMENT A - MEDICAL PLAN BOOKLET (003) Agenda Item 2642 - February 15 2017 FINANCIAL IMPACT: Effective Date: N/A Expiration Date: N/A Total Dollar Value of Contract: N/A Total Cost to County: Current Year Portion: Budgeted: Source of Funds: CPI: Indirect Costs: Estimated Ongoing Costs Not Included in above dollar amounts: Revenue Producing: Grant: County Match: Insurance Required: Additional Details: If yes, amount: REVIEWED BY: Bryan Cook Completed Cynthia Hall Completed Assistant County Administrator Christine Hurley 11/28/2017 3:50 PM Budget and Finance Skipped Maria Slavik Skipped Kathy Peters Completed Board of County Commissioners Completed 11/28/2017 3:20 PM 11/28/2017 3:47 PM Completed 11/28/2017 2:54 PM 11/28/2017 2:54 PM 11/28/2017 4:18 PM 12/13/2017 9:00 AM MONROE COUNTY REQUEST FOR PROPOSALS FOR MEDICAL THIRD PARTY ADMINISTRATION SERVICES CLAIM ADMINISTRATION, CASE MANAGEMENT AND UTILIZATION REVIEW SERVICES, DISEASE MANAGEMENT (DM), NETWORK MANAGEMENT, WELLNESS PROGRAMS, AND OTHER RELATED SERVICES BOARD OF COUNTY COMMISSIONERS Mayor, David Rice, District 4 Mayor Pro Tem, Sylvia J. Murphy, District 5 Danny L. Kolhage, District 1 George Neugent, District 2 Heather Carruthers, District 3 COUNTY ADMINISTRATOR Roman Gastesi CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES DEPARTMENT Kevin Madok Employee Benefits February 26, 2018 Pglof3l TABLE OF CONTENTS SECTION ONE - INSTRUCTIONS TO PROPOSERS SECTION TWO - COUNTY FORMS EXHIBITS: EXHIBIT A EXHIBIT B EXHIBIT C EXHIBIT D EXHIBIT E EXHIBIT F ATTACHMENTS: A. 2017 SCOPE OF SERVICES MEDICAL QUESTIONNAIRE NETWORK DISRUPTION BENEFIT COMPARISON CPT CODE WORKSHEET PRICING EXHIBIT MEDICAL PLAN BOOKLET B. MEDICAL CLAIMS, LAG, AND ENROLLMENT BY MONTH C. LARGE LOSS REPORT - MEDICAL D. CENSUS E. RATE EQUIVALENTS Pg2of31 NOTICE OF REQUEST FOR COMPETITIVE SOLICITATIONS NOTICE IS HEREBY GIVEN that on Thursday, April 12, 2018, at 3:00 P.M., the Monroe County Purchasing Office will receive and open sealed responses for the following: MEDICAL THIRD PARTY ADMINISTRATION SERVICES MONROE COUNTY, FLORIDA Requirements for submission and the selection criteria may be requested from DemandStar by Onvia at www.demandstar.com OR www.monroecountvbids.com or call toll-free at I- 800-711-1712. The Public Record is available at the Monroe County Purchasing Office located at The Gato Building, 1100 Simonton Street, Room 2-213, Key West, Florida. All Responses must be sealed and must be submitted to the Monroe County Purchasing Office. Publication dates Citizen Mon., 02/26/18 Keynoter Sat., 02/24/18 Reporter Fri., 03/02/18 Pg 3 of3l SECTION ONE: INSTRUCTIONS TO PROPOSERS 1. Objective of the Request for Proposals (RFP) The County's objective is to secure the most cost - effective solution for its medical plan with the overarching goal to save money through reduced administrative costs; along with greater discounts, stronger network, and effective care management. The Monroe County Board of County Commissioners wishes to receive competitive proposals for its PPO Medical Plan Administration, including: claim administration, case management and utilization review services, Disease Management (DM), network management, wellness programs, and other related services as set out in the Scope of Services — Exhibit A, for its current Self - insured Medical Benefits Plan. There is no request for Pharmacy Benefit Management Services at this time. The County contracts with EnvisionRx for Pharmacy Benefit Management Services. PPACA requires the County to integrate the pharmacy claims with the medical claims to calculate maximum out of pocket amounts for participants. Special consideration will be given to proposals that will allow the County to contain costs, maintain integration of the medical and pharmacy claim data, and provide medical benefits that match the current benefit design. It is critical to the County that the overall medical plan is well coordinated and effective in the delivery of services to its employees, retirees, and their dependents. Proposers must demonstrate that they can effectively coordinate with other service providers, how they can integrate necessary data, and what the administrative cost of this integration will be. The County anticipates that this contract will be awarded for an effective date of January 1, 2019. The initial contract term may be up to thirty six (36) months and the County may elect to renew for up to two (2) additional consecutive 1 year terms. The contract term will be dependent upon the acceptability of premium guarantees, coverage, service, provider stability and market conditions. The County is requesting Proposals only for Medical Third Party Administration Services as follows: Proposals are requested to be submitted net of commissions, although it is not required. If any compensation for an agent is included in the rates, this must be fully disclosed along with the exact services the agent will be providing to the County. Please note that any entity and /or person who participated in the drafting of this RFP is disqualified from submitting a proposal in response to this RFP or receiving a commission as a result of the award of a contract for services arising out of this RFP. Calendar Date Activity February 26, 2018 RFP Release Date March 12, 2018 Deadline for Vendor Questions March 19, 2018 Addendum Release Date April 12, 2018 Bid Opening — 3:00 PM. No late bids will be accepted May 24, 2018 Selection Committee Ranking Meeting May 30, 2018 Finalist Interviews if necessa June 20, 2018 Monroe County BOCC Meeting — Approval to negotiate contract January 1, 2019 Contract Effective Date 4431 NOTICE OF POSSIBLE INTERVIEW The County may wish to interview finalists in Key West on May 30, 2018. Proposers who are to be invited for finalist interviews will be notified no later than May 25, 2018 (specific instructions regarding the presentation will be provided no later than May 25, 2018) and should be committed to accommodating this time frame to meet in Key West. Staff present should include all key staff with direct client responsibilities for the MCBCC account, as well as an individual who is authorized to contractually obligate the firm. 2. Background Information Monroe County is a non - charter county and a political subdivision of the State of Florida. The County population is approximately 76,000. The Board of County Commissioners, constituted as the governing body, has all the powers of a body corporate, including the powers to contract; to sue and be sued; to acquire, purchase, hold, lease and convey real estate and personal property; to borrow money and to generally exercise the powers of a public authority organized and existing for the purpose of providing community services to citizens within its territorial boundaries. In order to carry out this function, the County is empowered to levy taxes to pay the cost of operations. Monroe County is the southernmost county in the United States. It is comprised of the Florida Keys and a portion of the Florida Everglades. The Florida Keys are an archipelago of islands stretching from Key West, only 90 miles from Cuba, up to the mainland. In addition to the unincorporated county, there are five municipalities in the Florida Keys: Key West, Marathon, Key Colony Beach, Layton, and Islamorada. Further information about the demographics of the County can be found here: http://www.monroecounty-fl.gov/index.aspx?NID=27 Approximately one -third of the population is situated in the City of Key West, which is the county seat; however, the County offers services throughout the Keys, and has government buildings throughout the Lower Keys (primarily Big Pine Key), Middle Keys (primarily Marathon), and Upper Keys (primarily Plantation Key and Key Largo) in addition to Key West, with employees stationed in all locations. 3. Present Information Monroe County currently offers self - insured PPO Plans to its employees, retirees, and dependents. Plan benefits from 2017 are shown in Attachment A and a Benefit Comparison Grid is provided in Exhibit D. The 2018 plan documents will not be finalized until after the Opening Date, however, the underlying administration of the plan is anticipated to be substantially the same as in the 2017 documents. Monroe County added a High Deductible Health Plan and made several modifications to their existing benefits (highlighted in Exhibit D) to their offering on January 1, 2018. The anniversary date for the plan year is January 1. Premiums for active employees may be paid on a pretax basis through the County's Section 125 Plan. Premiums for Retirees and Surviving Spouses are collected by the County. The Administration Fee is paid by the County on a monthly basis. Effective 1/1/2018 Monroe County modified their Self- Insured Medical plan by introducing a HDHP and one Medicare Retiree EGWP Plan based on the active employee plans. The plans offered are: 1. Option 1- PPO 03559 for active employees 2. Option 2- PPO HDHP for active employees 3. Option 3- Medicare Retiree EGWP Plan based on 03559 5of31 Coverage is currently tracked by the following groupings: • The Board of County Commissioners; • The Clerk of the Circuit Court; • Tax Collector; • Property Appraiser; • Supervisor of Elections; • Sheriff's Office; • Land Authority, and; • Court Administration. Domestic Partners are included as dependents subject to the criteria in Monroe County's RESOLUTION 081 -1998 Active participant (along with their dependents') premiums are deducted bi- weekly and retiree /surviving spouses and COBRA premiums are paid on a monthly basis. All invoices are paid monthly. Contribution rates for the 2018 are included in Attachment E — Rate Equivalents. Rates do not include commissions. The current plan is administered by Florida Blue, which has provided coverage since 2011. With the Implementation of Florida Blue as the TPA, the County achieved savings in their claims costs of over $5.7 million over the first 12 months of the contract. They are committed to maintaining strong network access, aggressive cost controls, effective medical management programs, and transparency. The County has not carried Stop Loss coverage for the Medical Plan since it dropped the coverage in 2001. Compensation: Proposer shall be in compliance with Section 624.428, Florida Statutes. If any commissions and /or service fees are included in your rate quotation, you shall specify the amount of the commissions and /or service fees, to whom they may be paid and your reason(s) for including them. contract. The consultants are paid a fee from the County for these services and are not eligible to receive a fee or commission from any proposer or to submit a proposal on behalf of any agency, broker, or carrier with regard to this RFP The medical administration program currently includes the following provisions: • Coordination of Benefits • Subrogation /Right of Reimbursement • Pre - Admission Certification • Prior authorization for certain procedures • Care Coordination for facility admissions • Care Consultants: one -to -one support and guidance with health care needs • Condition Management for medical conditions 6 of31 • 24x7 nurse line for questions • Prenatal health management program • Diabetes health management program • Clinical prior authorization for certain physician or facility administered medications • Onsite biometric screening for all participants with outreach as warranted • Onsite presentations on health related topics /conditions • Wellness program consultant to help design programs • Teladoc 4. Evaluation Criteria A Selection Committee will be convened to review the Proposals and recommend which Vendor should be selected for the project. The successful Proposer will be selected based on the following criteria. Network disruption analysis — higher points will be granted according to the higher percentage of participating providers as compared to Exhibit C — Network Disruption. 20 points PPO Network accessibility for all participants — higher 10 points points will be assessed for vendors having the higher percentage match for the total population. Overall costs (total financial impact to the County for 55 points — awarded based administrative costs and claim costs / savings on the following criteria. guarantees) • Total ASO Fees and multiple year guarantee (3 year • ASO Fees — level fees preferred) maximum 10 points • Claim Costs — points to be awarded for the lowest • Claim Costs — anticipated claim costs based on the following criteria: maximum 45 points, • CPT Code and Hospital pricing analysis with equal weight performed by the Consulting Actuary between the 3 • Network Discounts, specifically with regard to categories (i.e. 15 Monroe County and including proposed points apiece) hospital and professional services. • Discount Guarantees, including the calculation methodology, the amount of discounts guaranteed, and the financial risk to the vendor. Pg7of31 Ability to provide the Scope of Services. The points for 20 points this criterion will be assigned based on both the responses /compliance to the Scope of Services and the overall information included in the Proposal. This criterion will evaluate both quantitative and qualitative information including: • Qualifications of Proposer and staff; availability of staff • Ability to integrate data with the current external Pharmacy Benefits Manager • Types and description of programs offered: Disease Management, Case Management, Utilization Review, Wellness Programs, Network Management, etc. • Performance guarantees, including the amount of Compliance with RFP Specifications (responsiveness, 5 points submission of required forms, follows required format, etc. Prior experience with government clients 5 points Total points earned are on a scale of 1 — 115 points 1 = lowest 115 = highest A Selection Committee will be analyzing Proposals and providing recommendations to the County Administrator who will ultimately make a recommendation to the Board of County Commissioners regarding which Proposer should be hired. 8431 5. Requests for Additional Information or Clarification Requests for additional information or clarification relating to the specifications of this Request for Proposals shall be submitted in writing directly to: Maria Fernandez - Gonzalez, Benefits Administrator /HIPAA Privacy Officer 1100 Simonton Street, Suite 2 -268 Key West, Florida 33040 Facsimile (305) 292 -4452 All requests for additional information must be received no later than 3:00 PM. March 12, 2018 Any requests received after that date and time will not be answered. All requests for additional information will be answered via an addendum to the RFP, which shall be distributed to all interested Proposers on the schedule listed above. Oral requests will not be answered All addenda are a part of the contract documents and each Proposer will be bound by such addenda, whether or not received by him /her. It is the responsibility of each Proposer to verify that he /she has received all addenda issued before responses are opened. 6. Content of Submission The Proposal submitted in response to this Request for Proposals (RFP) shall be printed on 8 -1/2" x 11" white paper and bound; shall be clear and concise, tabulated, and provide the information requested herein. Statements submitted without the required information will not be considered. Responses shall be organized as indicated below. The Proposer should not withhold any information from the written response in anticipation of presenting the information orally or in a demonstration, since oral presentations or demonstrations may not be solicited. Each Proposer must submit adequate documentation to certify the Proposer's compliance with the County's requirements. Proposer should focus specifically on the information requested. 7. Format. The Proposal shall include the following: A cover page that states "Request for Proposals for Medical Third Party Administration Services ". The cover page should contain Proposer's name, address, telephone number, and the name of the Proposer's contact person(s). B. Table of Contents .Plg •= Tab 1. Letter of Transmittal The Proposer shall provide a letter confirming that the Proposal is an authorized offer by the Proposer and shall list the names of the persons who will be authorized to make representations for the Proposer, their titles, addresses and telephone numbers. Tab 2. Minimum Qualifications Proposer shall provide a statement addressing each item below and supply evidence in this Tab that demonstrates compliance with the minimum qualifications. • The Proposer must be willing and be able to offer the Medical benefits in conjunction with carved out Prescription Drug benefit (Envision RX). • The Proposer shall be licensed in the State of Florida to provide the requested services (TPA or insurer). • The Proposer shall have an A.M. Best rating of A- or higher and a financial size category of VI or higher. • If the Proposer is not rated by A.M. Best or the A.M. Best rating is below A -/VI, Proposer must submit three (3) years of independent audited financial statements. • The Proposer must provide a current (Statement of Standards for Attestation Engagements) SSAE 16 report or its equivalent, reflecting the evaluation of the Suitability of Design and Operating Effectiveness of Controls for the processing of Health Care Claims. • The Proposer shall provide a minimum of five (5) customer references for which they have provided Medical Third Party Administration Services within the past three (3) years. At least two (2) of these references must be from other city or county governments of a similar size within the State of Florida. Each reference at a minimum shall include: o Name and full address of the client; o Name, address, title, and telephone number of the client contact; o Identification of services provided, including years for which the services were offered • The Proposer shall include at least three (3) letters of reference from clients which describes the services performed and the client's satisfaction with the services provided. Letters of reference are preferred, however, if the Proposer desires to include surveys completed by clients regarding the service of the Proposer, they will be considered. Documents from governmental /public entity clients are preferred. Copies are acceptable. Only those Proposers who provide references along with their Proposal will be awarded points. Tab 3. Scope of Services Please include your completed Exhibit A — Scope of Services under this Tab. If your response indicates that you "can comply with deviations ", you must fully explain the deviations in this Tab. Pa 10 431 Tab 4. Questionnaire and Cost Proposal Please include the completed Questionnaire (Exhibit B) under this tab in the file format as provided in the RFP package. Responses should be succinct while providing sufficient information to reply to the specific question. Claim projections are to be based on the historical claims information provided with this RFP. Excessive language is not desired. All Fees for the services described in this RFP shall be included in EXHIBIT F - Pricing Exhibit. The total fee shall be an all- inclusive cost for all services proposed. The fees should all be stated on a Per Employee Per Month (PEPM) basis. No additional costs or fees will be paid, including but not limited to travel costs, per diems, telephone charges, facsimile charges, and postage charges. It is not anticipated that contingencies will be included in the Proposal. However, please include your underwriting assumptions under this Tab, immediately after the Pricing Exhibit. Tab 5. Staffing for this Project and Qualifications of Key Personnel The Proposer shall describe the composition and structure of the firm (sole proprietorship, corporation, partnership, joint venture) and include names of persons with an interest in the firm. Proposer shall include a list of the proposed staff that will perform the work required and shall identify any sub - contractors that will be used, if awarded this contract. The Proposer shall describe the qualifications for each employee on the project team and identify his /her role on the team. If sub - contractors are to be utilized, Proposer must clearly specify the role of each sub - contractor and provide evidence of their qualifications. Include in this section the location of the main office and the location of the office proposed to work on this project. Resumes of all key members of the account team who will be assigned including professional designations and copies of licenses and diplomas are to be included under this Tab. Tab 6. Other Information Tab 6 shall include: • Exhibit C — Network Disruption; • Exhibit D — Benefit Comparison; • Exhibit E — CPT Code Worksheet; • GeoAccess Reports; and • Excel List of PPO network providers as described in Question 15 of the Questionnaire. • Deviations to the RFP not provided elsewhere. • Sample financial and claims reports. • Sample Agreement. Proposer shall provide any additional project experience not already described in other tabs that will give an indication of the Proposer's overall abilities. Pgllof3l If the Proposer cannot fully comply with any of the terms contained in the Request for Proposals, all deviations to the terms must be spelled out in this section, i.e. Tab 6. Tab 7. Litigation In accordance with Section 2- 347(h) of the Monroe County Code, the Proposer must provide the following information: (1) A list of the person's or entity's shareholders with five (5) percent or more of the stock or, if a general partnership, a list of the general partners; or, if a limited liability company, a list of its members; or, if a solely owned proprietorship, names(s) of owner(s); (2) A list of the officers and directors of the entity; (3) The number of years the person or entity has been operating and, if different, the number of years it has been providing the services, goods, or construction services called for in the bid specifications (include a list of similar projects); (4) The number of years the person or entity has operated under its present name and any prior names; (5) Answers to the following questions regarding claims and suits: a. Has the person, principals, entity, or any entity previously owned, operated or directed by any of its officers, major shareholders or directors, ever failed to complete work or provide the goods for which it has contracted? If yes, provide details; b. Are there any judgments, claims, arbitration proceeding or suits pending or outstanding against the person, principal of the entity, or entity, or any entity previously owned, operated or directed by any of its officers, directors, or general partners? If yes, provide details; c. Has the person, principal of the entity, entity, or any entity previously owned, operated or directed by any of its officers, major shareholders or directors, within the last five (5) years, been a party to any lawsuit, arbitration, or mediation with regard to a contract for services, goods or construction services similar to those requested in the specifications with private or public entities? If yes, provide details; d. Has the person, principal of the entity, or any entity previously owned, operated or directed by any of its officers, owners, partners, major shareholders or directors, ever initiated litigation against the county or been sued by the county in connection with a contract to provide services, goods or construction services? If yes, provide details; e. Whether, within the last five (5) years, the owner, an officer, general partner, principal, controlling shareholder or major creditor of the person or entity was an officer, director, general partner, principal, controlling shareholder or major creditor of any other entity that failed to perform services or furnish goods similar to those sought in the request for competitive solicitation. f. Credit references (minimum of three), including name, current address and current telephone number. Tab 8. County Forms Proposer shall complete, execute, and attach the forms specified below which are located in Section Two in this RFP, as well as a copy of a business tax receipt from the Tax Collector's Office and shall include it in this section, i.e. Tab 8: Forms: • Submission Response Form • Lobbying and Conflict of Interest Ethics Clause • Non - Collusion Affidavit • Drug Free Workplace Form • Public Entity Crime Statement 8. COPIES OF RFP DOCUMENTS A. Only complete sets of RFP Documents will be issued and shall be used in preparing responses. The County does not assume any responsibility for errors or misinterpretations resulting from the use of incomplete sets. B. Complete sets of RFP Documents may be obtained in the manner and at the locations stated in the Notice of Request for Competitive Solicitations. C. Each Proposer is responsible for obtaining all Addenda for this RFP and for acknowledging receipt of all Addenda on the RESPONSE FORM. 9. STATEMENT OF PROPOSAL REQUIREMENTS See also Notice of Request for Competitive Solicitation. Interested firms or individuals are requested to indicate their interest by submitting a total of two (2) signed originals, six (6) complete copies of the Proposal, and two (2) complete copies on CD or other electronic media, in a sealed envelope, clearly marked on the outside with the Proposer's name and " PROPOSAL FOR MEDICAL THIRD PARTY ADMINISTRATION SERVICES ", addressed to Monroe County Purchasing Department, 1100 Simonton Street, Room 2 -213, Key West, FL 33040, which must be received on or before 3:00 P.M. local time on Thursday April 12• 2018. The electronic copies must retain all of the Exhibits in the original or requested format (not PDF) in order to be considered compliant with the Bid Specifications. Hand delivered Proposals may request a receipt. No Proposals will be accepted after 3:00 P.M. Faxed or e- mailed Proposals shall be automatically rejected. It is the sole responsibility of each Proposer to ensure its Proposal is received in a timely fashion. 10. DISQUALIFICATION OF PROPOSER A. NON - COLLUSION AFFIDAVIT: Any person submitting a proposal in response to this invitation must execute the enclosed NON - COLLUSION AFFIDAVIT. If it is discovered that collusion exists among the Proposers, the proposals of all participants in such collusion shall be rejected, and no participants in such collusion will be considered in future proposals for the same work. B. PUBLIC ENTITY CRIME: A person or affiliate who has been placed on the convicted vendor list following a conviction for a public entity crime may not submit a proposal on a contract to provide any goods or services to a public entity, may not submit a proposal on a contract with a public entity for the construction or repair of a public building or public work, may not submit Proposals on leases or perform work as a contractor, supplier, subcontractor, or contractor under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. Category Two: $25,000.00 C. DRUG -FREE WORKPLACE FORM: Any person submitting a bid or proposal in response to this invitation must execute the enclosed DRUG - FREE WORKPLACE FORM and submit it with his /her proposal. Failure to complete this form in every detail and submit it with the bid or proposal may result in immediate disqualification of the bid or proposal. D. LOBBYING AND CONFLICT OF INTEREST ETHICS CLAUSE: Any person submitting a bid or proposal in response to this invitation must execute the enclosed LOBBYING AND CONFLICT OF INTEREST CLAUSE and submit it with his /her bid or proposal. Failure to complete this form in every detail and submit it with the bid or proposal may result in immediate disqualification of the bid or proposal. 11. EXAMINATION OF RFP DOCUMENTS A. Each Proposer shall carefully examine the RFP and other contract documents, and inform himself /herself thoroughly regarding any and all conditions and requirements that may in any manner affect cost, progress, or performance of the work to be performed under the contract. Ignorance on the part of the Proposer shall in no way relieve him /her of the obligations and responsibilities assumed under the contract. B. Should a Proposer find discrepancies or ambiguities in, or omissions from, the specifications, or should he be in doubt as to their meaning, he shall at once notify the County. 14 of 31 12. GOVERNING LAWS AND REGULATIONS The Proposer is required to be familiar with and shall be responsible for complying with all federal, state, and local laws, ordinances, rules, professional license requirements and regulations that in any manner affect the work. Knowledge of business tax requirements for Monroe County and municipalities within Monroe County are the responsibility of the Proposer. 13. PREPARATION OF RESPONSES Signature of the Proposer: The Proposer must sign the response forms in the space provided for the signature. If the Proposer is an individual, the words "doing business as ", or "Sole Owner" must appear beneath such signature. In the case of a partnership, the signature of at least one of the partners must follow the firm name and the words "Member of the Firm" should be written beneath such signature. If the Proposer is a corporation, the title of the officer signing the Response on behalf of the corporation must be stated along with evidence of his authority to sign the Response must be submitted. The Proposer shall state in the response the name and address of each person having an interest in the submitting entity. 14. MODIFICATION OF RESPONSES Written modifications will be accepted from Proposers if addressed to the entity and address indicated in the Notice of Request for Competitive Solicitation and received prior to Proposal due date and time. Modifications must be submitted in a sealed envelope clearly marked on the outside, with the Proposer's name and "MODIFICATION TO Proposal for Medical Third Party Administration Services." If sent by mail or by courier, the above - mentioned envelope shall be enclosed in another envelope addressed to the entity and address stated in the Notice of Request for Proposals. Faxed or e- mailed modifications shall be automatically rejected. 15. RESPONSIBILITY FOR RESPONSE The Proposer is solely responsible for all costs of preparing and submitting the response, regardless of whether a contract award is made by the County. 16. RECEIPT AND OPENING OF RESPONSES Responses will be received until the designated time and will be publicly opened. Proposers names shall be read aloud at the appointed time and place stated in the Notice of Request for Competitive Solicitation. Monroe County's representative authorized to open the responses will decide when the specified time has arrived and no responses received thereafter will be considered. No responsibility will be attached to anyone for the premature opening of a response not properly addressed and identified. Proposers or their authorized agents are invited to be present. The County reserves the right to reject any and all responses and to waive technical error and irregularities as may be deemed best for the interests of the County. Responses that contain modifications that are incomplete, unbalanced, conditional, Pg 15 of 31 obscure, or that contain additions not requested or irregularities of any kind, or that do not comply in every respect with the Instruction to Proposer, may be rejected at the option of the County. 17. PROPRIETARY AND CONFIDENTIAL INFORMATION All Proposals received as a result of this RFP are subject to Chapter 119, Florida Statutes and will be made available for inspection by any person in accordance with Florida Statutes. Any Proposer asserting that any portion of its Proposal is confidential or exempt from disclosure under Florida's public records laws must specifically identify the portions of the Proposal asserted to be confidential and must provide specific citations of the Florida Statutes that establish the confidentiality or exemption. All material that is designated as exempt from Chapter 119 must be submitted in a separate envelope, clearly identified as "PUBLIC RECORDS EXEMPT" with your name and the Proposal name marked on the outside. If that material is requested through a public records request, the County will notify the Proposer of the request and give the Proposer five (5) calendar days to obtain a court order blocking the production of the material. If court order is not issued during that time to block the production, the material will be produced. By your designation of material in your Proposal as "Public Records Exempt ", you agree to defend and hold harmless the County from any claims, judgments, damages, costs, and attorney's fees and costs of the challenger and for costs and attorney's fees incurred by the County by reason of any legal action challenging your designation. Please be advised that the designation of an item as exempt from disclosure as a Public Record may impact the ability of the Evaluating Body to adequately assess a Proposal and may therefore affect the ultimate award of the contract. 18. AWARD OF CONTRACT A. The County reserves the right to award separate contracts for the services based on geographic area or other criteria, and to waive any informality in any response, or to re- advertise for all or part of the work contemplated. B. The County also reserves the right to reject the response of a Proposer who has previously failed to perform properly or to complete contracts of a similar nature on time. C. The recommendation of staff shall be presented to the Board of County Commissioners of Monroe County, Florida, for final selection and award of contract. 19. CERTIFICATE OF INSURANCE AND INSURANCE REQUIREMENTS The Proposer shall be responsible for all necessary insurance coverage as indicated below. Certificates of Insurance must be provided to Monroe County within fifteen (15) days after award of contract, with Monroe County BOCC listed as additional 16 of 31 insured as indicated. If the proper insurance forms are not received within the fifteen (15) day period, the contract may be awarded to the next selected Proposer. Policies shall be written by companies licensed to do business in the State of Florida and having an agent for service of process in the State of Florida. Companies shall have an A.M. Best rating of VI or better, The required insurance shall be maintained at all times while Proposer is providing service to County. Worker's Compensation Statutory Limits Employers' Liability Insurance Bodily Injury by Accident Bodily Injury by Disease, policy limits Bodily Injury by Disease, each employee $100,000 $500,000 $100,000 General Liability, including Premises Operation Products and Completed Operations Blanket Contractual Liability Personal Injury Liability Expanded Definition of Property Damage $300,000 Combined Single Limit If split limits are provided, the minimum limits acceptable shall be: Professional Liability $200,000 per person $300,000 per occurrence $200,000 property damage $1,000,000 per Occurrence $2,000,000 Aggregate Monroe County shall be named as an Additional Insured on the General Liability 20. INDEMNIFICATION The Proposer to whom a contract is awarded shall defend, indemnify and hold harmless the County as outlined below. The Proposer covenants and agrees to indemnify, hold harmless and defend Monroe County, its commissioners, officers, employees, agents and servants from any and all claims for bodily injury, including death, personal injury, and property damage, including damage to property owned by Monroe County, and any other losses, damages, and expenses of any kind, including attorney's fees, court costs and expenses, which arise out of, in connection with, or by reason of services provided by the Proposer or any of its Subcontractor(s), occasioned by the negligence, errors, or other wrongful act or omission of the Proposer, its Subcontractor(s), their officers, employees, servants or agents. In the event that the service is delayed or suspended as a result of the Proposer/Vendor's failure to purchase or maintain the required insurance, the Vendor shall indemnify the County from any and all increased expenses resulting from such delay. The first ten dollars ($10.00) of remuneration paid to the Proposer is consideration for the indemnification provided for above. The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere within this agreement. 21. EXECUTION OF CONTRACT The County intends to make an award to the Proposer that has complied with the terms, conditions and requirements of the RFP. Any agreement resulting from this RFP must be governed by the laws of the State of Florida, and must have venue established in the State of Florida. The agreement will be submitted to the Monroe County Board of County Commissioners for final approval. Pg 18 of 31 SECTION TWO: COUNTY FORMS AND INSURANCE FORMS [This page intentionally left blank, with forms to follow.] RESPONSE FORM RESPOND TO: MONROE COUNTY BOARD OF COUNTY COMMISSIONERS Purchasing Department GATO BUILDING, ROOM 2 -213 1100 SIMONTON STREET KEY WEST, FLORIDA 33040 ❑ I acknowledge receipt of Addenda No. (s) I have included: • Response Form ❑ • Lobbying and Conflict of Interest Clause ❑ • Non - Collusion Affidavit ❑ • Drug Free Workplace Form ❑ • Public Entity Crime Statement ❑ • Copy of business tax receipt from the ❑ Tax Collector's office ❑ I have included a current copy of the following professional and occupational licenses: If the applicant is not an individual (sole proprietor), please supply the following information: APPLICANT ORGANIZATION: (Registered business name must appear exactly as it appears on www.sunbiz.org Any applicant other than an individual (sole proprietor) must submit a printout of the "Detail by Entity Name" screen from Sunbiz, and a copy of the most recent annual report filed with the Florida Department of State, Division of Corporations. Fees for services included in contract (total PEPM Administration Fees) per Exhibit F: $ Total Projected Incurred Claims for 1/1/2019 through 12/31/2019: $ Proposed Network Discounts: Professional %. Facility Performance Guarantees — amount at risk: $ The fee is an all- inclusive cost. No additional costs or fees will be paid, including but not limited to travel costs, per diems, telephone charges, facsimile charges, and postage charges. Mailing Address: Signed: (Print Name) Telephone: Fax: Date Witness: (Title) STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by to me or has produced identification. (name of affiant). He /She is personally known (type of identification) as NOTARY PUBLIC My Commission SWORN STATEMENT UNDER ORDINANCE NO. 010 -1990 MONROE COUNTY, FLORIDA ETHICS CLAUSE (Company) "...warrants that he /it has not employed, retained or otherwise had act on his /her behalf any former County officer or employee in violation of Section 2 of Ordinance No. 010- 1990 or any County officer or employee in violation of Section 3 of Ordinance No. 010- 1990. For breach or violation of this provision the County may, in its discretion, terminate this Agreement without liability and may also, in its discretion, deduct from the Agreement or purchase price, or otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration paid to the former County officer or employee." (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by personally known to me or has produced (type of identification) as identification (name of affiant). He /She is NOTARY PUBLIC My Commission Expires: Pg 21 of 31 I, of the city of according to law on my oath, and under penalty of perjury, depose and say that 1. 1 am of the firm of the bidder making the Proposal for the project described in the Request for Proposals for and that I executed the said proposal with full authority to do so; 2. The prices in this bid have been arrived at independently without collusion, consultation, communication or agreement for the purpose of restricting competition, as to any matter relating to such prices with any other bidder or with any competitor; 3. Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prior to bid opening, directly or indirectly, to any other bidder or to any competitor; and 4. No attempt has been made or will be made by the bidder to induce any other person, partnership or corporation to submit, or not to submit, a bid for the purpose of restricting competition; 5. The statements contained in this affidavit are true and correct, and made with full knowledge that Monroe County relies upon the truth of the statements contained in this affidavit in awarding contracts for said project. (Signature) STATE OF: COUNTY OF: Date: Subscribed and sworn to (or affirmed) before me on (date) by (name of affiant). He /She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: Pg 22 of 31 The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that. (Name of Business) 1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Informs employees about the dangers of drug abuse in the workplace, the business' policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed upon employees for drug abuse violations. 3. Gives each employee engaged in providing the commodities or contractual services that are under bid a copy of the statement specified in subsection (1). 4. In the statement specified in subsection (1), notifies the employees that, as a condition of working on the commodities or contractual services that are under bid, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction. 5. Imposes a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, or any employee who is so convicted. 6. Makes a good faith effort to continue to maintain a drug -free workplace through implementation of this section. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. (Signature) STATE OF: COUNTY OF: Date: Subscribed and sworn to (or affirmed) before me on (date) by (name of affiant). He /She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: Pg 23 of 31 PUBLIC ENTITY CRIME STATEMENT "A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on a contract to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list." I have read the above and state that neither (Proposer's name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months. (Signature) STATE OF: Date: COUNTY OF: Subscribed and sworn to (or affirmed) before me on (date) by (name of affiant). He /She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: Pg24of31 MONROE COUNTY, FLORIDA RISK MANAGEMENT POLICY AND PROCEDURES CONTRACT ADMINISTRATION MANUAL Indemnification and Hold Harmless For Other Contractors and Subcontractors The Contractor covenants and agrees to indemnify and hold harmless Monroe County Board of County Commissioners from any and all claims for bodily injury (including death), personal injury, and property damage (including property owned by Monroe County) and any other losses, damages, and expenses (including attorney's fees) which arise out of, in connection with, or by reason of services provided by the Contractor or any of its Subcontractor(s) in any tier, occasioned by negligence, errors, or other wrongful act of omission of the Contractor or its Subcontractors in any tier, their employees, or agents. In the event the completion of the project (to include the work of others) is delayed or suspended as a result of the Contractor's failure to purchase or maintain the required insurance, the Contractor shall indemnify the County from any and all increased expenses resulting from such delay. The first ten dollars ($10.00) of remuneration paid to the Contractor is for the indemnification provided for above. The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere within this agreement. 25 of 31 WORKERS' COMPENSATION INSURANCE REQUIREMENTS FOR CONTRACT BETWEEN MONROE COUNTY, FLORIDA AND Prior to the commencement of work governed by this contract, the Contractor shall obtain Workers' Compensation Insurance with limits sufficient to respond to the applicable state statutes. In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than: $100,000 Bodily Injury by Accident $500,000 Bodily Injury by Disease, policy limits $100,000 Bodily Injury by Disease, each employee Coverage shall be maintained throughout the entire term of the contract. Coverage shall be provided by a company or companies authorized to transact business in the state of Florida. If the Contractor has been approved by the Florida's Department of Labor, as an authorized self- insurer, the County shall recognize and honor the Contractor's status. The Contractor may be required to submit a Letter of Authorization issued by the Department of Labor and a Certificate of Insurance, providing details on the Contractor's Excess Insurance Program. If the Contractor participates in a self- insurance fund, a Certificate of Insurance will be required. In addition, the Contractor may be required to submit updated financial statements from the fund upon request from the County. Pg 26 of 31 GENERAL LIABILITY INSURANCE REQUIREMENTS FOR CONTRACT BETWEEN MONROE COUNTY, FLORIDA AND Prior to the commencement of work governed by this contract, the Contractor shall obtain General Liability Insurance. Coverage shall be maintained throughout the life of the contract and include, as a minimum: • Premises Operations • Products and Completed Operations • Blanket Contractual Liability • Personal Injury Liability • Expanded Definition of Property Damage The minimum limits acceptable shall be: $300,000 Combined Single Limit (CSL) If split limits are provided, the minimum limits acceptable shall be: $200,000 per Person $300,000 per Occurrence $200,000 Property Damage An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its provisions should include coverage for claims filed on or after the effective date of this contract. In addition, the period for which claims may be reported should extend for a minimum of twelve (12) months following the acceptance of work by the County. The Monroe County Board of County Commissioners shall be named as Additional Insured on all policies issued to satisfy the above requirements. 27 of 31 PROFESSIONAL LIABILITY INSURANCE REQUIREMENTS FOR CONTRACT BETWEEN MONROE COUNTY, FLORIDA AND Recognizing that the work governed by this contract involves the furnishing of advice or services of a professional nature, the Contractor, shall purchase and maintain, throughout the life of the contract, Professional Liability Insurance which will respond to damages resulting from any claim arising out of the performance of professional services or any error or omission of the Contractor arising out of work governed by this contract. The minimum limits of liability shall be: $1,000,000 per occurrence /$2,000,000 aggregate 28 of 31 MONROE COUNTY, FLORIDA RISK MANAGEMENT POLICY AND PROCEDURES CONTRACT ADMINISTRATION MANUAL WAIVER OF INSURANCE REQUIREMENTS There will be times when it will be necessary, or in the best interest of the County, to deviate from the standard insurance requirements specified within this manual. Recognizing this potential and acting on the advice of the County Attorney, the Board of County Commissioners has granted authorization to Risk Management to waive and modify various insurance provisions. Specifically excluded from this authorization is the right to waive: • The County as being named as an Additional Insured — If a letter from the Insurance Company (not the Agent) is presented, stating that they are unable or unwilling to name the County as an Additional Insured, Risk Management has not been granted the authority to waive this provision. and • The Indemnification and Hold Harmless provisions Waiving of insurance provisions could expose the County to economic loss. For this reason, every attempt should be made to obtain the standard insurance requirements. If a waiver or a modification is desired, a Request for Waiver of Insurance Requirement form should be completed and submitted for consideration with the proposal. After consideration by Risk Management and if approved, the form will be returned, to the County Attorney who will submit the Waiver with the other contract documents for execution by the Clerk of the Courts. Should Risk Management deny this Waiver Request, the other party may file an appeal with the County Administrator or the Board of County Commissioners, who retains the final decision - making authority. P29of31 MONROE COUNTY, FLORIDA Request For Waiver of Insurance Requirements It is requested that the insurance requirements, as specified in the County's Schedule of Insurance Requirements, be waived or modified on the following contract: Contractor: Contract for: Address of Contractor: Phone: Scope of Work: Reason for Waiver: Policies Waiver will apply to: Signature of Contractor: Approved Not Approved Risk Management: Date: County Administrator appeal: Approved Not Approved Date: Board of County Commissioners appeal: Approved Not Approved Meeting Date: PROPOSER SIGNATURE 30 of 31 I W-' I ay Js Benefit Booklet for Covered Plan Participants of Monroe County BOCC Group Health Plan Supplement to the Blue Options Effective as of January 1, 2017 This is a supplement to the Blue Options Benefit Booklet (`Booklet ") and is intended to provide information not otherwise included in the Booklet. In the event of a conflict between this Supplement and the Booklet, the provisions of this Supplement shall govern. In the event of a conflict between this Supplement and a County Resolution, the County Resolution shall govern. Table of Contents RESOLUTION NO. 018 -1998 - Domestic Partnerships Requirements ............... ..............................3 RESOLUTION NO. 388 -2013 - Retiree Eligibility Requirements .......................... ..............................6 RE- ENROLL ELIGIBILITY FOR FORMER EMPLOYEES RETIRING WITH FRS ..........................7 MEDICARE COORDINATION OF BENEFITS AFTER RETIREMENT ..................... ............................... 7 OPTOUT .................................................................................................................................... ............................... 7 InitialEnrollment Period ................................................................................................ ............................... 7 OpenEnrollment Period ................................................................................................. ............................... 7 CESSATION OF ACTIVE WORK .......................................................................................... ..............................8 Insurance Coverage While on Leave of Absence ................................................... ............................... 8 Rehire / Reinstatement ..................................................................................................... ............................... 8 ActiveMilitary Duty ......................................................................................................... ............................... 9 CONTINUATIONOF COVERAGE ........................................................................................ ..............................9 EligibleRetirees ........................................................................................... ..............................9 Surviving Spouses of Covered Retirees .................................................................... ............................... 9 DomesticPartners ............................................................................................................. ..............................9 GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS ......... .............................10 SELF - FUNDED PROGRAMS ............................................................................................. ............................... 13 NON- TOBACCO USE POLICY ........................................................................................... ............................... 13 FALSE OR FRAUDLENT INSURANCE CLAIMS .............................................. .............................15 CARRIERS AND CONTACT INFORMATION ................................................... .............................16 2 RESOLUTION NO. 081 -1998 - DOMESTIC PARTNERSHIP Eligible Domestic Partner means an individual who meets the requirements of Resolution No. 08 1- 1998 as restated below: 14.02 DEFINITIONS A. Domestic Partners. "Domestic Partners" are two adults who have chosen to share one another's lives in a committed family relationship of mutual caring. Two individuals are considered to be Domestic Partners if: 1. they consider themselves to be members of each others immediate family; 2. they agree to be jointly responsible for each other's basic living expenses; 3. neither of them is married or a member of another Domestic Partnership; 4. they are not blood related in a way that would prevent them from being married to each other under the laws of Florida; 5. each is at least of the legal age and competency required by Florida law to enter into a marriage or other binding contract; 6. they must each sign a Declaration of Domestic Partnership as provided for in Section 14.03 of Monroe County BOCC's Personnel Policies and Procedures Manual; 7. they both reside at the same address. B. Joint Responsibility for Basic Living Expenses. "Basic living expenses" means basic food and shelter. "Joint responsibility" means that each partner agrees to provide for the other's basic living expenses while the domestic partnership is in effect if the partner is unable to provide for him or herself. It does not mean that the partners must contribute equally or jointly to basic living expenses. C. Competent to Contract. "Competent to Contract" means the two partners are mentally competent to contract. D. Domestic Partnership. "Domestic Partnership" means the entity formed by two individuals who have met the criteria listed above and file a Declaration of Domestic Partnership as described below. E. Declaration of Domestic Partnership. "Declaration of Domestic Partnership" or "DDP" is a form provided by the Human Resources Director. By signing it, two people swear under penalty of perjury that they meet the requirements of the definition of domestic partnership when they sign the statement. The form shall require each partner to provide a mailing address. F. Dependent. "Dependent" means an individual who lives within the household of a domestic partnership and is: 1. A biological child or adopted child of a domestic partner; or c 2. A dependent as defined under County employee benefit plan document. 0 3. A ward of a domestic partner as determined in a guardianship proceeding. U G. Employee means an employee of the Board of County Commissioners, the constitutional officers or the Mosquito Control Board, except where the context is otherwise. 3 14.03 ESTABLISHING A DOMESTIC PARTNERSHIP A. An employee and his/her domestic partner as set out in Section 14.02 are eligible to declare a Declaration of Domestic Partnership (hereafter DPP) in the presence of the Human Resources Director, or the employee partner may present a signed and notarized DDP to the Human Resources Director. The DDP shall include the name and date of birth of each of the domestic partners, the address of their common household, and the names and dates of birth of any dependents of the domestic partnership, and shall be signed, under the pain and penalties of perjury, by both domestic partners and witnessed (two) and notarized. B. As further evidence of two individuals being involved in a domestic partnership, two of the following documents must be presented along with the DDP to the Human Resources Director: 1. A lease, deed or mortgage indicating that both parties are joint responsible; 2. Driver's licenses for both partners showing same address; 3. Passports for both partners showing the same address; 4. Verification of a joint bank account (savings or checking) 5. Credit cards with the same account numbers in both names; 6. Joint wills; 7. Powers of attorney; or 8. Joint title indicating both partners own a vehicle. C. An individual cannot become a member of a domestic partnership until at least six months after any other domestic partnership of which she or he was a member has ended and a notice that the partnership has ended was given as provided for in Section 14.04. This does not apply if their domestic partners are deceased. D. Domestic partners may amend the DDP to add or delete dependents or change the household address. Amendments to the DDP shall be executed in the same manner as the declaration of a domestic partnership. 14.04 TERMINATION OF A DOMESTIC PARTNERSHIP A. A domestic partnership is terminated when: 1. one of the partners dies; 2. one of the partners marries; or 3. a domestic partner files a termination statement with the Human Resources Director. A domestic partnership may be terminated by a domestic partner who files with the Human Resources Director by hand or by certified = mail, a termination statement. The person filing the termination statement must declare under pain and penalties of perjury that the domestic partnership is terminated and that a copy of the termination statement has been mailed by certified mail to the other domestic partner at his or her last known address. The ;; person filing the termination statement must include on such statement the address to which the copy was mailed. U B. The termination of a domestic partnership shall be effective immediately upon the ig date of a domestic partner. The voluntary termination of a domestic partnership < by a partner shall be effective thirty (30) days after the receipt of a termination F statement by the Human Resources Director. If the termination statement is withdrawn before the effective date, the domestic partner shall give notice of the withdrawal, by certified mail, to the other domestic partner. C. If a domestic partnership is terminated by the death of a domestic partner, there shall be no required waiting period prior to filing another domestic partnership. If a domestic partnership is terminated by one or both domestic partners, neither domestic partner may file another domestic partnership until six (6) months have elapsed from effective termination. D. It is the obligation of the employee domestic partner to notify the Human Resources Director of the termination of a domestic partnership as soon as possible after it occurs. 14.05 HUMAN RESOURCES DIRECTOR RECORDS A. The Human Resources Director will keep a record of all employees DDP's, Amendments and Termination Statements. The records will be maintained so that DDPs, Amendments and Termination Statements will be filed to which they apply. B. The Human Resources Director shall indentify on the DDP what type of documents was presented for further verification of the domestic partnership. C. Upon determination by the Human Resources Director that the DDP is complete and that further evidence of the domestic partnership has been presented as provided in Section 14.03(B); the Human Resources Director shall provide the employee with a copy of the DDP. The employee /domestic partner shall become eligible to elect domestic partnership health and other employee fringe benefits as provided in Section 14.06. It will be the employee's responsibility to notify the Employee Benefits Section of their intent to enroll the domestic partner and/or any eligible dependents under the Monroe County Employee Benefit Plan. Domestic partner /dependents enrolled in the Monroe County Employee Benefit Plan are subject to the same rules and provision applicable to covered spouses /dependents. D. The Human Resources Director shall provide forms to employees requesting them. E. The Human Resources Director shall allow public access to domestic partnership records to the same extend and in the same manner as any other public record. 5 RESOLUTION NO. 388 -2013 - RETIREMENT ELIGIBILITY FOR GROUP HEALTH PLAN Eligible Retiree means an individual who meets one of the following requirements as established by the Board of County Commissioners Resolution No. 388 -2013 - Retirement Eligibility Requirements for Group Health Insurance Coverage for Monroe County Employees • Hire date prior to 10 /01 /01; a minimum of ten (10) years of full -time service with Monroe County; retire under the FRS on, or after, the Normal Retirement date as described in Section 121.021(29), F.S.; and covered under the Plan at retirement. Current contribution is $5.00 per month for each year of creditable service with the Florida Retirement System at the time of retirement with Monroe County. Premium minimum is $50 for ten years of service and the premium maximum is $150 for 30 years of service. • Hire date prior to 10 /01 /01; a minimum of ten (10) years of full -time service with Monroe County; retire under the FRS at an Early Retirement date as described in Section 121.021(30), F.S.; covered under the Plan at retirement; 60 years of age or age and years of service must satisfy Rule of 70 ** at time of retirement. Current contribution is $5.00 per month for each year of creditable service with the Florida Retirement System at the time of retirement with Monroe County. Premium minimum is $50 for ten years of service and the premium maximum is $150 for 30 years of service. • Hire date prior to 10 /01 /01; a minimum of ten (10) years of full -time service with Monroe County; retire under the FRS at an Early Retirement date as described in Section 121.021(30), F.S.; covered under the Plan upon retirement; NOT 60 years of age and age and years of service do not satisfy Rule of 70 * *. Current contribution is the departmental rate. Upon attaining either the age of 60 or satisfy Rule of 70 ** the contribution will change to the current contribution of $5.00 per month for each year of creditable service with the Florida Retirement System at the time of retirement with Monroe County. Premium minimum is $50 for ten years of service and the premium maximum is $150 for 30 years of service. • Hire date on or after 10/01/01; a minimum of ten (10) years of full -time service with Monroe County; retire with the FRS as described in Section 121.021(29 or 121.021 (30), F.S.; covered under the Plan upon retirement. Current contribution is departmental rate. • Retire from FRS as described in Section 121.021(29) or 121.021(30), F.S.; less than ten (10) years of full -time service with Monroe County; covered under the Plan upon retirement. Current contribution is the departmental rate. • Former Eligible Employee with at least ten (10) years of full -time service with Monroe z County; covered under the Plan upon termination of employment and fully vested under FRS who elect not to retire under FRS upon termination of employment with Monroe v County, may elect to re- enroll under the Plan upon retirement under FRS, provided that h Monroe County was their last FRS employer. Current contribution is the departmental rate. C i *HIS: Health Insurance Subsidy per Section 112.363, Florida Statutes. E **Rule of 70: Eligible Retirees satisfy the Rule of 70 if their age, combined with the number of years of service with Monroe County, totals 70 or more. 6 RE- ENROLL ELIGIBILITY FOR FORMER EMPLOYEES RETIRING WITH FRS Former Employee Retiring with FRS - An individual who meets the eligibility criteria specified below is an Eligible Retiree and is eligible to apply for coverage under the Blue Options Benefit Booklet for Covered Monroe County Group Health Participants: A person who elects to continue re- enroll in the Monroe County Group Health Plan at the time of their official retirement under the Florida Retirement System (FRS), and is not currently an Eligible Employee but Monroe County was their last FRS employer prior to retirement. Coverage will be offered within 30 days of retirement. If the Eligible Retiree fails to elect retiree coverage at time of retirement, waives retiree coverage or lets coverage lapse, the Eligible Retiree will permanently lose entitlement to re- enroll under the Monroe County Group Health Plan. MEDICARE COORDINATION OF BENEFITS AFTER RETIREMENT Retirees, their eligible dependents, or a surviving spouse who becomes eligible for Medicare due to age 65, End state Renal Disease (ERSD), or disability must notify the Monroe County BOCC Benefits Office immediately. It is the responsibility of the ensured to enroll in Medicare as soon as they are eligible. Medicare will become the Primary Payer and coverage under the Monroe County Health Plan will become the Secondary Payer. The Monroe County BOCC will not be liable to any individual covered under this health plan on account of any nonpayment of primary benefits resulting from failure to be timely notified by the enrolled participant of their eligibility for enrollment in Medicare. OPT OUT Initial Enrollment Period means the 30 day period starting on your date of hire during which you and your eligible dependent(s) have the ability to either elect coverage for yourself and /or your eligible dependents, or Opt Out of coverage. You can Opt Out by indicating that you elect to waive coverage on the Monroe County Benefits Enrollment Form. If you Opt Out during your Initial Enrollment Period, you will not be able to enroll in the Monroe County Group Health Plan unless you have a Special Enrollment right or during a future Open Enrollment Period. Open Enrollment Period means the period selected by Monroe County during which you can E elect coverage for yourself and /or your eligible dependents, or Opt Out of coverage, for the immediately following Plan Year. You can Opt Out by indicating that you elect to waive coverage on the Monroe County Benefits Enrollment Form. If you Opt Out during the Open C i Enrollment Period, you will not be able to enroll in the Monroe County Group Health Plan unless you have a Special Enrollment right or during a future Open Enrollment Period. U 7 CESSATION OF ACTIVE WORK - Insurance Coverage While on Leave of Absence The Plan will continue to maintain group insurance benefits for employees while on approved paid leave status. MEDICAL LEAVE - If an Eligible Employee ceases Active Work due to illness, injury or pregnancy the Employer in its sole discretion may approve a medical leave of absence. Coverage for the Eligible Employee will continue under the Plan, but for no longer than six (6) months from the date the approved medical leave begins, including any approved FMLA leave. Coverage of Eligible Dependents will continue during this time provided required premiums are continued to be paid. Notification of all approved medical leave must be provided to the Monroe County Group Health Plan Administrator (Benefits Office) by the Employer. The notification should contain the date on which the leave began and when it will end. An Eligible Employee who has been on an approved medical leave must return to active work for a minimum of 30 days after the approved medical leave ends. In the event an Eligible Employee on an approved medical leave does not return to active work at the end of the leave, the Eligible Employee will be required to reimburse the Plan for the health benefit premiums paid during the leave to continue coverage. *EXCEPTION: When an Eligible Employee fails to return to active work because of the continuation, recurrence, or onset of either a serious health condition of the Eligible Employee or an Eligible Employee's family member the Plan will not recover the health benefit premium payments made on the Eligible Employee's behalf during the approved medical leave. The Monroe County Group Health Plan Administrator (Benefits Office) may require medical certification of the Eligible Employee's or the Eligible Employee's family member's serious health condition. If leave extends beyond the maximum allowed period of six months and the employee is on a non -paid status, said employee must make the monthly premium payments for themselves in order to continue health insurance coverage. Failure to make payment(s) on a timely basis will result in termination of coverage. PERSONAL LEAVE — If personal leave without pay is approved by the Employer, said employee must reimburse the Plan for the health benefit premiums paid during the leave to continue coverage. Coverage of Eligible Dependents will continue during this time provided required premiums are continued to be paid. Personal Leave under the Plan cannot exceed six (6) months Rehire /Reinstatement If subsequent to termination of coverage an Eligible Employee is rehired or reinstated as an Eligible Employee the Eligible Employee must meet the eligibility requirements in the Eligibility �— for Coverage section. However, the Plan allows a grace period of 2 days following the date of termination of coverage during which an Eligible Employee may be rehired or reinstated without c penalty. ' U Active Military Duty Return from active military duty by a former Eligible Employee of two weeks or longer who is rehired or reinstated will be treated as if the Eligible Employee were on an approved leave of absence for purposes of eligibility under the Plan. The Plan's waiting period or preexisting condition exclusion period will not be applicable CONTINUATION OF COVERAGE Eligible Retirees: If any Eligible Retiree fails to elect retiree coverage at time of retirement, waives retiree coverage or lets coverage lapse, the Eligible Retiree will permanently lose entitlement to re- enroll under the Monroe County Group Health Plan. Surviving Spouses of Covered Retirees: Upon the death of a Covered Retiree, the Surviving Spouse may continue coverage under the Monroe County Group Health Plan provided: (1) the Surviving Spouse does not remarry; and (2) the Surving Spouse makes timely payment of any required contribution. It is the sole responsibility of the Surviving Spouse to notify the Monroe County Group Health Plan Administrator (Employee Benefits Office) of a change in marital status. Domestic Partners: For purposes of COBRA Continuation Coverage Rights, a Domestic Partner of an Eligible Employee shall be treated as the Eligible Employee's "spouse" and the dependent child(ren) of a Domestic Partner shall be treated as the Eligible Employee's stepchild(ren). 9 Cn DIN DI :10►[1119to DEB] 9*3 ►Y0 10111:1Y1110[IL YDI:Al"D1N1":1V Introduction You're getting this notice because you recently gained coverage under a group health plan (Monroe County Group Health Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan's Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out -of- pocket costs. Additionally, you may qualify for a 30 -day special enrollment period for another group health plan for which you are eligible (such as a spouse's plan), even if that plan generally doesn't accept late enrollees. What is COBRA continuation or? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a "qualifying event." Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a ,. qualified beneficiary." You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you're an employee, you'll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you're the spouse of an employee, you'll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; _ v • Your spouse's hours of employment are reduced; • Your spouse's employment ends for any reason other than his or her gross misconduct; E' Q • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because U of the following qualifying events: • The parent - employee dies; • The parent - employee's hours of employment are reduced; 10 • The parent - employee's employment ends for any reason other than his or her gross misconduct; • The parent - employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a "dependent child." The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer; or • The employee's becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child's losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 30 days after the qualifying event occurs. You must provide this notice to: Maria Fernandez - Gonzalez, Benefits Administrator, 1100 Simonton Street, Suite 2 -268, Key West, FL 33040; Facsimile (305) 292 -4452. How is continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18 -month period of COBRA continuation coverage can be extended: `` ci Disability extension of 18 -month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled U and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. 11 *NOTE: The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18 -month period of COBRA continuation coverage. A copy of the letter from Social Security with the date disability was determined and approved must be provided this to: Maria Fernandez - Gonzalez, Benefits Administrator, 1100 Simonton Street, Suite 2 -268, Key West, FL 33040, Facsimile (305) 292 -4452. Second qualifying event extension of 18 -month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there offer coverage options besides COBRA Continuation Coverage" Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse's plan) through what is called a "special enrollment period." Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at ww.healthear . ov If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit wwwAol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website.) For more information about the Marketplace, visit yvyywJJea1thCnrP.f3nv. Keep your Plea informed o address changes To protect your family's rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan contact information You can obtain information about the Monroe County Group Health Plan and COBRA from: Natalie Maddox, Coordinator 1100 Simonton Street, Suite 2 -268 E Key West, FL 33040 Phone: 305 -292 -4450 d Email: maddox- natalie@monroecounty -fl.gov 12 SELF - FUNDED PROGRAMS Where the Board of County Commissioners has determined that the use of a self - funded program is in its best interest, it will be the County Administrator's responsibility to oversee the Administration of said programs. Any proposed change to the self - funded health insurance program that would constitute a material reduction in benefits or change in cost to current employees and retirees that will be presented to the Board of County Commissioners will be preceded by a two week written notice to the affected employees and retirees. NON- TOBACCO USE POLICY Monroe County BOCC has implemented a non - tobacco use policy for all newly enrolled Medical Health plan members effective January 1, 2015. All Newly Enrolled individuals in the Medical Health Plan will be assessed a surcharge if currently using tobacco products. Tobacco products are defined as cigarettes, cigars, pipe tobacco, chewing tobacco, snuff, dip, electronic or e- cigarettes that contain nicotine or any other product that contains tobacco or nicotine. Nicotine replacement products, such as gum and patches, are also considered tobacco products. Tobacco user Surcharge & Penalty 1. The non - tobacco use policy applies to employees and their dependents enrolled in the medical health and prescription benefit plans. Enrolled employees are required to complete the Tobacco Use Attestation Certification form within 30 days of enrollment. Failure to complete and return the Tobacco Attestation Certification form will be treated as an admission that the employee is a tobacco user. 2. Each newly covered dependent(s) over the age of 18 must complete the Tobacco Use Attestation form before dependent coverage becomes effective. 3. Changes in the use of tobacco products by anyone covered in the plan require the immediate completion of a new certification form. 4. Discontinuing the use of tobacco products requires a new non - tobacco user certification. 5. Using tobacco products requires a new tobacco user certification. 6. All certification forms must be submitted to the BOCC Group Benefits office. 7. Tobacco users will be charged a monthly surcharge of $50 each per month. U 8. Failing to certify or providing false information will result in a $50 surcharge and a S penalty of $50 each per month (Total $100 each per month). d 13 9. Nonrefundable surcharges and /or penalties for the employee and /or dependents will be deducted from the employee's next paycheck in accordance with the payroll schedule. 10. Changes to the surcharge and penalties will be processed by the group benefits office in accordance with the employer's next payroll schedule. 11. In the absence of a completed Non - Tobacco use Attestation Certification Form, the surcharge will be assessed. 12. Please obtain the Tobacco use Attestation Certification form from the group benefits office. The BOCC Group Health Plan is committed to helping you achieve your best health. The ability to avoid the Tobacco Use Surcharge is available to all employees. If you think you might be unable to meet a standard to avoid the Tobacco Use Surcharge, you might qualify to avoid the surcharge by different means. Contact the group benefits office and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status. 14 Important Notice about False or Fraudulent Insurance Claims As the sponsor of a medical insurance plan, Monroe County is an "insurer" when it comes to the medical insurance plan offered to you and other eligible employees. You should understand that insurance fraud is a punishable crime under Florida law. Fraud occurs when you or a provider intend to injure, defraud or deceive an insurer. Fraudulent acts can include such things as: • Presenting any written or oral statement as part of or in support of a claim for payment, knowing that such statement contains any false, incomplete or misleading information. • Knowingly concealing information concerning any fact material to an application for insurance. • Agreeing with a service provider other than a hospital to waive deductibles or copayments when the service provider will bill the County's medical plan for its usual and customary charges. • An individual being charged for procedures that weren't performed. • A Provider making it a practice to waive all coinsurance responsibility or deductibles for certain procedures on patients. In addition to fraud being a crime, you should understand that fraudulent claims have an adverse impact on the costs of the County's medical plan. Since the medical plan is funded by the County and its employees and retirees, false or fraudulent claims result in higher premium amounts for you and your co- workers, retirees, and the County. The Florida Statute regarding False or Fraudulent Insurance Claims can be found at Florida Statutes 817.234. The Benefits Office will provide you with a copy of the statute upon written request at no charge. HOW TO RESPOND TO IMPROPER CHARGES OR SUSPECTED FRAUD • If you believe that there is an issue with the billing or an EOB (Explanation of Benefits), you should contact BCBSFL Customer Service at (800) 664 -5295. • If you believe there has been an improper charge(s) on your bill after you receive the EOB (Explanation of Benefits) from BCBSFL and the EOB does not show that the charge(s) was corrected, you should contact the doctor (or their billing office) to correct the issue first and if the issue is not resolved, you should contact Employee Benefits at 305- 292 -4446. • To report suspected insurance fraud or abuse, you should complete the form located on the BCBSFL website: http: // 3. bcbsfl. coml wpslportal/bebsfl /aboutush-epoi . The Benefits Office will provide you with a copy of the form upon written request at no charge. Individuals can also contact the Special Investigation Unit at 1- 888 - 237 - 1501. 15 CARRIERS AND CONTACT INFORMATION: Medical Benefits (Administered by Blue Cross Blue Shield of Florida) Toll -Free Customer Service: (800)664 -5295 Website: floridablue.com Prescription Drug Benefits (Administered by Envision Rx) Toll -Free Customer Service: (800) 361 -4542 Website: Nv vNv.envisiomx.com Vision Benefits (Insured and Administered by Vision service Plan Insurance Company) Toll -Free Customer Service: (800) 877 -7195 Website: `vww.vsp.com Dental Benefits (Insured and Administered by Delta Dental Toll -free Customer Service: (800) 521 -2651 Website: www.deltadcntalins,com Group Life, Accidental Death and Dismemberment, and Supplemental Life (Insured by Minnesota Life Insurance Company, A Securian Financial Group Affiliate) (Administered by Ochs, Inc.) Toll -Free Life and AD &D Claims: (888)658 -0193 Toll -Free Group & Supplemental Life Customer Service: (800)392 -7295 Email: ochsL&ochsinc.com Employee Assistance Program (Administered by Quantum Health Solutions of Florida) Toll -Free Customer Service: (877)747 -1200 Services Available: 24 Hours Per Day /365 Days Per Year 16 BlueOptions Schedule of Benefits — Plan 03559 Important things to keep in mind as you review this Schedule of Benefits: • This Schedule of Benefits is part of your Benefit Booklet, where more detailed information about your benefits can be found. • NetworkBlue is the panel of Providers designated as In- Network for your plan. You should always verify a Provider's participation status prior to receiving Health Care Services. To verify a Provider's specialty or participation status, you may contact the local BCBSF office or access the most recent BlueOptions Provider directory on our website at www.floridablue.com If you receive Covered Services outside the state of Florida from BlueCard participating PPO Providers, payment will be made based on In- Network benefits. • References to Deductible are abbreviated as "DED ". • Your benefits accumulate toward the satisfaction of Deductibles, Out -of- Pocket Maximums, and any applicable benefit maximums based on your Benefit Period unless indicated otherwise within this Schedule of Benefits. Your Benefit Period ........................................................ ............................... ..........................01 /01 — 12/31 Deductible, Coinsurance and Out -of- Pocket Maximums Benefit Description In- Network Out -of- Network Deductible (DED) $400 Per Person per Benefit Period -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- $800 Per Family per Benefit Period Per Admission Deductible (PAD) $150 $150 Emergency Room Per Visit Deductible (PVD) $300 $300 Coinsurance (The percentage of the Allowed Amount you 25% 55% pay for Covered Services) Out -of- Pocket Maximums $7,150 Per Person per Benefit Period -------------------------------------------------------------------------------- -------------------------------------------------------------------------------- $14,300 Per Family per Benefit Period BlueOptions ASO Plan 03559 PC Amounts incurred for In- Network Services will only be applied to the amounts listed in the In- Network column and amounts incurred for Out -of- Network Services will only be applied to the amounts listed in the Out -of- Network column, unless otherwise indicated within this Schedule of Benefits. This includes the Deductible and Out -of- Pocket Maximum amounts. What applies to out -of- pocket maximums? 0 DED • PAD, when applicable • Coinsurance • Copayments • PVD when applicable What does not apply to out -of- pocket maximums? • Non - covered charges • Any benefit penalty reductions • Charges in excess of the Allowed Amount Important information affecting the amount you will pay: As you review the Cost Share amounts in the following charts, please remember: • Review this Schedule of Benefits carefully; it contains important information concerning your share of the expenses for Covered Services you receive. Amounts listed in this schedule are the Cost Share amounts you pay. • Your Cost Share amounts will vary depending upon the Provider you choose, the type of Services you receive, and the setting in which the Services are rendered. • Payment for Covered Services is based on our Allowed Amount and may be less than the amount the Provider bills for such Service. You are responsible for any charges in excess of the Allowed Amount for Out -of- Network Providers. • If a Copayment is listed in the charts that follow, the Copayment applies per visit. BlueOptions ASO Plan 03559 PC 2 Office Services A Family Physician is a Physician whose primary specialty is, according to BCBSF's records, one of the following: Family Practice, General Practice, Internal Medicine, and Pediatrics. Benefit Description In- Network Out -of- Network Office visits and Services not otherwise outlined in this table rendered by Family Physicians --------------------------------------------------------------------------------- Office visit only --------------------------------- - - - - -- $25 --------------------------------------- DED + 55% All Services other than office visit DED + 25% DED + 55% Other health care professionals licensed to perform such Services --------------------------------------------------------------------------------- Office visit only --------------------------------- - - - - -- $25 --------------------------------------- DED + 55% All Services other than office visit DED + 25% DED + 55% Advanced Imaging Services (CT /CAT Scans, MRAs, MRIs, PET Scans and nuclear cardiology) DED + 25% DED + 55% --------------------------------------------------------------------------------- --------------------------------- - - - - -- --------------------------------------- DED + 55% All other diagnostic Services (e.g., X -rays) DED + 25% Allergy Injections rendered by Family Physicians $10 DED + 55% --------------------------------------------------------------------------------- Other health care professionals licensed to --------------------------------- - - - - -- $10 --------------------------------------- ° DED + 55 /° perform such Services E- Visits rendered by Family Physicians $10 DED + 55% --------------------------------------------------------------------------------- Other health care professionals licensed to --------------------------------- - - - - -- $10 --------------------------------------- ° DED + 55 /° perform such Services Durable Medical Equipment, Prosthetics, and DED + 25% DED + 55% Orthotics Convenient Care Centers $25 DED + 55% Chiropractic Services DED + 25% DED + 55% Note: Includes office and free - standing facilities Telemedicine $0 Not Covered BlueOptions ASO Plan 03559 PC Medical Pharmacy Benefit Description In- Network Out -of- Network Prescription Drugs administered in the office by: Family Physicians 20% DIED + 50% ------------------------------------------------------------------------------ Physicians other than Family Physicians and --------------------------------- - - - - -- ----------------------------------------- other health care professionals licensed to 20% DIED + 50% perform such Services Out -of- Pocket Maximum per Person per Month $200 Not Applicable Important — The Cost Share for Medical Pharmacy Services applies to the Prescription Drug only and is in addition to the office Services Cost Share. Immunizations, allergy injections as well as Services covered through a pharmacy program are not considered Medical Pharmacy. Please refer to your Benefit Booklet for a description of Medical Pharmacy. i BlueOptions ASO Plan 03559 PC Preventive Health Services Benefit Description In- Network Out -of- Network Adult Wellness Services Rendered by $0 55% Family Physicians --------------------------------------------------------------------------------- Other health care professionals licensed to --------------------------------- - - - - -- $0 --------------------------------------- ° 55 /o perform such Services --------------------------------------------------------------------------------- All other locations --------------------------------- - - - - -- $0 --------------------------------------- 55% Adult Well Woman Services Rendered by $0 55% Family Physicians --------------------------------------------------------------------------------- Other health care professionals licensed to --------------------------------- - - - - -- $0 --------------------------------------- 55% perform such Services All other locations $0 55% Child Health Supervision Services rendered by Family Physicians $0 55% --------------------------------------------------------------------------------- Other health care professionals licensed to --------------------------------- - - - - -- $0 --------------------------------------- 55% perform such Services All other locations $0 55% Mammograms $0 $0 Routine Colonoscopy $0 $0 i BlueOptions ASO Plan 03559 PC Outpatient Diagnostic Services Benefit Description In- Network Out -of- Network Independent Clinical Lab $0 DED + 55% Independent Diagnostic Testing Facility Emergency Room Visits DED + 55% Advanced Imaging Services (CT /CAT Scans, Emergency Room Visits Urgent Care Center MRAs, MRIs, PET Scans and nuclear DED + 25% DED + 55% medicine) DED + $25 All Services other than office visit All other diagnostic Services (e.g., X -rays) DED + 25% DED + 55% See Hospital Services Outpatient Hospital Facility Outpatient Emergency and Urgent Care Services Benefit Description In- Network Out -of- Network Ambulance Services In- Network DED + 25% See Hospital Services Emergency Room Visits DED + 55% --------------------------------------------------------------------------------- Radiologists, Anesthesiologists, and Emergency Room Visits Urgent Care Center Pathologists a) Office visit only $25 DED + $25 All Services other than office visit DED + 25% DED + $25 Outpatient Surgical Services Benefit Description In- Network Out -of- Network Ambulatory Surgical Center Facility (per visit) DED + 25% DED + 55% --------------------------------------------------------------------------------- Radiologists, Anesthesiologists, and --------------------------------- - - - - -- DED + 25% --------------------------------------- DED + 25% Pathologists --------------------------------------------------------------------------------- Other health care professional Services --------------------------------- - - - - -- DED + 25% --------------------------------------- DED + 55% rendered by all other Providers See Hospital Services Outpatient Hospital Facility Outpatient V BlueOptions ASO Plan 03559 PC Hospital Services *Please refer to the current Provider Directory to determine the applicable option for each In- Network Hospital. Important: Certain categories of Providers may not be available In- Network in all geographic regions. This includes, but is not limited to, anesthesiologists, radiologists, pathologists and emergency room physicians. This Plan will pay for Covered Services rendered by a Physician in a Hospital setting (i.e., inpatient, outpatient, or emergency room) at the In- Network benefit level. Claims paid in accordance with this note will be applied to the In- Network DED and Out -of- Pocket Maximums. BlueOptions ASO Plan 03559 PC In- Network Benefit Description Out -of- Network and Option 1* Option 2* and Out -of -State Traditional BlueCard Participati Providers ng Inpatient Facility Services (per admission) $150 PAD + DED + 25% $150 PAD + DED + 55% -------------------------------------------------------- Physician and other health care ---------------------------------------------------------------- - - - - -- DED + 25% --------------------------------- DED + 25% professional Services Outpatient Facility (per visit) DED + 25% DED + 55% -------------------------------------------------------- Physician and other health care ---------------------------------------------------------------- - - - - -- DED + 25% --------------------------------- DED + 25% professional Services -------------------------------------------------------- Therapy Services ---------------------------------------------------------------- - - - - -- --------------------------------- DED + 55% DED + 25% Emergency Room Visits $300 PVD + DED + 25% $300 PVD + DED + Facility 25% -------------------------------------------------------- Physician and other health care ---------------------------------------------------------------- - - - - -- DED + 25% --------------------------------- DED + 25% professional Services *Please refer to the current Provider Directory to determine the applicable option for each In- Network Hospital. Important: Certain categories of Providers may not be available In- Network in all geographic regions. This includes, but is not limited to, anesthesiologists, radiologists, pathologists and emergency room physicians. This Plan will pay for Covered Services rendered by a Physician in a Hospital setting (i.e., inpatient, outpatient, or emergency room) at the In- Network benefit level. Claims paid in accordance with this note will be applied to the In- Network DED and Out -of- Pocket Maximums. BlueOptions ASO Plan 03559 PC Behavioral Health Services Benefit Description In- Network Out -of- Network Mental Health and Substance Dependency Treatment Services Outpatient Facility Services rendered at: Emergency Room $300 PVD + DED + 25% $300 PVD + DED + 25% --------------------------------------------------------------------------------- Hospital --------------------------------- - - - - -- DED + 25% --------------------------------------- DED + 55% --------------------------------------------------------------------------------- Physician Services at Hospital and ER --------------------------------- - - - - -- DED + 25% --------------------------------------- DED + 25% Physician and other health care professionals licensed to perform such Services Family Physician office $25 DED + 55% a.) Office Visit Only b.) All Services other than office visit DED + 25% DED + 55% - - - - -- --- - - - - -- --- - - - - -- --- - - - - -- --- - - - - -- --- - - - - -- --- - - - - -- --- - - - - -- Specialist office --- - - - - -- --- - - - - -- ------------ - - - - -- $25 --- - - - - -- --- - - - - -- --------------- - DED + 55% a.) Office Visit Only b.) All Services other than office visit DED + 25% DED + 55% --------------------------------------------------------------------------------- All other locations --------------------------------- - - - - -- DED + 25% --------------------------------------- DED + 55% Inpatient Facility Services $150 PAD + DED + 25% $150 PAD + DED + 55% - - - - -- --- - - - - -- --- - - - - -- --- - - - - -- --- - - - - -- --- - - - - -- --- - - - - -- --- - - - - -- Physician and other health care professionals --- - - - - -- ----------------------- - - - - -- --------------------------------------- DED + 25% DED + 25% licensed to perform such Services j i BlueOptions ASO Plan 03559 PC Benefit Maximums Home Health Care Visits per Benefit Period ............................................................... ............................... 40 Inpatient Rehabilitation days per Benefit Period ....................................................... ............................... 30 Outpatient Therapies and Spinal Manipulations Visits (combined) per Benefit Period ......................... 50 Note: Spinal Manipulations are limited to 26 visits per Benefit Period and accumulate towards the Outpatient Therapies and Spinal Manipulations benefit maximum. Refer to the Benefit Booklet for reimbursement guidelines. Skilled Nursing Facility days per Benefit Period ............................................ ............................... Unlimited Additional Benefits /Features Benefit Maximum Carryover If, immediately before the Effective Date of the Group, you or your Covered Dependent were covered under a prior group policy form issued by BCBSF or Health Options, Inc. to the Group, amounts applied to your Benefit Period maximums under the prior BCBSF or Health Options, Inc. policy will be applied toward your Benefit Period maximums under this plan. BlueOptions ASO Plan 03559 PC 9 BlueOptions Benefit Booklet for Covered Plan Participants of Monroe County BOCC Group Health Plan A Self- funded Group Health Benefit Plan For Customer Service Assistance: (800) 352 -2583 B0611 — Plan 03559 Divisions — 001, 002, C01, R01, R02 Table of Contents Section 1: How to Use Your Benefit Booklet .............................. ............................... 1 -1 Section 2: What Is Covered? ...................................................... ............................... 2 -1 Section 3: What Is Not Covered? ............................................... ............................... 3 -1 Section 4: Medical Necessity ..................................................... ............................... 4 -1 Section 5: Understanding Your Share of Health Care Expenses .............................. 5 -1 Section 6: Physicians, Hospitals and Other Provider Options .... ............................... 6 -1 Section 7: BlueCard (Out -of- State) Program ............................ ............................... 7 -1 Section 8: Blueprint for Health Programs ................................... ............................... 8 -1 Section 9: Eligibility for Coverage ............................................... ............................... 9 -1 Section 10: Enrollment and Effective Date of Coverage ................. ...........................10 -1 Section 11: Termination of Coverage ............................................. ...........................11 -1 Section 12: Continuing Coverage Under COBRA .......................... ...........................12 -1 Section 13: Conversion Privilege ........................................ ...........................13 -1 Section 14: Extension of Benefits ....................................... ...........................14 -1 Section 15: The Effect of Medicare Coverage/ Medicare Secondary Payer Provisions................................................................... ...........................15 -1 Section 16: Duplication of Coverage Under Other Health Plans /Programs ...............16 -1 Section 17: Claims Processing ....................................................... ...........................17 -1 Section 18: Relationship Between the Parties ................................ ...........................18 -1 Section 19: General Provisions ...................................................... ...........................19 -1 Section 20: Definitions .................................................................... ...........................20 -1 Table of Contents Section 1: How to Use Your Benefit Booklet This is your Benefit Booklet ( "Booklet "). It describes your coverage, benefits, limitations and exclusions for the self- funded Group Health Benefit Plan ( "Group Health Plan" or "Group Plan ") established and maintained by Monroe County Board of County Commissioners. be coordinated with other policies or plans; and the Group Health Plan's subrogation rights and right of reimbursement. You will need to refer to the Schedule of Benefits to determine how much you have to pay for particular Health Care Services. The sponsor of your Group Health Plan has contracted with Blue Cross Blue Shield of Florida, Inc. ( BCBSF), under an Administrative Services Only Agreement ( "ASO Agreement "), to provide certain third party administrative services, including claims processing, customer service, and other services, and access to certain of its Provider networks. BCBSF provides certain administrative services only and does not assume any financial risk or obligation with respect to Health Care Services rendered to Covered Persons or claims submitted for processing under this Benefit Booklet for such Services. The payment of claims under the Group Health Plan depends exclusively upon the funding provided by Monroe County BOCC. You should read your Benefit Booklet carefully before you need Health Care Services. It contains valuable information about: • your BlueOptions benefits; • what is covered; • what is excluded or not covered; • coverage and payment rules; • Blueprint for Health Programs; • how and when to file a claim; • how much, and under what circumstances, payment will be made; • what you will have to pay as your share; and • other important information including when benefits may change; how and when coverage stops; how to continue coverage if you are no longer eligible; how benefits will When reading your Booklet, please remember that: • you should read this Booklet in its entirety in order to determine if a particular Health Care Service is covered. • the headings of sections contained in this Booklet are for reference purposes only and shall not affect in any way the meaning or interpretation of particular provisions. • references to "you" or "your" throughout refer to you as the Covered Plan Participant and to your Covered Dependents, unless expressly stated otherwise or unless, in the context in which the term is used, it is clearly intended otherwise. Any references which refer solely to you as the Covered Plan Participant or solely to your Covered Dependent(s) will be noted as such. • references to "we ", "us ", and "our" throughout refer to Blue Cross and Blue Shield of Florida, Inc. We may also refer to ourselves as "BCBSF ". • if a word or phrase starts with a capital letter, it is either the first word in a sentence, a proper name, a title, or a defined term. If the word or phrase has a special meaning, it will either be defined in the Definitions section or defined within the particular section where it is used. How to Use Your Benefit Booklet 1 -1 Where do you find information on........ • what particular types of Health Care Services are covered? Read the "What Is Covered ?" and "What Is Not Covered ?" sections. • how much will be paid under your Group Health Plan and how much do you have to pay? Read the "Understanding Your Share of Health Care Expenses" section along with the Schedule of Benefits. • how the amount you pay for Covered Services under the BlueCard (Out -of- State) Program will be determined when you receive care outside the state of Florida? Read the "BlueCard (Out -of- State) Program" section. • how to add or remove a Dependent? Read the "Enrollment and Effective Date of Coverage" section. • what happens if you are covered under this Benefit Booklet and another health plan? Read the "Duplication of Coverage Under Other Health Plans Programs" section. • what happens when your coverage ends? Read the "Termination of Coverage" section. • what the terms used throughout this Booklet mean? Read the "Definitions" section. Overview of How BlueOptions Works Whenever you need care, you have a choice. If you visit an: In- Network Provider Out -of- Network Provider You receive In- Network benefits, the You receive the Out -of- Network level of highest level of coverage available. benefits — you will share more of the cost of your care. You do not have to file a claim; the claim You may be required to submit a claim form. will be filed by the In- Network Provider for you. The In- Network Provider* is responsible You should notify BCBSF of inpatient for Admission Notification if you are admissions. admitted to the Hospital. *For Services rendered by an In- Network Provider located outside of Florida, you should notify us of inpatient admissions. How to Use Your Benefit Booklet 1 -2 Section 2: What Is Covered? Introduction This section describes the Health Care Services that are covered under this Benefit Booklet. All benefits for Covered Services are subject to your share of the cost and the benefit maximums listed on your Schedule of Benefits, the applicable Allowed Amount, any limitations and /or exclusions, as well as other provisions contained in this Booklet, and any Endorsement(s) in accordance with BCBSF's Medical Necessity coverage criteria and benefit guidelines then in effect. Remember that exclusions and limitations also apply to your coverage. Exclusions and limitations that are specific to a type of Service are included along with the benefit description in this section. Additional exclusions and limitations that may apply can be found in the "What Is Not Covered ?" section. More than one limitation or exclusion may apply to a specific Service or a particular situation. Expenses for the Health Care Services listed in this section will be covered under this Booklet only if the Services are: 1. within the Health Care Services categories in the "What Is Covered ?" section; 2. actually rendered (not just proposed or recommended) by an appropriately licensed health care Provider who is recognized for payment under this Benefit Booklet and for which an itemized statement or description of the procedure or Service which was rendered is received, including any applicable procedure code, diagnosis code and other information required in order to process a claim for the Service; 3. Medically Necessary, as defined in this Booklet and determined by BCBSF or BOCC in accordance with BCBSF's Medical Necessity coverage criteria then in effect, except as specified in this section; 4. in accordance with the benefit guidelines listed below; 5. rendered while your coverage is in force; and 6. not specifically or generally limited or excluded under this Booklet. BCBSF or Monroe County BOCC will determine whether Services are Covered Services under this Booklet after you have obtained the Services and a claim has been received for the Services. In some circumstances BCBSF or Monroe County BOCC may determine whether Services might be Covered Services under this Booklet before you are provided the Service. For example, BCBSF or Monroe County BOCC may determine whether a proposed transplant is a Covered Service under this Booklet before the transplant is provided. Neither BCBSF nor Monroe County BOCC are obligated to determine, in advance, whether any Service not yet provided to you would be a Covered Service unless we have specifically designated that a Service is subject to a prior authorization requirement as described in the "Blueprint for Health Programs" section. We are also not obligated to cover or pay for any Service that has not actually been rendered to you. In determining whether Health Care Services are Covered Services under this Booklet, no written or verbal representation by any employee or agent of BCBSF or Monroe County BOCC, or by any other person, shall waive or otherwise modify the terms of this Booklet and, therefore, neither you, nor any health care Provider or other person should rely on any such written or verbal representation. What Is Covered? 2 -1 Our Benefit Guidelines In providing benefits for Covered Services, the benefit guidelines listed below apply as well as any other applicable payment rules specific to particular categories of Services: 1. Payment for certain Health Care Services is included within the Allowed Amount for the primary procedure, and therefore no additional amount is payable for any such Services. 2. Payment is based on the Allowed Amount for the actual Service rendered (i.e., payment is not based on the Allowed Amount for a Service which is more complex than that actually rendered), and is not based on the method utilized to perform the Service or the day of the week or the time of day the procedure is performed. 3. Payment for a Service includes all components of the Health Care Service when the Service can be described by a single procedure code, or when the Service is an essential or integral part of the associated therapeutic /diagnostic Service rendered. Covered Services Categories Accident Care Health Care Services to treat an injury or illness resulting from an Accident not related to your job or employment are covered. Exclusion: Health Care Services to treat an injury or illness resulting from an Accident related to your job or employment are excluded. Allergy Testing and Treatments Testing and desensitization therapy (e.g., injections) and the cost of hyposensitization serum are covered. The Allowed Amount for allergy testing is based upon the type and number of tests performed by the Physician. The Allowed Amount for allergy immunotherapy treatment is based upon the type and number of doses. Ambulance Services Ambulance Services for Emergency Medical Conditions and limited non - emergency ground transport may be covered only when: For Emergency Medical Conditions — it is Medically Necessary to transport you by air, ground or water, from the place an Emergency Medical Condition occurs to the nearest Hospital that can provide the Medically Necessary level of care. If it is determined that the nearest Hospital is unable to provide the Medically Necessary level of care for the Emergency Medical Condition, then coverage forAmbulance Services shall extend to the next nearest Hospital that can provide Medically Necessary care; or 2. For limited non - emergency ground Ambulance transport it is Medically Necessary to transport you by ground: a. from an Out -of- Network Hospital to the nearest In- Network Hospital that can provide care; b. to the nearest In- Network or Out -of- Network Hospital for a Condition that requires a higher level of care that was not available at the original Hospital; c. to the nearest more cost - effective acute care facility as determined solely by us; or d. from an acute facility to the nearest cost - effective sub -acute setting. Note: Non - emergency Ambulance transportation meets the definition of Medical Necessity only when the patient's Condition requires treatment at another facility and when another mode of What Is Covered? 2 -2 transportation, (regardless of whether covered by us or not) would endanger the patient's medical Condition. If another mode of transportation could be used safely and effectively, regardless of time, or mode (e.g. air, ground, water) then Ambulance transportation is not Medically Necessary. Limitations: Air Ambulance coverage is specifically limited to transport due to an Emergency Medical Condition when the patient's destination is an acute care Hospital, and: 1. the pick -up point is not accessible by ground Ambulance, or 2. speed in excess of the ground vehicle is critical for your health or safety. Air Ambulance transport not due to an Emergency Medical Condition are excluded unless specifically authorized by us in advance of the transport. Exclusions: Services for situations that are not Medically Necessary because they do not require Ambulance transportation including but not limited to: 1. Ambulance Services for a patient who is legally pronounced dead before the Ambulance is summoned. 2. Aid rendered by an Ambulance crew without transport. Examples include, but are not limited to situations when an Ambulance is dispatched and: a. the crew renders aid until a helicopter can be sent; b. the patient refuses care or transport; or c. only basic first aid is rendered. 3. Non - emergency transport (not due to an Emergency Medical Condition) to or from a patient's home or a residential, domiciliary or custodial facility. 4. Transfers by medical vans or commercial transportation (such as Physician owned limousines, public transportation, cab, etc.). 5. Ambulance transport for patient convenience or patient and /or family preference. Examples include but are not limited to: a. patient wants to be at a certain Hospital or facility for personal /preference reasons; b. patient is in a foreign country, or out -of- state, and wants to return home for a surgical procedure or treatment, or for continued treatment, including patients who have recently been discharged from inpatient care; or c. patient is going for a routine Service and is medically able to use another mode of transportation but can't pay for and /or find such transportation. 6. Air Ambulance Services in the absence of an Emergency Medical Condition, unless such Services are authorized by us in advance. Ambulatory Surgical Centers Health Care Services rendered at an Ambulatory Surgical Center are covered and include: 1. use of operating and recovery rooms; 2. respiratory, or inhalation therapy (e.g., oxygen); 3. drugs and medicines administered (except for take home drugs) at the Ambulatory Surgical Center; 4. intravenous solutions; 5. dressings, including ordinary casts; 6. anesthetics and their administration; What Is Covered? 2 -3 7. administration of, including the cost of, whole blood or blood products (except as outlined in the Drugs exclusion of the "What Is Not Covered ?" section); 8. transfusion supplies and equipment; 9. diagnostic Services, including radiology, ultrasound, laboratory, pathology and approved machine testing (e.g., EKG); and 10. chemotherapy treatment for proven malignant disease. Anesthesia Administration Services Administration of anesthesia by a Physician or Certified Registered Nurse Anesthetist ( "CRNA ") may be covered. In those instances where the CRNA is actively directed by a Physician other than the Physician who performed the surgical procedure, payment for Covered Services, if any, will be made for both the CRNA and the Physician Health Care Services at the lower directed - services Allowed Amount in accordance with BCBSF's payment program then in effect for such Covered Services. Exclusion: Coverage does not include anesthesia Services by an operating Physician, his or her partner or associate. Autism Spectrum Disorder Autism Spectrum Disorder Services provided to a Covered Dependent who is under the age of 18, or if 18 years of age or older, is attending high school and was diagnosed with Autism Spectrum Disorder prior to his or her 9 th birthday consisting of: 1. well -baby and well -child screening for the presence of Autism Spectrum Disorder; 2. Applied Behavior Analysis, when rendered by an individual certified pursuant to Section 393.17 of the Florida Statutes or licensed under Chapters 490 or 491 of the Florida Statutes; and 3. Physical Therapy by a Physical Therapist, Occupational Therapy by an Occupational Therapist, and Speech Therapy by a Speech Therapist. Covered therapies provided in the treatment of Autism Spectrum Disorder are covered even though they may be habilitative in nature (provided to teach a function) and are not necessarily limited to restoration of a function or skill that has been lost. Payment Guidelines for Autism Spectrum Disorder Applied Behavior Analysis Services for Autism Spectrum Disorder must be authorized in accordance with criteria established by us, before such Services are rendered. Services performed without authorization will be denied. Authorization for coverage is not required when Covered Services are provided for the treatment of an Emergency Medical Condition. Exclusion: Any Services for the treatment of Autism Spectrum Disorder other than as specifically identified as covered in this section. Note: In order to determine whether such Services are covered under this Benefit Booklet, we reserve the right to request a formal written treatment plan signed by the treating physician to include the diagnosis, the proposed treatment type, the frequency and duration of treatment, the anticipated outcomes stated as goals, and the frequency with which the treatment plan will be updated, but no less than every 6 months. This benefit booklet will only cover services to the extent included in the Treating Physician's formal written treatment plan. Behavioral Health Services Mental Health Services Diagnostic evaluation, psychiatric treatment, individual therapy, and group therapy rendered to you by a Physician, Psychologist or Mental Health Professional for the treatment of a Mental What Is Covered? 2 -4 and Nervous Disorder may be covered. Covered Services may include: 1. Physician office visits; 2. Intensive Outpatient Treatment (rendered in a facility), as defined in this Booklet; 3. Partial Hospitalization, as defined in this Booklet, when provided under the direction of a Physician; and 4. Residential Treatment Services, as defined in this Booklet. Exclusion: 1. Services rendered for a Condition that is not a Mental and Nervous Disorder as defined in this Booklet, regardless of the underlying cause, or effect, of the disorder; 2. Services for psychological testing associated with the evaluation and diagnosis of learning disabilities or intellectual disability; 3. Services beyond the period necessary for evaluation and diagnosis of learning disabilities or intellectual disability; 4. Services for educational purposes; 5. Services for marriage counseling unless related to a Mental and Nervous Disorder as defined in this Booklet, regardless of the underlying cause, or effect, of the disorder; 6. Services for pre - marital counseling; 7. Services for court- ordered care or testing, or required as a condition of parole or probation; 8. Services to test aptitude, ability, intelligence or interest [except as covered under the Autism Spectrum Disorder subsection]; 9. Services required to maintain employment; 10. Services for cognitive remediation; and 11. inpatient stays that are primarily intended as a change of environment. Substance Dependency Treatment Services When there is a sudden drop in consumption after prolonged heavy use of a substance a person may experience withdrawal, often causing both physiologic and cognitive symptoms. The symptoms of withdrawal vary greatly, ranging from minimal changes to potentially life threatening states. Detoxification Services can be rendered in different types of locations, depending on the severity of the withdrawal symptoms. Care and treatment for Substance Dependency includes the following: Inpatient and outpatient Health Care Services rendered by a Physician, Psychologist or Mental Health Professional in a program accredited by The Joint Commission or approved by the state of Florida for Detoxification or Substance Dependency. 2. Physician, Psychologist and Mental Health Professional outpatient visits for the care and treatment of Substance Dependency. We may provide you with information on resources available to you for non - medical ancillary services like vocational rehabilitation or employment counseling, when we are able to. We don't pay for any services that are provided to you by any of these resources; they are to be provided solely at your expense. You acknowledge that we do not have any Contractual or other formal arrangements with the Provider of such services. Exclusion: Long term Services for alcoholism or drug addiction, including specialized inpatient units or inpatient stays that are primarily intended as a change of environment. Breast Reconstructive Surgery Surgery to reestablish symmetry between two breasts and implanted prostheses incident to What Is Covered? 2 -5 Mastectomy is covered. In order to be covered, such surgery must be provided in a manner chosen by your Physician, consistent with prevailing medical standards, and in consultation with you. Child Cleft Lip and Cleft Palate Treatment Treatment and Services for Child Cleft Lip and Cleft Palate, including medical, dental, Speech Therapy, audiology, and nutrition Services for treatment of a child under the age of 18 who has cleft lip or cleft palate are covered. In order for such Services to be covered, your Covered Dependent's Physician must specifically prescribe such Services and such Services must be Medically Necessary and consequent to treatment of the cleft lip or cleft palate. Clinical Trials Clinical trials are research studies in which Physicians and other researchers work to find ways to improve care. Each study tries to answer scientific questions and to find better ways to prevent, diagnose, or treat patients. Each trial has a protocol which explains the purpose of the trial, how the trial will be performed, who may participate in the trial, and the beginning and end points of the trial. If you are eligible to participate in an Approved Clinical Trial, routine patient care for Services furnished in connection with your participation in the Approved Clinical Trial may be covered when: 1. an In- Network Provider has indicated such trial is appropriate for you; or 2. you provide us with medical and scientific information establishing that your participation in such trial is appropriate. Routine patient care includes all Medically Necessary Services that would otherwise be covered under this Booklet, such as doctor visits, lab tests, x -rays and scans and hospital stays related to treatment of your Condition and is subject to the applicable Cost Share(s) on the Schedule of Benefits. Even though benefits may be available under this Booklet for routine patient care related to an Approved Clinical Trial you may not be eligible for inclusion in these trials or there may not be any trials available to treat your Condition at the time you want to be included in a clinical trial. Exclusion: 1. Costs that are generally covered by the clinical trial, including, but not limited to: a. Research costs related to conducting the clinical trial such as research Physician and nurse time, analysis of results, and clinical tests performed only for research purposes. b. The investigational item, device or Service itself. c. Services inconsistent with widely accepted and established standards of care for a particular diagnosis. 2. Services related to an Approved Clinical Trial received outside of the United States Concurrent Physician Care Concurrent Physician care Services are covered, provided: (a) the additional Physician actively participates in your treatment; (b) the Condition involves more than one body system or is so severe or complex that one Physician cannot provide the care unassisted; and (c) the Physicians have different specialties or have the same specialty with different sub - specialties. Consultations Consultations provided by a Physician are covered if your attending Physician requests the consultation and the consulting Physician prepares a written report. Contraceptive Injections What Is Covered? 2 -6 Medication by injection is covered when provided and administered by a Physician, for the purpose of contraception, and is limited to the medication and administration when Medically Necessary. Dental Services Dental Services are limited to the following: 1. Care and stabilization treatment rendered within 90 days of an Accidental Dental Injury to Sound Natural Teeth. 2. Extraction of teeth required prior to radiation therapy when you have a diagnosis of cancer of the head and /or neck. 3. Anesthesia Services for dental care including general anesthesia and hospitalization Services necessary to assure the safe delivery of necessary dental care provided to you or your Covered Dependent in a Hospital or Ambulatory Surgical Center if: a) the Covered Dependent is under 8 years of age and it is determined by a dentist and the Covered Dependent's Physician that: i. dental treatment is necessary due to a dental Condition that is significantly complex; or ii. the Covered Dependent has a developmental disability in which patient management in the dental office has proven to be ineffective; or b) you or your Covered Dependent has one or more medical Conditions that would create significant or undue medical risk for you in the course of delivery of any necessary dental treatment or surgery if not rendered in a Hospital or Ambulatory Surgical Center. Exclusion: 1. Dental Services provided more than 90 days after the date of an Accidental Dental Injury regardless of whether or not such services could have been rendered within 90 days; and 2. Dental Implant. Diabetes Outpatient Self- Management Diabetes outpatient self- management training and educational Services and nutrition counseling (including all Medically Necessary equipment and supplies) to treat diabetes, if your treating Physician or a Physician who specializes in the treatment of diabetes certifies that such Services are Medically Necessary, are covered. In order to be covered, diabetes outpatient self- management training and educational Services must be provided under the direct supervision of a certified Diabetes Educator or a board - certified Physician specializing in endocrinology. Additionally, in order to be covered, nutrition counseling must be provided by a licensed Dietitian. Covered Services may also include the trimming of toenails, corns, calluses, and therapeutic shoes (including inserts and /or modifications) for the treatment of severe diabetic foot disease. Diagnostic Services Diagnostic Services when ordered by a Physician are limited to the following: 1. radiology, ultrasound and nuclear medicine, Magnetic Resonance Imaging (MRI); 2. laboratory and pathology Services; 3. Services involving bones or joints of the jaw (e.g., Services to treat temporomandibular joint [TMJ] dysfunction) or facial region if, under accepted medical standards, such diagnostic Services are necessary to treat Conditions caused by congenital or developmental deformity, disease, or injury; 4. approved machine testing (e.g., electrocardiogram [EKG], electroencephalograph [EEG], and other What Is Covered? 2 -7 electronic diagnostic medical procedures); and 5. genetic testing for the purposes of explaining current signs and symptoms of a possible hereditary disease. Dialysis Services Dialysis Services including equipment, training, and medical supplies, when provided at any location by a Provider licensed to perform dialysis including a Dialysis Center are covered. Down Syndrome Down syndrome Services provided to a Covered Dependent who is under the age of 18, or if 18 years of age or older is attending high school, consisting of: 1. Applied Behavior Analysis, when rendered by an individual certified per Section 393.17 of the Florida Statutes; and 2. Physical Therapy by a Physical Therapist, Occupational Therapy by an Occupational Therapist, and Speech Therapy by a Speech Therapist. Covered therapies provided in the treatment of Down syndrome are covered even though they may be habilitative in nature (provided to teach a function) and are not necessarily limited to restoration of a function or skill that has been lost. Payment Guidelines for Down Syndrome Applied Behavior Analysis Services for Down syndrome must be authorized in accordance with criteria established by us, before such Services are rendered. Services performed without authorization will be denied. Authorization for coverage is not required for Emergency Services provided for the treatment of an Emergency Medical Condition. Note: In order to determine whether such Services are covered under this Booklet, we reserve the right to request a formal written treatment plan signed by the treating Physician to include the diagnosis, the proposed treatment type, the frequency and duration of treatment, the anticipated outcomes stated as goals, and the frequency with which the treatment plan will be updated, but no less than every 6 months. Durable Medical Equipment Durable Medical Equipment when provided by a Durable Medical Equipment Provider and when prescribed by a Physician, limited to the most cost - effective equipment as determined by BCBSF or Monroe County BOCC is covered. Payment Guidelines for Durable Medical Equipment Supplies and service to repair medical equipment may be Covered Services only if you own the equipment or you are purchasing the equipment. Payment for Durable Medical Equipment will be based on the lowest of the following: 1) the purchase price; 2) the lease /purchase price; 3) the rental rate; or 4) the Allowed Amount. The Allowed Amount for such rental equipment will not exceed the total purchase price. Durable Medical Equipment includes, but is not limited to, the following: wheelchairs, crutches, canes, walkers, hospital beds, and oxygen equipment. Note: Repair or replacement of Durable Medical Equipment due to growth of a child or significant change in functional status is a Covered Service. Fyrhminn Equipment which is primarily for convenience and /or comfort; modifications to motor vehicles and /or homes, including but not limited to, wheelchair lifts or ramps; water therapy devices such as Jacuzzis, hot tubs, swimming pools or whirlpools; exercise and massage equipment, electric scooters, hearing aids, air conditioners and purifiers, humidifiers, water softeners and /or purifiers, pillows, mattresses or waterbeds, escalators, elevators, stair glides, emergency alert equipment, handrails and grab bars, heat What Is Covered? 2 -8 appliances, dehumidifiers, and the replacement of Durable Medical Equipment solely because it is old or used are excluded. Emergency Services Emergency Services for an Emergency Medical Condition are covered when rendered In- Network and Out -of- Network without the need for any prior authorization determination by us. When Emergency Services and care for an Emergency Medical Condition are rendered by an Out -of- Network Provider, any Copayment and /or Coinsurance amount applicable to In- Network Providers for Emergency Services will also apply to such Out -of- Network Provider. Special Payment Rules for Non - Grandfathered Plans The Patient Protection and Affordable Care Act (PPACA) requires that non - grandfathered health plans apply a specific method for determining the allowed amount for Emergency Services rendered for an Emergency Medical Condition by Providers who do not have a contract with us. Payment for Emergency Services rendered by an Out -of- Network Provider that has not entered into an agreement with BCBSF to provide access to a discount from the billed amount of that Provider will be the greater of: the amount equal to the median amount negotiated with all BCBSF In- Network Providers for the same Services; 2. the Allowed Amount as defined in the Booklet; or 3. what Medicare would have paid for the Services rendered. In no event will Out -of- Network Providers be paid more than their charges for the Services rendered. Enteral Formulas Prescription and non - prescription enteral formulas for home use when prescribed by a Physician as necessary to treat inherited diseases of amino acid, organic acid, carbohydrate or fat metabolism as well as malabsorption originating from congenital defects present at birth or acquired during the neonatal period are covered. Coverage to treat inherited diseases of amino acid and organic acids, for you up to your 25th birthday, shall include coverage for food products modified to be low protein. Eye Care Coverage includes the following Services: 1. Physician Services, soft lenses or sclera shells, for the treatment of aphakic patients; 2. initial glasses or contact lenses following cataract surgery; and 3. Physician Services to treat an injury to or disease of the eyes. Exclusion: Health Care Services to diagnose or treat vision problems which are not a direct consequence of trauma or prior ophthalmic surgery; eye examinations; eye exercises or visual training; eye glasses and contact lenses and their fitting are excluded. In addition to the above, any surgical procedure performed primarily to correct or improve myopia or other refractive disorders (e.g., radial keratotomy, PRK and LASIK) are excluded. Home Health Care The Home Health Care Services listed below are covered when the following criteria are met: 1. you are unable to leave your home without considerable effort and the assistance of another person because you are: bedridden or chairbound or because you are restricted in ambulation whether or not you use assistive devices; or you are significantly limited in physical activities due to a Condition; and What Is Covered? 2 -9 2. the Home Health Care Services rendered have been prescribed by a Physician by way of a formal written treatment plan that has been reviewed and renewed by the prescribing Physician every 30 days. In order to determine whether such Services are covered under this Booklet, you may be required to provide a copy of any written treatment plan; 3. the Home Health Care Services are provided directly by (or indirectly through) a Home Health Agency; and 4. you are meeting or achieving the desired treatment goals set forth in the treatment plan as documented in the clinical progress notes. Home Health Care Services are limited to: 1. part -time (i.e., less than 8 hours per day and less than a total of 40 hours in a calendar week) or intermittent (i.e., a visit of up to, but not exceeding, 2 hours per day) nursing care by a Registered Nurse, Licensed Practical Nurse and /or home health aide Services; 2. home health aide Services must be consistent with the plan of treatment, ordered by a Physician, and rendered under the supervision of a Registered Nurse; 3. medical social services; 4. nutritional guidance; 5. respiratory, or inhalation therapy (e.g., oxygen); and 6. Physical Therapy by a Physical Therapist, Occupational Therapy by a Occupational Therapist, and Speech Therapy by a Speech Therapist. Exclusions: 1. homemaker or domestic maid services; 2. sitter or companion services; 3. Services rendered by an employee or operator of an adult congregate living facility; an adult foster home; an adult day care center, or a nursing home facility; 4. Speech Therapy provided for a diagnosis of developmental delay; 5. Custodial Care except for any such care covered under this subsection when provided on a part -time or intermittent basis (as defined above) by a home health aide; 6. food, housing, and home delivered meals; and 7. Services rendered in a Hospital, nursing home, or intermediate care facility. Hospice Services Health Care Services provided in connection with a Hospice treatment program may be Covered Services, provided the Hospice treatment program is: 1. approved by your Physician; and 2. your doctor has certified to us in writing that your life expectancy is 12 months or less. Recertification is required every six months. Hospital Services Covered Hospital Services include: 1. room and board in a semi - private room when confined as an inpatient, unless the patient must be isolated from others for documented clinical reasons; 2. intensive care units, including cardiac, progressive and neonatal care; 3. use of operating and recovery rooms; 4. use of emergency rooms; 5. respiratory, pulmonary, or inhalation therapy (e.g., oxygen); 6. drugs and medicines administered (except for take home drugs) by the Hospital; 7. intravenous solutions; What Is Covered? 2 -10 8. administration of, including the cost of, whole blood or blood products except as outlined in the Drugs exclusion of the "What Is Not Covered ?" section); 9. dressings, including ordinary casts; 10. anesthetics and their administration; 11. transfusion supplies and equipment; 12. diagnostic Services, including radiology, ultrasound, laboratory, pathology and approved machine testing (e.g., EKG); 13. Physical, Speech, Occupational, and Cardiac Therapies; and 14. transplants as described in the Transplant Services subsection. PYr , hminn- Expenses for the following Hospital Services are excluded when such Services could have been provided without admitting you to the Hospital: 1) room and board provided during the admission; 2) Physician visits provided while you were an inpatient; 3) Occupational Therapy, Speech Therapy, Physical Therapy, and Cardiac Therapy; and 4) other Services provided while you were an inpatient. In addition, expenses for the following and similar items are also excluded: 1. gowns and slippers; 2. shampoo, toothpaste, body lotions and hygiene packets; 3. take -home drugs; 4. telephone and television; 5. guest meals or gourmet menus; and 6. admission kits. Inpatient Rehabilitation Inpatient Rehabilitation Services are covered when the following criteria are met: Services must be provided under the direction of a Physician and must be provided by a Medicare certified facility in accordance with a comprehensive rehabilitation program; 2. a plan of care must be developed and managed by a coordinated multi - disciplinary team; 3. coverage is subject to our Medical Necessity coverage criteria then in effect; 4. the individual must be able to actively participate in at least 2 rehabilitative therapies and be able to tolerate at least 3 hours per day of skilled Rehabilitation Services for at least 5 days a week and their Condition must be likely to result in significant improvement; and 5. the Rehabilitation Services must be required at such intensity, frequency and duration that further progress cannot be achieved in a less intensive setting. Inpatient Rehabilitation Services are subject to the inpatient facility Copayment, if applicable, and the benefit maximum set forth in the Schedule of Benefits. Exclusion: All Substance Dependency, drug and alcohol related diagnoses, Pain Management, and respiratory ventilator management Services are excluded. Mammograms Mammograms obtained in a medical office, medical treatment facility or through a health testing service that uses radiological equipment registered with the appropriate Florida regulatory agencies (or those of another state) for diagnostic purposes or breast cancer screening are Covered Services. Benefits for mammograms may not be subject to the Deductible, Coinsurance, or Copayment (if What Is Covered? 2 -11 applicable). Please refer to your Schedule of Benefits for more information. Mastectomy Services Breast cancer treatment including treatment for physical complications relating to a Mastectomy (including lymphedemas), and outpatient post- surgical follow -up in accordance with prevailing medical standards as determined by you and your attending Physician are covered. Outpatient post - surgical follow -up care for Mastectomy Services shall be covered when provided by a Provider in accordance with the prevailing medical standards and at the most medically appropriate setting. The setting may be the Hospital, Physician's office, outpatient center, or your home. The treating Physician, after consultation with you, may choose the appropriate setting. Maternity Services Health Care Services, including prenatal care, delivery and postpartum care and assessment, provided to you, by a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Hospital, Birth Center, Midwife or Certified Nurse Midwife may be Covered Services. Care for the mother includes the postpartum assessment. In order for the postpartum assessment to be covered, such assessment must be provided at a Hospital, an attending Physician's office, an outpatient maternity center, or in the home by a qualified licensed health care professional trained in care for a mother. Coverage under this Booklet for the postpartum assessment includes coverage for the physical assessment of the mother and any necessary clinical tests in keeping with prevailing medical standards. Under Federal law, your Group Plan generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery; or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending Provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 as applicable). In any case, under Federal law, your Group Plan can only require that a provider obtain authorization for prescribing an inpatient hospital stay that exceeds 48 hours (or 96 hours). Exclusion: Maternity Services rendered to a Covered Person who becomes pregnant as a Gestational Surrogate under the terms of, and in accordance with, a Gestational Surrogacy Contract or Arrangement are excluded. This exclusion applies to all expenses for prenatal, intra - partal, and post - partal Maternity /Obstetrical Care, and Health Care Services rendered to the Covered Person acting as a Gestational Surrogate. For the definition of Gestational Surrogate and Gestational Surrogacy Contract, see the "Definitions" section of this Benefit Booklet. Medical Pharmacy Physician- administered Prescription Drugs which are rendered in a Physician's office may be subject to a separate Cost Share amount that is in addition to the office visit Cost Share amount. The Medical Pharmacy Cost Share amount applies to each Prescription Drug and does not include the administration of the Prescription Drug. Your plan may also include a maximum monthly amount you will be required to pay out -of- pocket for Medical Pharmacy, when such Services are provided by an In- Network Provider or Specialty Pharmacy. If your plan includes a Medical Pharmacy out -of- pocket monthly maximum, it will be listed on your Schedule of Benefits and only applies after you have met your Deductible, if applicable. Please refer to your Schedule of Benefits for the additional Cost Share amount and /or monthly V What Is Covered? 2 -12 maximum out -of- pocket applicable to Medical Pharmacy for your plan. Note: For purposes of this benefit, allergy injections and immunizations are not considered Medical Pharmacy. Newborn Care A newborn child will be covered from the moment of birth provided that the newborn child is eligible for coverage and properly enrolled. Covered Services shall consist of coverage for injury or sickness, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities, and premature birth. Newborn Assessment An assessment of the newborn child is covered provided the Services were rendered at a Hospital, the attending Physician's office, a Birth Center, or in the home by a Physician, Midwife or Certified Nurse Midwife, and the performance of any necessary clinical tests and immunizations are within prevailing medical standards. These Services are not subject to the Deductible. Ambulance Services, when necessary to transport the newborn child to and from the nearest appropriate facility which is staffed and equipped to treat the newborn child's Condition, as determined by BCBSF or Monroe County BOCC and certified by the attending Physician as Medically Necessary to protect the health and safety of the newborn child, are covered. Under Federal law, your Group Plan generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery; or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending Provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 as applicable). In any case, under Federal law, your Group Plan can only require that a provider obtain authorization for prescribing an inpatient hospital stay that exceeds 48 hours (or 96 hours). Orthotic Devices Orthotic Devices including braces and trusses for the leg, arm, neck and back, and special surgical corsets are covered when prescribed by a Physician and designed and fitted by an Orthotist. Benefits may be provided for necessary replacement of an Orthotic Device which is owned by you when due to irreparable damage, wear, a change in your Condition, or when necessitated due to growth of a child. Payment for splints for the treatment of temporomandibular joint ( "TMJ") dysfunction is limited to payment for one splint in a six -month period unless a more frequent replacement is determined by BCBSF or Monroe County BOCC to be Medically Necessary. Exclusion: Expenses for arch supports, shoe inserts designed to effect conformational changes in the foot or foot alignment, orthopedic shoes, over - the - counter, custom -made or built -up shoes, cast shoes, sneakers, ready - made compression hose or support hose, or similar type devices /appliances regardless of intended use, except for therapeutic shoes (including inserts and /or modifications) for the treatment of severe diabetic foot disease; 2. Expenses for orthotic appliances or devices which straighten or re -shape the conformation of the head or bones of the skull or cranium through cranial banding or molding (e.g. dynamic orthotic cranioplasty or molding helmets), except when the orthotic appliance or device is used as an What Is Covered? 2 -13 alternative to an internal fixation device as a result of surgery for craniosynostosis; and 3. Expenses for devices necessary to exercise, train, or participate in sports, e.g. custom- made knee braces. Osteoporosis Screening, Diagnosis, and Treatment Screening, diagnosis, and treatment of osteoporosis for high -risk individuals is covered, as Medically Necessary including, but not limited to: 1. estrogen- deficient individuals who are at clinical risk for osteoporosis; 2. individuals who have vertebral abnormalities; 3. individuals who are receiving long -term glucocorticoid (steroid) therapy; or 4. individuals who have primary hype rparathyroidism; or 5. Individuals who have a family history of osteoporosis. Outpatient Cardiac, Occupational, Physical, Speech, Massage Therapies and Spinal Manipulation Services Outpatient therapies listed below may be Covered Services when ordered by a Physician or other health care professional licensed to perform such Services. The outpatient therapies listed in this category are in addition to the Cardiac, Occupational, Physical and Speech Therapy benefits listed in the Home Health Care, Hospital, and Skilled Nursing Facility categories herein. Cardiac Therapy Services provided under the supervision of a Physician, or an appropriate Provider trained for Cardiac Therapy, for the purpose of aiding in the restoration of normal heart function in connection with a myocardial infarction, coronary occlusion or coronary bypass surgery are covered. Occupational Therapy Services provided by a Physician or Occupational Therapist for the purpose of aiding in the restoration of a previously impaired function lost due to a Condition are covered. Speech Therapy Services of a Physician, Speech Therapist, or licensed audiologist to aid in the restoration of speech loss or an impairment of speech resulting from a Condition are covered. Physical Therapy Services provided by a Physician or Physical Therapist for the purpose of aiding in the restoration of normal physical function lost due to a Condition are covered. Massage Therapy Massage provided by a Physician, Massage Therapist, or Physical Therapist when the Massage is prescribed as being Medically Necessary by a Physician licensed pursuant to Florida Statutes Chapter 458 (Medical Practice), Chapter 459 (Osteopathy), Chapter 460 (Chiropractic) or Chapter 461 (Podiatry) is covered. The Physician's prescription must specify the number of treatments. Payment Guidelines for Massage and Physical Therapy 1. Payment for covered Massage Services is limited to no more than four (4) 15- minute Massage treatments per day, not to exceed the Outpatient Cardiac, Occupational, Physical, Speech, and Massage Therapies and Spinal Manipulations benefit maximum listed on the Schedule of Benefits. 2. Payment for a combination of covered Massage and Physical Therapy Services rendered on the same day is limited to no more than four (4) 15- minute treatments per day for combined Massage and Physical Therapy treatment, not to exceed the Outpatient Cardiac, Occupational, Physical, Speech, and Massage Therapies and Spinal V What Is Covered? 2 -14 Manipulations benefit maximum listed on the Schedule of Benefits. 3. Payment for covered Physical Therapy Services rendered on the same day as spinal manipulation is limited to one (1) Physical Therapy treatment per day not to exceed fifteen (15) minutes in length. Spinal Manipulations: Services by Physicians for manipulations of the spine to correct a slight dislocation of a bone or joint that is demonstrated by x -ray are covered. Payment Guidelines for Spinal Manipulation 1. Payment for covered spinal manipulation is limited to no more than 26 spinal manipulations per Benefit Period, or the maximum benefit listed in the Schedule of Benefits, whichever occurs first. 2. Payment for covered Physical Therapy Services rendered on the same day as a spinal manipulation is limited to one (1) Physical Therapy treatment per day, not to exceed fifteen (15) minutes in length. Your Schedule of Benefits sets forth the maximum number of visits covered under this plan for any combination of the outpatient therapies and spinal manipulation Services listed above. For example, even if you may have only been administered two (2) of the spinal manipulations for the Benefit Period, any additional spinal manipulations for that Benefit Period will not be covered if you have already met the combined therapy visit maximum with other Services. Oxygen Expenses for oxygen, the equipment necessary to administer it, and the administration of oxygen are covered. Physician Services Medical or surgical Health Care Services provided by a Physician, including Services rendered in the Physician's office, in an outpatient facility, or electronically through a computer via the Internet. Payment Guidelines for Physician Services Provided by Electronic Means through a Computer: Expenses for online medical Services provided electronically through a computer by a Physician via the Internet will be covered only if such Services: 1. were provided to a covered individual who was, at the time the Services were provided, an established patient of the Physician rendering the Services; 2. were in response to an online inquiry received through the Internet from the covered individual with respect to which the Services were provided; and 3. were provided by a Physician through a secure online healthcare communication services vendor that, at the time the Services were rendered, was under contract with BCBSF. The term "established patient," as used herein, shall mean that the covered individual has received professional services from the Physician who provided the online medical Services, or another physician of the same specialty who belongs to the same group practice as that Physician, within the past three years. Exclusion: Expenses for online medical Services provided electronically through a computer by a Physician via the Internet other than through a healthcare communication services vendor that has entered into contract with BCBSF are excluded. Expenses for online medical Services provided by a health care provider that is not a Physician and expenses for Health Care Services rendered by telephone (except as indicated as covered under the Preventive Health Services What Is Covered? 2 -15 category of the WHAT IS COVERED? section) are also excluded. Preventive Health Services Preventive Services are covered for both adults and children based on prevailing medical standards and recommendations which are explained further below. Some examples of preventive health Services include, but are not limited to, periodic routine health exams, routine gynecological exams, immunizations and related preventive Services such as Prostate Specific Antigen (PSA), routine mammograms and pap smears. In order to be covered, Services shall be provided in accordance with prevailing medical standards consistent with: 1. evidence -based items or Services that have in effect a rating of `A' or `B' in the current recommendations of the U.S. Preventive Services Task Force established under the Public Health Service Act; 2. immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention established under the Public Health Service Act with respect to the individual involved; 3. with respect to infants, children, and adolescents, evidence- informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and 4. with respect to women, such additional preventive care and screenings not described in paragraph number one as provided for in comprehensive guidelines supported by the Health Resources and Services Administration. More detailed information, such as medical management programs or limitations, on Services that are covered under the Preventive Health Services category is available in the Preventive Services Guide located on our website at www. FloridaBlue .com /healthresources Drugs or Supplies covered as Preventive Services are described in the Medication Guide. In order to be covered as a Preventive Health Service under this section the Service must be provided as described in the Preventive Services Guide or, for Drugs and Supplies, in the Medication Guide. Note: From time to time medical standards that are based on the recommendations of the entities listed in numbers 1 through 4 above change. Services may be added to the recommendations and sometimes may be removed. It is important to understand that your coverage for these preventive Services is based on what is in effect on your Effective Date. If any of the recommendations or guidelines change after your Effective Date, your coverage will not change until your Group's first Anniversary Date one year after the recommendations or guidelines go into effect. For example, if the USPSTF adds a new recommendation for a preventive Service that we do not cover and you are already covered under this Benefit Booklet; that new Service will not be a Covered Service under this category right away. The coverage for a new Service will start on your Group's Anniversary Date one year after the new recommendation goes into effect. Fvr minn- Routine vision and hearing examinations and screenings are not covered, except as required under paragraph one above. Prosthetic Devices The following Prosthetic Devices are covered when prescribed by a Physician and designed and fitted by a Prosthetist: 1. artificial hands, arms, feet, legs and eyes, including permanent implanted lenses What Is Covered? 2 -16 following cataract surgery, cardiac pacemakers, and prosthetic devices incident to a Mastectomy; 2. appliances needed to effectively use artificial limbs or corrective braces; or 3. penile prosthesis. Covered Prosthetic Devices (except cardiac pacemakers, and Prosthetic Devices incident to Mastectomy) are limited to the first such permanent prosthesis (including the first temporary prosthesis if it is determined to be necessary) prescribed for each specific Condition. Benefits may be provided for necessary replacement of a Prosthetic Device which is owned by you when due to irreparable damage, wear, or a change in your Condition, or when necessitated due to growth of a child. Exclusion: 1. Expenses for microprocessor controlled or myoelectric artificial limbs (e.g. C- legs); and 2. Expenses for cosmetic enhancements to artificial limbs. Self- Administered Prescription Drugs The following Self- Administered Drugs are covered: Self- Administered Prescription Drugs used in the treatment of diabetes, cancer, Conditions requiring immediate stabilization (e.g. anaphylaxis), or in the administration of dialysis; and 2. Specialty Drugs used to increase height or bone growth (e.g., growth hormone), must meet the following criteria in order to be covered: a. Must be prescribed for Conditions of growth hormone deficiency documented with two abnormally low stimulation tests of less than 10 ng /ml and one abnormally low growth hormone dependent peptide or for Conditions of growth hormone deficiency associated with loss of pituitary function due to trauma, surgery, tumors, radiation or disease, or for state mandated use as in patients with AIDS. b. Continuation of growth hormone therapy is only covered for Conditions associated with significant growth hormone deficiency when there is evidence of continued responsiveness to treatment. Treatment is considered responsive in children less than 21 years of age, when the growth hormone dependent peptide (IGF -1) is in the normal range for age and Tanner development stage; the growth velocity is at least 2 cm per year, and studies demonstrate open epiphyses. Treatment is considered responsive in both adolescents with closed epiphyses and for adults, who continue to evidence growth hormone deficiency and the IGF- 1 remains in the normal range for age and gender. Skilled Nursing Facilities The following Health Care Services may be Covered Services when you are an inpatient in a Skilled Nursing Facility: 1. room and board; 2. respiratory, pulmonary, or inhalation therapy (e.g., oxygen); 3. drugs and medicines administered while an inpatient (except take home drugs); 4. intravenous solutions; 5. administration of, including the cost of, whole blood or blood products(except as outlined in the Drugs exclusion of the "What Is Not Covered ?" section); 6. dressings, including ordinary casts; What Is Covered? 2 -17 7. transfusion supplies and equipment; 8. diagnostic Services, including radiology, ultrasound, laboratory, pathology and approved machine testing (e.g., EKG); 9. chemotherapy treatment for proven malignant disease; and 10. Physical, Speech, and Occupational Therapies; A treatment plan from your Physician may be required in order to determine coverage and payment. Exclusion: Expenses for an inpatient admission to a Skilled Nursing Facility for purposes of Custodial Care, convalescent care, or any other Service primarily for the convenience of you and /or your family members or the Provider are excluded. Surgical Assistant Services Services rendered by a Physician, Registered Nurse First Assistant or Physician Assistant when acting as a surgical assistant (provided no intern, resident, or other staff physician is available) when the assistant is necessary are covered. Surgical Procedures Surgical procedures performed by a Physician may be covered including the following: 1. sterilization (tubal ligations and vasectomies), regardless of Medical Necessity; 2. surgery to correct deformity which was caused by disease, trauma, birth defects, growth defects or prior therapeutic processes; 3. oral surgical procedures for excisions of tumors, cysts, abscesses, and lesions of the mouth; 4. surgical procedures involving bones or joints of the jaw (e.g., temporomandibular joint [TMJ]) and facial region if, under accepted medical standards, such surgery is necessary to treat Conditions caused by congenital or developmental deformity, disease, or injury; 5. Services of a Physician for the purpose of rendering a second surgical opinion and related diagnostic services to help determine the need for surgery; and 6. Surgical procedures performed on a Covered Plan Participant for the treatment of Morbid Obesity (e.g., intestinal bypass, stomach stapling, balloon dilation) and the associated care provided the Covered Plan Participant has not previously undergone the same or similar procedure in the lifetime of this Group Health Plan when medically necessary. Fxrrh minn- a. Surgical procedures for the treatment of Morbid Obesity including: intestinal bypass; stomach stapling; balloon dilation and associated care for the surgical treatment of Morbid Obesity, if the Covered Plan Participant has previously undergone the same or similar procedures in the lifetime of this Group Health Plan. Surgical procedures performed to revise, or correct defects related to, a prior intestinal bypass, stomach stapling or balloon dilation are also excluded. b. Reversal of a weight loss surgery, surgical procedures to revise, correct, and correction of defects to include adjustment to devices implanted or any fills not performed during the initial surgical event. Payment Guidelines for Surgical Procedures 1. Payment for multiple surgical procedures performed in addition to the primary surgical procedure, on the same or different areas of the body, during the same operative session What Is Covered? 2 -18 will be based on 50 percent of the Allowed Amount for any secondary surgical procedure(s) performed. In addition, Coinsurance or Copayment (if any) indicated in your Schedule of Benefits will apply. This guideline is applicable to all bilateral procedures and all surgical procedures performed on the same date of service. 2. Payment for incidental surgical procedures is limited to the Allowed Amount for the primary procedure, and there is no additional payment for any incidental procedure. An "incidental surgical procedure" includes surgery where one, or more than one, surgical procedure is performed through the same incision or operative approach as the primary surgical procedure which, in BCBSF's or Monroe County BOCC's opinion, is not clearly identified and /or does not add significant time or complexity to the surgical session. For example, the removal of a normal appendix performed in conjunction with a Medically Necessary hysterectomy is an incidental surgical procedure (i.e., there is no payment for the removal of the normal appendix in the example). 3. Payment for surgical procedures for fracture care, dislocation treatment, debridement, wound repair, unna boot, and other related Health Care Services, is included in the Allowed Amount of the surgical procedure. Transplant Services Transplant Services, limited to the procedures listed below, may be covered when performed at a facility acceptable to BCBSF or Monroe County BOCC, subject to the conditions and limitations described below. Transplant includes pre - transplant, transplant and post- discharge Services, and treatment of complications after transplantation. Benefits will only be paid for Services, care and treatment received or provided in connection with a: Bone Marrow Transplant, as defined herein, which is specifically listed in the rule 596- 12.001 of the Florida Administrative Code or any successor or similar rule or covered by Medicare as described in the most recently published Medicare Coverage Issues Manual issued by the Centers for Medicare and Medicaid Services. Coverage will be provided for the expenses incurred for the donation of bone marrow by a donor to the same extent such expenses would be covered for you and will be subject to the same limitations and exclusions as would be applicable to you. Coverage for the reasonable expenses of searching for the donor will be limited to a search among immediate family members and donors identified through the National Bone Marrow Donor Program; 2. corneal transplant; 3. heart transplant (including a ventricular assist device, if indicated, when used as a bridge to heart transplantation); 4. heart -lung combination transplant; 5. liver transplant; 6. kidney transplant; 7. pancreas; 8. pancreas transplant performed simultaneously with a kidney transplant; or 9. lung -whole single or whole bilateral transplant. Coverage will be provided for donor costs and organ acquisition for transplants, other than Bone Marrow Transplants, provided such costs are not covered in whole or in part by any other insurance carrier, organization or person other than the donor's family or estate. You may call the customer service phone number indicated in this Booklet or on your Identification Card in order to determine which Bone Marrow Transplants are covered under this Booklet. What Is Covered? 2 -19 Exclusions: Expenses for the following are excluded: 1. transplant procedures not included in the list above, or otherwise excluded under this Booklet (e.g., Experimental or Investigational transplant procedures); 2. transplant procedures involving the transplantation or implantation of any non- human organ or tissue; 3. transplant procedures related to the donation or acquisition of an organ or tissue for a recipient who is not covered under this Benefit Booklet; 4. transplant procedures involving the implant of an artificial organ, including the implant of the artificial organ; 5. any organ, tissue, marrow, or stem cells which is /are sold rather than donated; 6. any Bone Marrow Transplant, as defined herein, which is not specifically listed in rule 5913- 12.001 of the Florida Administrative Code or any successor or similar rule or covered by Medicare pursuant to a national coverage decision made by the Centers for Medicare and Medicaid Services as evidenced in the most recently published Medicare Coverage Issues Manual; 7. any Service in connection with the identification of a donor from a local, state or national listing, except in the case of a Bone Marrow Transplant; 8. any non - medical costs, including but not limited to, temporary lodging or transportation costs for you and /or your family to and from the approved facility; and 9. any artificial heart or mechanical device that replaces either the atrium and /or the ventricle. What Is Covered? 2 -20 Section 3: What Is Not Covered? Introduction Your Booklet expressly excludes expenses for the following Health Care Services, supplies, drugs or charges. The following exclusions are in addition to any exclusions specified in the "What Is Covered ?" section or any other section of the Booklet. Abortions which are elective. Arch Supports, shoe inserts designed to effect conformational changes in the foot or foot alignment, orthopedic shoes, over - the - counter, custom -made or built -up shoes, cast shoes, sneakers, ready -made compression hose or support hose, or similar type devices /appliances regardless of intended use, except for therapeutic shoes (including inserts and /or modifications) for the treatment of severe diabetic foot disease. Assisted Reproductive Therapy (Infertility) including, but not limited to, associated Services, supplies, and medications for In Vitro Fertilization (IVF); Gamete Intrafallopian Transfer (GIFT) procedures; Zygote Intrafallopian Transfer (ZIFT) procedures; Artificial Insemination (AI); embryo transport; surrogate parenting; donor semen and related costs including collection and preparation; and infertility treatment medication. Autopsy or postmortem examination services, unless specifically requested by BCBSF or Monroe County BOCC. Complementary or Alternative Medicine including, but not limited to, self -care or self -help training; homeopathic medicine and counseling; Ayurvedic medicine such as lifestyle modifications and purification therapies; traditional Oriental medicine including acupuncture; naturopathic medicine; environmental medicine including the field of clinical ecology; chelation therapy; thermography; mind -body interactions such as meditation, imagery, yoga, dance, and art therapy; biofeedback; prayer and mental healing; manual healing methods such as the Alexander technique, aromatherapy, Ayurvedic massage, craniosacral balancing, Feldenkrais method, Hellerwork, polarity therapy, Reichian therapy, reflexology, rolfing, shiatsu, traditional Chinese massage, Trager therapy, trigger -point myotherapy, and biofield therapeutics; Reiki, SHEN therapy, and therapeutic touch; bioelectromagnetic applications in medicine; and herbal therapies. Complications of Non - Covered Services, including the diagnosis or treatment of any Condition which is a complication of a non - covered Health Care Service (e.g., Health Care Services to treat a complication of cosmetic surgery are not covered). Contraceptive medications, devices, appliances, or other Health Care Services when provided for contraception, except when indicated as covered, under the Preventive Health Services category of the "What Is Covered ?" section. Cosmetic Services, including any Service to improve the appearance or self - perception of an individual (except as covered under the Breast Reconstructive Surgery category), including and without limitation: cosmetic surgery and procedures or supplies to correct hair loss or skin wrinkling (e.g., Minoxidil, Rogaine, Retin -A), and hair implants /transplants,or services used to improve the gender specific appearance of an individual including, but not limited to reduction thyroid chondroplasty, liposuction, rhinoplasty, facial bone reconstruction, face lift, blepharoplasty, voice modification surgery, hair removal /hairplasty, breast augmentation. What Is Not Covered? 3 -1 Costs related to telephone consultations (except as indicated as covered under the Preventive Health Services category of the COVERED SERVICES section), failure to keep a scheduled appointment, or completion of any form and /or medical information. Custodial Care and any service of a custodial nature, including and without limitation: Health Care Services primarily to assist in the activities of daily living; rest homes; home companions or sitters; home parents; domestic maid services; respite care; and provision of services which are for the sole purposes of allowing a family member or caregiver of a Covered Person to return to work. Dental Care or treatment of the teeth or their supporting structures or gums, or dental procedures, including but not limited to: extraction of teeth, restoration of teeth with or without fillings, crowns or other materials, bridges, cleaning of teeth, dental implants, dentures, periodontal or endodontic procedures, orthodontic treatment (e.g., braces), intraoral prosthetic devices, palatal expansion devices, bruxism appliances, and dental x -rays. This exclusion also applies to Phase II treatments (as defined by the American Dental Association) for TMJ dysfunction. This exclusion does not apply to an Accidental Dental Injury and the Child Cleft Lip and Cleft Palate Treatment Services category as described in the "What Is Covered ?" section. Drugs 1. Prescribed for uses other than the Food and Drug Administration (FDA) approved label indications. This exclusion does not apply to any drug that has been proven safe, effective and accepted for the treatment of the specific medical Condition for which the drug has been prescribed, as evidenced by the results of good quality controlled clinical studies published in at least two or more peer- reviewed full length articles in respected national professional medical journals. This exclusion also does not apply to any drug prescribed for the treatment of cancer that has been approved by the FDA for at least one indication, provided the drug is recognized for treatment of your particular cancer in a Standard Reference Compendium or recommended for treatment of your particular cancer in Medical Literature. Drugs prescribed for the treatment of cancer that have not been approved for any indication are excluded. 2. All drugs dispensed to, or purchased by, you from a pharmacy. This exclusion does not apply to drugs dispensed to you when: a. you are an inpatient in a Hospital, Ambulatory Surgical Center, Skilled Nursing Facility, Psychiatric Facility or a Hospice facility; b. you are in the outpatient department of a Hospital; 3. dispensed to your Physician for administration to you in the Physician's office and prior coverage authorization has been obtained (if required); Any non - Prescription medicines, remedies, vaccines, biological products (except insulin), pharmaceuticals or chemical compounds, vitamins, mineral supplements, fluoride products, over - the - counter drugs, products, or health foods, except as described in the Preventive Health Services category of the "What Is Covered ?" section. 4. Any drug which is indicated or used for sexual dysfunction (e.g., Cialis, Levitra, Viagra, Caverject). The exception described in exclusion number one above does not apply to sexual dysfunction drugs excluded under this paragraph. 5. Any Self- Administered Prescription Drug not indicated as covered in the "What Is Covered ?" section of this Benefit Booklet. V What Is Not Covered? 3 -2 6. Blood or blood products used to treat hemophilia, except when provided to you for: a. emergency stabilization; b. during a covered inpatient stay; or c. when proximately related to a surgical procedure. The exceptions to the exclusion for drugs purchased or dispensed by a pharmacy described in subparagraph number two do not apply to hemophilia drugs excluded under this subparagraph. 7. Drugs, which require prior coverage authorization when prior coverage authorization is not obtained. 8. Specialty Drugs used to increase height or bone growth (e.g., growth hormone) except for Conditions of growth hormone deficiency documented with two abnormally low stimulation tests of less than 10 ng /ml and one abnormally low growth hormone dependent peptide or for Conditions of growth hormone deficiency associated with loss of pituitary function due to trauma, surgery, tumors, radiation or disease, or for state mandated use as in patients with AIDS. Continuation of growth hormone therapy will not be covered except for Conditions associated with significant growth hormone deficiency when there is evidence of continued responsiveness to treatment. (See "What is Covered ?" section for additional information.) Experimental or Investigational Services, except as otherwise covered under the Bone Marrow Transplant provision of the Transplant Services category. Food and Food Products prescribed or not, except as covered in the Enteral Formulas subsection of the "What Is Covered ?" section. Foot Care which is routine, including any Health Care Service, in the absence of disease. This exclusion includes, but is not limited to: non- surgical treatment of bunions; flat feet; fallen arches; chronic foot strain; trimming of toenails corns, or calluses. General Exclusions include, but are not limited to: 1. any Health Care Service received prior to your Effective Date or after the date your coverage terminates; 2. any Service to diagnose or treat any Condition resulting from or in connection with your job or employment; 3. any Health Care Services not within the service categories described in the "What is Covered ?" section, any rider, or Endorsement attached hereto, unless such services are specifically required to be covered by applicable law; 4. any Health Care Service you render to yourself or those rendered by a Physician or other health care Provider related to you by blood or marriage; 5. any Health Care Service which is not Medically Necessary as determined by us or Monroe County BOCC and defined in this Booklet. The ordering of a Service by a health care Provider does not in itself make such Service Medically Necessary or a Covered Service; 6. any Health Care Services rendered at no charge; 7. expenses for claims denied because we did not receive information requested from you regarding whether or not you have other coverage and the details of such coverage; 8. any Health Care Services to diagnose or treat a Condition which, directly or indirectly, resulted from or is in connection with: What Is Not Covered? 3 -3 a) war or an act of war, whether declared or not; b) your participation in, or commission of, any act punishable by law as a felony whether or not you are charged or convicted, or which constitutes riot, or rebellion except for an injury resulting from an act of domestic violence or a medical condition; c) your engaging in an illegal occupation, except for an injury resulting from an act of domestic violence or a medical condition; d) Services received at military or government facilities to treat a condition arising out of your service in the armed forces, reserves and /or National Guard; or e) Services received to treat a Condition arising out of your service in the armed forces, reserves and /or National Guard; f) Services that are not patient- specific, as determined solely by us. 9. Health Care Services rendered because they were ordered by a court, unless such Services are Covered Services under this Benefit Booklet; and 10. any Health Care Services rendered by or through a medical or dental department maintained by or on behalf of an employer, mutual association, labor union, trust, or similar person or group; or 11. Health Care Services that are not direct, hands -on, and patient specific, including, but not limited to the oversight of a medical laboratory to assure timeliness, reliability, and /or usefulness of test results, or the oversight of the calibration of laboratory machines, equipment, or laboratory technicians. Genetic screening, including the evaluation of genes to determine if you are a carrier of an abnormal gene that puts you at risk for a Condition, except as provided under the Preventive Health Services category of the "What Is Covered ?" section. Hearing Aids (external or implantable) and Services related to the fitting or provision of hearing aids, including tinnitus maskers, batteries, and cost of repair. Immunizations except those covered under the Preventive Health Services category of the "What Is Covered ?" section. Motor Vehicle Accidents Injuries and Services you incur due to an accident involving any motor vehicle for which no -fault insurance is available. Oral Surgery except as provided under the "What Is Covered ?" section. Orthomolecular Therapy including nutrients, vitamins, and food supplements. Oversight of a medical laboratory by a Physician or other health care Provider. "Oversight" as used in this exclusion shall, include, but is not limited to, the oversight of: 1. the laboratory to assure timeliness, reliability, and /or usefulness of test results; 2. the calibration of laboratory machines or testing of laboratory equipment; 3. the preparation, review or updating of any protocol or procedure created or reviewed by a Physician or other health care Provider in connection with the operation of the laboratory; and 4. laboratory equipment or laboratory personnel for any reason. Personal Comfort, Hygiene or Convenience Items and Services deemed to be not Medically Necessary and not directly related to your treatment including, but not limited to: 1. beauty and barber services; 2. clothing including support hose; What Is Not Covered? 3 -4 3. radio and television; 4. guest meals and accommodations; 5. telephone charges; 6. take -home supplies; 7. travel expenses (other than Medically Necessary Ambulance Services); 8. motel /hotel accommodations; 9. air conditioners, furnaces, air filters, air or water purification systems, water softening systems, humidifiers, dehumidifiers, vacuum cleaners or any other similar equipment and devices used for environmental control or to enhance an environmental setting; 10. hot tubs, Jacuzzis, heated spas, pools, or memberships to health clubs; 11. heating pads, hot water bottles, or ice packs; 12. physical fitness equipment; 13. hand rails and grab bars; and 14. Massages except as covered in the "What Is Covered ?" section of this Booklet. Private Duty Nursing Care rendered at any location. Rehabilitative Therapies provided on an inpatient or outpatient basis, except as provided in the Hospital, Skilled Nursing Facility, Home Health Care, and Outpatient Cardiac, Occupational, Physical, Speech, Massage Therapies and Spinal Manipulations categories of the "What Is Covered?" section. Rehabilitative Therapies provided for the purpose of maintaining rather than improving your Condition are also excluded. Reversal of Voluntary, Surgically- Induced Sterility including the reversal of tubal ligations and vasectomies. Sexual Reassignment, or Modification Services including, but not limited to, any Health Care Services related to such treatment, such as psychiatric Services. Smoking Cessation Programs including any service to eliminate or reduce the dependency on, or addiction to, tobacco, including but not limited to nicotine withdrawal programs and nicotine products (e.g., gum, transdermal patches, etc.),except as indicated as covered under the Preventive Health Services category of the WHAT IS COVERED? section. Sports - Related devices and services used to affect performance primarily in sports- related activities; all expenses related to physical conditioning programs such as athletic training, bodybuilding, exercise, fitness, flexibility, and diversion or general motivation. Training and Educational Programs, or materials, including, but not limited to programs or materials for pain management and vocational rehabilitation, except as provided under the Diabetes Outpatient Self Management category of the "What Is Covered?" section. Travel or vacation expenses even if prescribed or ordered by a Provider. Volunteer Services or Services which would normally be provided free of charge and any charges associated with Deductible, Coinsurance, or Copayment (if applicable) requirements which are waived by a health care Provider. Weight Control Services including any service to lose, gain, or maintain weight, including without limitation: any weight control /loss program; appetite suppressants; dietary regimens; food or food supplements; exercise programs; equipment; whether or not it is part of a treatment plan for a Condition. Wigs and /or cranial prosthesis. What Is Not Covered? 3 -5 Section 4: Medical Necessity In order for Health Care Services to be covered under this Booklet, such Services must meet all of the requirements to be a Covered Service, including being Medically Necessary, as defined by this Benefit Booklet. It is important to remember that any review of Medical Necessity we undertake is solely for the purposes of determining coverage, benefits, or payment under the terms of this Booklet and not for the purpose of recommending or providing medical care. In conducting a review of Medical Necessity, BCBSF may review specific medical facts or information pertaining to you. Any such review, however, is strictly for the purpose of determining whether a Health Care Service provided or proposed meets the definition of Medical Necessity in this Booklet. In applying the definition of Medical Necessity in this Booklet to a specific Health Care Service, coverage and payment guidelines then in effect may be applied by BCBSF. All decisions that require or pertain to independent professional medical /clinical judgement or training, or the need for medical services, are solely your responsibility and that of your treating Physicians and health care Providers. You and your Physicians are responsible for deciding what medical care should be rendered or received and when that care should be provided. Monroe County BOCC is ultimately responsible for determining whether expenses incurred for medical care are covered under this Booklet. In making coverage decisions, neither BCBSF nor Monroe County BOCC will be deemed to participate in or override your decisions concerning your health or the medical decisions of your health care Providers. Examples of hospitalization and other Health Care Services that are not Medically Necessary include, but are not limited to: 1. staying in the Hospital because arrangements for discharge have not been completed; 2. use of laboratory, x -ray, or other diagnostic testing that has no clear indication, or is not expected to alter your treatment; 3. staying in the Hospital because supervision in the home, or care in the home, is not available or is inconvenient; or being hospitalized for any Service which could have been provided adequately in an alternate setting (e.g., Hospital outpatient department or at home with Home Health Care Services); or 4. inpatient admissions to a Hospital, Skilled Nursing Facility, or any other facility for the purpose of Custodial Care, convalescent care, or any other Service primarily for the convenience of the patient or his or her family members or a Provider. Note: Whether or not a Health Care Service is specifically listed as an exclusion, the fact that a Provider may prescribe, recommend, approve, or furnish a Health Care Service does not mean that the Service is Medically Necessary (as defined by this Benefit Booklet) or a Covered Service. Please refer to the "Definitions" section for the definitions of "Medically Necessary" or "Medical Necessity ". Medical Necessity 4 -1 Section 5: Understanding Your Share of Health Care Expenses This section explains what your share of the health care expenses will be for Covered Services you receive. In addition to the information explained in this section, it is important that you refer to your Schedule of Benefits to determine your share of the cost with regard to Covered Services. WARNING: LIMITED BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE USED. You should be aware that when you elect to utilize the services of a nonparticipating provider for a covered nonemergency service, benefit payments to the provider are not based upon the amount the provider charges. The basis of the payment will be determined according to your policy's out -of- network reimbursement benefit. Nonparticipating providers may bill insureds for any difference in the amount. YOU MAY BE REQUIRED TO PAY MORE THAN THE COINSURANCE OR COPAYMENT AMOUNT. Participating providers have agreed to accept discounted payments for services with no additional billing to you other than coinsurance, copayment, and deductible amounts. You may obtain further information about the providers who have contracted with your insurance plan by consulting your insurer's website or contacting your insurer or agent directly. individual Deductible and only up to the applicable Allowed Amount. Please see your Schedule of Benefits for more information. Family Deductible If your plan includes a family Deductible, after the family Deductible has been met by your family, neither you nor your Covered Dependents will have any additional Deductible responsibility for the remainder of that Benefit Period. The maximum amount that any one Covered Person in your family can contribute toward the family Deductible, if applicable, is the amount applied toward the individual Deductible. Please see your Schedule of Benefits for more information. Copayment Requirements Covered Services rendered by certain Providers or at certain locations or settings will be subject to a Copayment requirement. This is the dollar amount you have to pay when you receive these Services. Please refer to your Schedule of Benefits for the specific Covered Services which are subject to a Copayment. Listed below is a brief description of some of the Copayment requirements that may apply to your plan. If the Allowed Amount or the Provider's actual charge for a Covered Service rendered is less than the Copayment amount, you must pay the lesser of the Allowed Amount or the Provider's actual Deductible Requirement Individual Deductible This amount, when applicable, must be satisfied by you and each of your Covered Dependents each Benefit Period, before any payment will be made by the Group Health Plan. Only those charges indicated on claims received for Covered Services will be credited toward the charge for the Covered Service. 1. Office Services Copayment: If your plan is a Copayment plan, the Copayment for Covered Services rendered in the office (when applicable) must be satisfied by you, for each office Service before any payment will be made. The office Services Copayment applies regardless of the reason for the office visit Understanding Your Share of Health Care Expenses 5 -1 and applies to all Covered Services rendered in the office, with the exception of Durable Medical Equipment, Medical Pharmacy, Prosthetics, and Orthotics. Generally, if more than one Covered Service that is subject to a Copayment is rendered during the same office visit, you will be responsible for a single Copayment which will not exceed the highest Copayment specified in the Schedule of Benefits for the particular Health Care Services rendered. 2. Inpatient Facility Copayment: The inpatient facility Copayment must be satisfied by you, for each inpatient admission to a Hospital, Psychiatric Facility, or Substance Abuse Facility, before any payment will be made for any claim for inpatient Covered Services. The inpatient facility Copayment applies regardless of the reason for the admission, and applies to all inpatient admissions to a Hospital, Psychiatric Facility or Substance Abuse Facility in or outside the state of Florida. Additionally, you will be responsible for out - of- pocket expenses for Covered Services provided by Physicians and other health care professionals for inpatient admissions. Note: Inpatient facility Copayments vary depending on the facility chosen. (Please see the Schedule of Benefits for more information). 3. Outpatient Facility Copayment: The outpatient facility Copayment may be satisfied by you, for each outpatient visit to a Hospital, Ambulatory Surgical Center, Facility in or outside the state of Florida. Additionally, you will be responsible for out - of- pocket expenses for Covered Services provided by Physician and other healthcare professionals. Note: Outpatient facility Copayments vary depending on the facility chosen. (Please see the Schedule of Benefits for more information). Hospital Per Admission Deductible The Hospital Per Admission Deductible (PAD) must be satisfied by each Covered Plan Participant, for each Hospital admission, before any payment will be made for any claim for inpatient Health Care Services. The Hospital Per Admission Deductible applies regardless of the reason for the admission, is in addition to the Deductible requirement, and applies to all Hospital admissions in or outside the state of Florida. Emergency Room Per Visit Deductible The Emergency Room Per Visit Deductible (PVD) is set forth in the Schedule of Benefits. The Emergency Room Per Visit Deductible applies regardless of the reason for the visit, is in addition to the Deductible, and applies to emergency room services in or outside the state of Florida. The Emergency Room Per Visit Deductible must be satisfied by each Covered Plan Participant for each visit. If the Covered Plan Participant is admitted to the Hospital at the time of the emergency room visit, the Emergency Room Per Visit Deductible will be waived. Independent Diagnostic Testing Facility, Psychiatric Facility or Substance Abuse Coinsurance Requirements Facility, before any payment will be made for All applicable Deductible or Copayment amounts any claim for outpatient Covered Services. must be satisfied before any portion of the The Outpatient Facility Copayment applies ' Allowed Amount will be paid for Covered regardless of the reason for the visit, and Services. For Services that are subject to applies to all outpatient visits to a Hospital, Coinsurance, the Coinsurance percentage of the Psychiatric Facility or Substance Abuse Understanding Your Share of Health Care Expenses 5 -2 applicable Allowed Amount you are responsible for is listed in the Schedule of Benefits. Out -of- Pocket Maximums Individual out -of- pocket maximum Once you have reached the individual out -of- pocket maximum amount listed in the Schedule of Benefits, you will have no additional out -of- pocket responsibility for the remainder of that Benefit Period and we will pay 100 percent of the Allowed Amount for Covered Services rendered during the remainder of that Benefit Period. Family out -of- pocket maximum If your plan includes a family out -of- pocket maximum, once your family has reached the family out -of- pocket maximum amount listed in the Schedule of Benefits, neither you nor your covered family members will have any additional out -of- pocket responsibility for the remainder of that Benefit Period and we will pay 100 percent of the Allowed Amount for Covered Services rendered during the remainder of that Benefit Period. The maximum amount any one Covered Person in your family can contribute toward the family out -of- pocket maximum, if applicable, is the amount applied toward the individual out -of- pocket maximum. Please see your Schedule of Benefits for more information. Note: The Deductible, PAD, PVD, any applicable Copayments and Coinsurance amounts will accumulate toward the out -of- pocket maximums. Any benefit penalty reductions, non - covered charges or any charges in excess of the Allowed Amount will not accumulate toward the out -of- pocket maximums. Prior Coverage Credit You will be given credit for the satisfaction or partial satisfaction of any Deductible and Coinsurance maximums met by you under a prior group insurance, blanket insurance, or franchise insurance or group Health Maintenance Organization (HMO) policy or plan maintained by Monroe County BOCC if the coverage provided hereunder replaces such a policy or plan. This provision only applies if the prior group insurance, blanket insurance, franchise insurance, HMO or plan coverage was in effect immediately preceding the Effective Date of the coverage provided under this Benefit Booklet. This provision is only applicable for you during the initial Benefit Period of coverage under this Benefit Booklet and the following rules apply: 1. Prior Coverage Credit for Deductible: For the initial Benefit Period of coverage under this Benefit Booklet only, charges credited towards your Deductible requirement under the prior policy or plan, for Services rendered during the 90 -day period immediately preceding the Effective Date of the coverage under this Benefit Booklet, will be credited to the Deductible requirement under this Booklet. 2. Prior Coverage Credit for Coinsurance: Charges credited by Monroe County BOCC's prior policy or plan, towards your Coinsurance Maximum, for Services rendered during the 90 -day period immediately preceding the Effective Date of coverage under this Benefit Booklet, will be credited to your out -of- pocket maximum under this Booklet. 3. Prior coverage credit towards the Deductible or out -of- pocket maximums will only be given for Health Care Services which would have been Covered Services under this Booklet. 4. Prior coverage credit under this Booklet only applies at the initial enrollment of the entire Group. You and /or Monroe County BOCC are responsible for providing BCBSF with any information necessary for BCBSF to apply this prior coverage credit. Understanding Your Share of Health Care Expenses 5 -3 Benefit Maximum Carryover If immediately before the Effective Date of the coverage under this Benefit Booklet, you were covered under a prior Monroe County BOCC group plan insured or administered by BCBSF, amounts applied to your benefit maximums under the prior group plan, will be applied toward your benefit under this Booklet. Additional Expenses You Must Pay In addition to your share of the expenses described above, you are also responsible for: 1. any applicable Copayments; 2. expenses incurred for non - covered Services; 3. charges in excess of any maximum benefit limitation listed in the Schedule of Benefits (e.g., the Benefit Period maximums); 4. charges in excess of the Allowed Amount for Covered Services rendered by Providers who have not agreed to accept the Allowed Amount as payment in full; 5. any benefit reductions; 6. payment of expenses for claims denied because we did not receive information requested from you regarding whether or not you have other coverage and the details of such coverage; and 7. charges for Health Care Services which are excluded. Additionally, you are responsible for any contribution amount required by Monroe County BOCC. How Benefit Maximums Will Be Credited Only amounts actually paid for Covered Services will be credited towards any applicable benefit maximums. The amounts paid which are credited towards your benefit maximums will be based on the Allowed Amount for the Covered Services provided. Understanding Your Share of Health Care Expenses 5 -4 Section 6: Physicians, Hospitals and Other Provider Options Introduction encouraged to select and develop a relationship It is important for you to understand how the with an In- Network Family Physician. There are Provider you select and the setting in which you several advantages to selecting a Family receive Health Care Services affects how much Physician. Family Physicians are trained to you are responsible for paying under this Booklet. This section, along with the Schedule of Benefits, describes the health care Provider options available to you and the payment rules for Services you receive. As used throughout this section "out -of- pocket expenses" or "out -of- pocket" refers to the amounts you are required to pay including any applicable Copayments, the Deductible and /or Coinsurance amounts for Covered Services. You are entitled to preferred provider type benefits when you receive Covered Services from In- Network Providers. You are entitled to traditional program type benefits at the point of service when you receive Covered Services from Traditional Program Providers or BlueCard (Out -of- State) Traditional Program Providers, in conformity with Section 7: BlueCard (Out -of- State) Program. Value Choice Providers To find a Value Choice Provider you may access the most recent provider directory at www.floridablue.com These Providers will be designated under the heading Value Choice Providers. Provider Participation Status With BlueOptions, you may choose to receive Services from any Provider. However, you may be able to lower the amount you have to pay for Covered Services by receiving care from an In- Network Provider. Although you have the option to select any Provider you choose, you are provide a broad range of medical care and can be a valuable resource to coordinate your overall healthcare needs. Developing and continuing a relationship with a Family Physician allows the physician to become knowledgeable about you and your family's health history. A Family Physician can help you determine when you need to visit a specialist and also help you find one based on their knowledge of you and your specific healthcare needs. Types of Family Physicians are Family Practitioners, General Practitioners, Internal Medicine doctors and Pediatricians. Additionally, care rendered by Family Physicians usually results in lower out -of- pocket expenses for you. Whether you select a Family Physician or another type of Physician to render Health Care Services, please remember that using In- Network Providers may result in lower out -of- pocket expenses for you. You should always determine whether a Provider is In- Network or Out -of- Network prior to receiving Services to determine the amount you are responsible for paying out -of- pocket. Location of Service In addition to the participation status of the Provider, the location or setting where you receive Services can affect the amount you pay. For example, the amount you are responsible for paying out -of- pocket will vary whether you receive Services in a Hospital, a Provider's office, or an Ambulatory Surgical Center. Please refer to your Schedule of Benefits for specific information regarding your out -of- pocket expenses for such situations. After you and your Physician have determined the plan of treatment most appropriate for your care, you Physicians, Hospitals and Other Provider Options 6 -1 should refer to the "What Is Covered ?" section and your Schedule of Benefits to find out if the specific Health Care Services are covered and how much you will have to pay. You should also consult with your Physician to determine the most appropriate setting based on your health care and financial needs. To verify if a Provider is In- Network for your plan you can: If in Florida, review your current BlueOptions Provider Directory; 2. If in Florida, access the BlueCiptions Provider directory at BCBSF's web -site at www.floridablue.com 3. If outside of Florida, access the on -line BlueCard Doctor and Hospital Finder at www.floridablue.com and /or 4. Call the customer service phone number in this Booklet or on your Identification Card to search for PPO providers. Please remember that changes to Provider network participation can occur at any time. Consequently, it is your responsibility to determine whether a specific Provider is In- Network at the time you receive Covered Services. In- Network Providers When you use In- Network Providers, your out - of- pocket expenses for Covered Services may be lower. Payment will be based on the Allowed Amount and your share of the cost will be at the In- Network benefit level listed in the Schedule of Benefits. Out -of- Network Providers When you use Out -of- Network Providers your out -of- pocket expenses for Covered Services will be higher. We will base our payment on the Allowed Amount at the Coinsurance percentage listed in the Schedule of Benefits. Further, if the Out -of- Network Provider is a Traditional Program Provider or a BlueCard (Out -of- State) Traditional Program Provider, our payment to such Provider may be under the terms of that Provider's contract. If your Schedule of Benefits and BlueOptions Provider directory do not include a Provider as In- Network under your benefit plan, the Provider is considered Out -of- Network. Physicians, Hospitals and Other Provider Options 6 -2 Note: You are solely responsible for selecting a Provider when obtaining Health Care Services and for verifying whether that Provider is In- Network or Out -of- Network. You are also responsible for determining the corresponding payment options, if any, at the time the Health Care Services are rendered. Physicians, Hospitals and Other Provider Options 6 -3 In- Network Out -of- Network What expenses • Any applicable Copayments, Deductible(s) and /or Coinsurance requirements; are you 0 Expenses for Services which are not covered; responsible for • Expenses for Services in excess of any benefit maximum limitations; paying? 0 Expenses for claims denied because we did not receive information requested from you regarding whether or not you have other coverage and the details of such coverage; and • Expenses for Services which are excluded. Who is • The Provider will file the claim You are responsible for filing the responsible for for you and payment will be claim and payment will be made filing your made directly to the Provider. directly to the Covered Plan claims? Participant. If you receive Services from a Provider who participates in our Traditional Program or is a BlueCard (Out -of- State) Traditional Program Provider, the Provider will file the claim for you. In those instances payment will be made directly to the Provider. Can you be billed NO. You are protected from YES. You are responsible for paying the difference being billed for the difference in the difference between what we pay between what the the Allowed Amount and the and the Provider's charge. However, Provider is paid Provider's charge when you use if you receive Services from a and the Provider's In- Network Providers. The Provider who participates in our charge? Provider will accept the Allowed Traditional Program, the Provider will Amount as payment in full for accept our Allowed Amount as Covered Services except as payment in full for Covered Services otherwise permitted under the since such Traditional Program terms of the Provider's contract Providers have agreed not to bill you and this Booklet. for the difference. Further, under the BlueCard (Out -of- State) Program, when you receive Covered Services from a BlueCard (Out -of- State) Traditional Program Provider, you may be responsible for paying the difference between what the Host Blue pays and the Provider's billed charge. Note: You are solely responsible for selecting a Provider when obtaining Health Care Services and for verifying whether that Provider is In- Network or Out -of- Network. You are also responsible for determining the corresponding payment options, if any, at the time the Health Care Services are rendered. Physicians, Hospitals and Other Provider Options 6 -3 Physicians When you receive Covered Services from a Physician you will be responsible for a Copayment and /or the Deductible and the applicable Coinsurance. Several factors will determine your out -of- pocket expenses including your Schedule of Benefits, whether the Physician is In- Network or Out -of- Network, the location of service, the type of Service rendered, and the Physician's specialty. Remember that the location or setting where a Service is rendered can affect the amount you are responsible for paying out -of- pocket. After you and your Physician have determined the plan of treatment most appropriate for your care, you should refer to the Schedule of Benefits and consult with your Physician to determine the most appropriate setting based on your health care and financial needs. Refer to your Schedule of Benefits to determine the applicable Copayments, Coinsurance percentage and /or Deductible amount you are responsible for paying for Physician Services. Hospitals Each time you receive inpatient or outpatient Covered Services at a Hospital, in addition to any out -of- pocket expenses related to Physician Services, you will be responsible for out -of- pocket expenses related to Hospital Services. In- Network Hospitals have been divided into two groups that are referred to as "options" on the Schedule of Benefits. The amount you are responsible for paying out -of- pocket is different for each of these options. Remember that there are also different out -of- pocket expenses for Out -of- Network Hospitals. Since not all Physicians admit patients to every Hospital, it is important when choosing a Physician that you determine the Hospitals where your Physician has admitting privileges. You can find out what Hospitals your Physician admits to by contacting the Physician's office. This will provide you with information that will help you determine a portion of what your out -of- pocket costs may be in the event you are hospitalized. Refer to your Schedule of Benefits to determine the applicable out -of- pocket expenses you are responsible for paying for Hospital Services. Specialty Pharmacy Certain medications, such as injectable, oral, inhaled and infused therapies used to treat complex medical Conditions are typically more difficult to maintain, administer and monitor when compared to traditional Drugs. Specialty Drugs may require frequent dosage adjustments, special storage and handling and may not be readily available at local pharmacies or routinely stocked by Physicians' offices, mostly due to the high cost and complex handling they require. Using the Specialty Pharmacy to provide these Specialty Drugs should lower the amount you have to pay for these medications, while helping to preserve your benefits. Other Providers With BlueOptions you have access to other Providers in addition to the ones previously described in this section. Other Providers include facilities that provide alternative outpatient settings or other persons and entities that specialize in a specific Service(s). While these Providers may be recognized for payment, they may not be included as In- Network Providers for your plan. Additionally, all of the Services that are within the scope of certain Providers' licenses may not be Covered Services under this Booklet. Please refer to the "What Is Covered ?" and "What Is Not Covered ?" sections of this Booklet and your Schedule of Benefits to determine your out -of- pocket Physicians, Hospitals and Other Provider Options 6 -4 expenses for Covered Services rendered by these Providers. You may be able to receive certain outpatient Services at a location other than a Hospital. The amount you are responsible for paying for Services rendered at some alternative facilities is generally less than if you had received those same Services at a Hospital. Remember that the location of service can impact the amount you are responsible for paying out -of- pocket. After you and your Physician have determined the plan of treatment most appropriate for your care, you should refer to the Schedule of Benefits and consult with your Physician to determine the most appropriate setting based on your health care and financial needs. When Services are rendered at an outpatient facility other than a Hospital there may be an out -of- pocket expense for the facility Provider as well as an out -of- pocket expense for other types of Providers. Assignment of Benefits to Providers Except as set forth in the last paragraph of this section, any of the following assignments, or attempted assignments, by you to any Provider will not be honored: • an assignment of the benefits due to you for Covered Services under this Benefit Booklet; • an assignment of your right to receive payments for Covered Services under this Benefit Booklet; or • an assignment of a claim for damage resulting from a breach, or an alleged breach of the terms of this Benefit Booklet. We specifically reserve the right to honor an assignment of benefits or payment by you to a Provider who: 1) is In- Network under your plan of coverage; 2) is a NetworkBlue Provider even if that Provider is not in the panel for your plan of coverage; 3) is a Traditional Program Provider; 4) is a BlueCard (Out -of- State) PPO Program Provider; 5) is a BlueCard (Out -of- State) Traditional Program Provider; 6) is a licensed Hospital, Physician, or dentist and the benefits which have been assigned are for care provided pursuant to section 395.1041, Florida Statutes ; or 7) is an Ambulance Provider that provides transportation for Services from the location where an "Emergency Medical Condition ", defined in section 395.002(8) Florida Statutes, first occurred to a Hospital, and the benefits which have been assigned are for transportation to care provided pursuant to section 395.1041, Florida Statutes. A written attestation of the assignment of benefits may be required. Physicians, Hospitals and Other Provider Options 6 -5 Section 7: BlueCard (Out -of- State) Program Out -of -Area Services Overview We have a variety of relationships with other Blue Cross and /or Blue Shield Licensees. Generally, these relationships are called "Inter - Plan Arrangements." These Inter -Plan Arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association ( "Association "). Whenever you access Health Care Services outside Florida, the claim for those Services may be processed through one of these Inter -Plan Arrangements. The Inter -Plan Arrangements are described below. When you receive care outside of Florida, you will receive it from one of two kinds of Providers. Most Providers ( "Participating Providers ") contract with the local Blue Cross and /or Blue Shield Licensee in that geographic area ( "Host Blue "). Some Providers ( "Nonparticipating Providers ") don't contract with the Host Blue. We explain below how both kinds of Providers are paid. Inter -Plan Arrangements Eligibility — Claim Types All claim types are eligible to be processed through Inter -Plan Arrangements, as described above, except for all dental care benefits except when paid as medical claims /benefits, and those prescription drug benefits or vision care benefits that may be administered by a third party contracted by us to provide the specific Service or Services. BlueCard Program Under the BlueCard Program, when you receive Covered Services within the geographic area served by a Host Blue, we will remain responsible for fulfilling our contractual obligations to you. However, the Host Blue is responsible for contracting with and generally handling all interactions with its Participating Providers. When you receive Covered Services outside of Florida and the claim is processed through the BlueCard Program, the amount you pay for Covered Services is calculated based on the lower of: • The billed charges for Covered Services; or • The negotiated price that the Host Blue makes available to us. Often, this "negotiated price" will be a simple discount that reflects an actual price that the Host Blue pays to your Provider. Sometimes, it is an estimated price that takes into account special arrangements with your Provider or Provider group that may include types of settlements, incentive payments and /or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of Providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price we have used for your claim because they will not be applied after a claim has already been paid. Special Cases: Value -Based Programs If you receive Covered Services under a Value - Based Program inside a Host Blue's service area, you will not be responsible for paying any of the Provider Incentives, risk - sharing, and /or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes BlueCard (Out -of- State) Program 7 -1 these fees to us through average pricing or fee schedule adjustments. Additional information is available upon request. Inter -Plan Programs: Federal /State Taxes /Surcharges /Fees Federal or state laws or regulations may require a surcharge, tax or other fee that applies to self - funded accounts. If applicable, we will include any such surcharge, tax or other fee as part of the claim charge passed on to you. Nonparticipating Providers Outside Florida When Covered Services are provided outside of Florida by Nonparticipating Providers, payment will be based on the Allowed Amount, as defined in the DEFINITIONS section of the Benefit Booklet. BlueCard Worldwide Program If you are outside the United States, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands (hereinafter "BlueCard Service Area "), you may be able to take advantage of the BlueCard Worldwide Program when accessing Covered Services. The BlueCard Worldwide Program is unlike the BlueCard Program available in the BlueCard Service Area in certain ways. For instance, although the BlueCard Worldwide Program assists you with accessing a network of inpatient, outpatient and professional Providers, the network is not served by a Host Blue. As such, when you receive care from Providers outside the BlueCard Service Area, you will typically have to pay the Providers and submit the claims yourself to obtain reimbursement for these Services. If you need medical assistance services (including locating a doctor or hospital) outside the BlueCard Service Area, you should call the BlueCard Worldwide Service Center at 1.800.810.BLUE (2583) or call collect at 804- 673 -1177, 24 hours a day, seven days a week. An assistance coordinator, working with a medical professional, can arrange a physician appointment or hospitalization, if necessary. Inpatient Services In most cases, if you contact the BlueCard Worldwide Service Center for assistance, hospitals will not require you to pay for inpatient Covered Services, except for your Cost Share amounts. In such cases, the hospital will submit your claims to the BlueCard Worldwide Service Center to begin claims processing. However, if you paid in full at the time of Service, you must submit a claim to receive reimbursement for Covered Services. You must notify us of any non - emergency inpatient Services. Outpatient Services Physicians, Urgent Care Centers and other outpatient Providers located outside the BlueCard Service Area will typically require you to pay in full at the time of Service. You must submit a claim to obtain reimbursement for Covered Services. Submitting a BlueCard Worldwide Claim When you pay for Covered Services outside the BlueCard Service Area, you must submit a claim to obtain reimbursement. For institutional and professional claims, you should complete a BlueCard Worldwide International claim form and send the claim form with the Provider's itemized bill(s) to the BlueCard Worldwide Service Center (the address is on the form) to initiate claims processing. Following the instructions on the claim form will help ensure timely processing of your claim. The claim form is available from the BlueCard Worldwide Service Center or online at www.bluecardworldwide.com If you need assistance with your claim submission, you should call the BlueCard Worldwide Service Center at 800 - 810 -BLUE (2583) or call collect at 804 - 673 -1177, 24 hours a day, seven days a week.. BlueCard (Out -of- State) Program 7 -2 Section 8: Blueprint for Health Programs Introduction BCBSF has established (and from time to time establishes) various customer - focused health education and information programs as well as benefit utilization management and utilization review programs. Under the terms of the ASO Agreement between BCBSF and Monroe County BOCC, BCBSF has agreed to make these programs available to you. These programs, collectively called the Blueprint for Health Programs, are designed to 1) provide you with information that will help you make more informed decisions about your health, 2) help facilitate the management and review of coverage and benefits provided under this Booklet and 3) present opportunities, as explained below, to mutually agree upon alternative benefits or payment alternatives for cost - effective medically appropriate Health Care Services. Some BluePrint For Health Programs may not be available outside the state of Florida. Admission Notification The admission notification requirements vary depending on whether you are admitted to a Hospital, Psychiatric Facility, Substance Abuse Facility or Skilled Nursing Facility which is In- Network or Out -of- Network. In- Network Under the admission notification requirement, we must be notified of all inpatient admissions (i.e., elective, planned, urgent or emergency) to In- Network Hospitals, Psychiatric Facilities, Substance Abuse Facilities or Skilled Nursing Facilities. While it is the sole responsibility of the In- Network Provider located in Florida to comply with our admission notification requirements, you should ask the Hospital, Psychiatric Facility, Substance Abuse Facility or Skilled Nursing Facility (as applicable) if we have been notified of your admission. For an admission outside of Florida, you or the Hospital, Psychiatric Facility, Substance Abuse Facility or Skilled Nursing Facility (as applicable) should notify us of the admission. Making sure that we are notified of your admission will enable us to provide you information about the Blueprint for Health Programs available to you. You or the Hospital, Psychiatric Facility, Substance Abuse Facility or Skilled Nursing Facility (as applicable) may notify us of your admission by calling the toll free customer service number on your ID card. Out -of- Network For admissions to an Out -of- Network Hospital, Psychiatric Facility, Substance Abuse Facility or Skilled Nursing Facility, you or the Hospital, Psychiatric Facility, Substance Abuse Facility or Skilled Nursing Facility should notify BCBSF of the admission. Notifying BCBSF of your admission will enable BCBSF to provide you information about the Blueprint for Health Programs available to you. You or the Hospital may notify BCBSF of your admission by calling the toll -free customer service number on your ID card. Inpatient Facility Program Under the inpatient facility program, we may review Hospital stays, Hospice, Inpatient Rehabilitation, LTAC and Skilled Nursing Facility (SNF) Services, and other Health Care Services rendered during the course of an inpatient stay or treatment program. We may conduct this review while you are inpatient, after your discharge, or as part of a review of an episode of care when you are transferred from one level Blueprint for Health Programs 8 -1 of inpatient care to another for ongoing treatment. The review is conducted solely to determine whether we should provide coverage and /or payment for a particular admission or Health Care Services rendered during that admission. Using our established criteria then in effect, a concurrent review of the inpatient stay may occur at regular intervals, including in advance of a transfer from one inpatient facility to another. We will provide notification to your Physician when inpatient coverage criteria are no longer met. In administering the inpatient facility program, we may review specific medical facts or information and assess, among other things, the appropriateness of the Services being rendered, health care setting and /or the level of care of an inpatient admission or other health care treatment program. Any such reviews by us, and any reviews or assessments of specific medical facts or information which we conduct, are solely for purposes of making coverage or payment decisions under this Benefit Booklet and not for the purpose of recommending or providing medical care. Provider Focused Utilization Management Program Certain NetworkBlue Providers have agreed to participate in our focused utilization management program. This pre - service review program is intended to promote the efficient delivery of medically appropriate Health Care Services by NetworkBlue Providers. Under this program we may perform focused prospective reviews of all or specific Health Care Services proposed for you. In order to perform the review, we may require the Provider to submit to us specific medical information relating to Health Care Services proposed for you. These NetworkBlue Providers have agreed not to bill, or collect, any payment whatsoever from you or us, or any other person or entity, with respect to a specific Health Care Service if: 1. they fail to submit the Health Care Service for a focused prospective review when required under the terms of their agreement with us; or 2. we perform a focused review under the focused utilization management program and we determine that a Health Care Service is not Medically Necessary in accordance with our Medical Necessity criteria or inconsistent with our benefit guidelines then in effect unless the following exception applies. Exception for Certain NetworkBlue Physicians Certain NetworkBlue Physicians licensed as Doctors of Medicine (M.D.) or Doctors of Osteopathy (D.O.) only may bill you for Services determined to be not Medically Necessary by BCBSF under this focused utilization management program if, before you receive the Service: a. they give you a written estimate of your financial obligation for the Service; b. they specifically identify the proposed Service that BCBSF has determined not to be Medically Necessary; and c. you agree to assume financial responsibility for such Service. Prior Coverage Authorization/Pre- Service Notification Programs It is important for you to understand our prior coverage authorization programs and how the Provider you select and the type of Service you receive affects these requirements and ultimately how much you are responsible for paying under this Benefit Booklet. You or your Provider will be required to obtain prior coverage authorization from us for: 1. advanced diagnostic imaging Services, such as CT scans, MRIs, MRA and nuclear imaging; 2. Autism Spectrum Disorder; and Blueprint for Health Programs 8 -2 3. other Health Care Services that are or may become subject to a prior coverage authorization program or a pre- service notification program as defined and administered by us. Prior coverage authorization requirements vary, depending on whether Services are rendered by an In- Network Provider or an Out -of- Network Provider, as described below: In- Network Providers It is the In- Network Provider's sole responsibility to comply with our prior coverage authorization requirements, and therefore you will not be responsible for any benefit reductions if prior coverage authorization is not obtained before Medically Necessary Services are rendered. Once we have received the necessary medical documentation from the Provider, we will review the information and make a prior coverage authorization decision, based on our established criteria then in effect. The Provider will be notified of the prior coverage authorization decision. Out -of- Network Providers In the case of advanced diagnostic imaging Services such as CT scans, MRIs, MRA and nuclear imaging, it is your sole responsibility to comply with our prior coverage authorization requirements when rendered or referred by an Out -of- Network Provider before the advanced diagnostic imaging Services are provided. Your failure to obtain prior coverage authorization will result in denial of coverage for such Services. For additional details on how to obtain prior coverage authorization for advanced diagnostic imaging Services, please call the customer service phone number on the back of your ID Card. 2. In the case of Autism Spectrum Disorder, under a prior coverage authorization or pre - service notification program, it is your sole responsibility to comply with our prior coverage authorization or pre - service notification requirements when rendered or referred by an Out -of- Network Provider, before the Services are provided. Failure to obtain prior coverage authorization will result in denial of coverage for such Services. 3. In the case of other Health Care Services under a prior coverage authorization or pre - service notification program, it is your sole responsibility to comply with our prior coverage authorization or pre - service notification requirements when rendered or referred by an Out -of- Network Provider, before the Services are provided. Failure to obtain prior coverage authorization or provide pre - service notification may result in denial of the claim or application of a financial penalty assessed at the time the claim is presented for payment to us. The penalty applied will be the lesser of $500 or 20% of the total Allowed Amount of the claim. The decision to apply a penalty or deny the claim will be made uniformly and will be identified in the notice describing the prior coverage authorization and pre- service notification programs. Once the necessary medical documentation has been received from you and /or the Out -of- Network Provider, BCBSF or a designated vendor, will review the information and make a prior coverage authorization decision, based on our established criteria then in effect. You will be notified of the prior coverage authorization decision. BCBSF will provide you information for any Out - of- Network Health Care Service subject to a prior coverage authorization or pre- service notification program, including how you can Blueprint for Health Programs 8 -3 obtain prior coverage authorization and /or provide the pre - service notification for such Service not already listed here. This information will be provided to you upon enrollment, or at least 30 days prior to such Out -of- Network Services becoming subject to a prior coverage authorization or pre - service notification program. See the "Claims Processing" section for information on what you can do if prior coverage authorization is denied. Note: Prior coverage authorization is not required when Covered Services are provided for the treatment of an Emergency Medical Condition. Member Focused Programs The Blueprint for Health Programs may include voluntary programs for certain members. These programs may address health promotion, prevention and early detection of disease, chronic illness management programs, case management programs and other member focused programs. Personal Case Management Program The personal case management program focuses on members who suffer from a catastrophic illness or injury. In the event you have a catastrophic or chronic Condition, we may, in BCBSF's sole discretion, assign a Personal Case Manager to you to help coordinate coverage, benefits, or payment for Health Care Services you receive. Your participation in this program is completely voluntary Under the personal case management program, you may be offered alternative benefits or payment for cost - effective Health Care Services. These alternative benefits or payments may be made available on a case -by -case basis when you meet BCBSF's case management criteria then in effect. Such alternative benefits or payments, if any, will be made available in accordance with a treatment plan with which you, or your representative, and your Physician agree to in writing. In addition, Monroe County BOCC will be required to specifically agree to such treatment plan and the alternative benefits or payment. The fact that certain Health Care Services under the personal case management program have been provided or payment has been made in no way obligates BCBSF, Monroe County BOCC, or the Group Health Plan to continue to provide or pay for the same or similar Services. Nothing contained in this section shall be deemed a waiver of Monroe County BOCC's right to enforce this Booklet in strict accordance with its terms. The terms of this Booklet will continue to apply, except as specifically modified in writing in accordance with the personal case management program rules then in effect. Blueprint for Health Programs 8 -4 Health Information, Promotion, Prevention and Illness Management Programs These Blueprint for Health Programs may include health information that supports health care education and choices for healthcare issues. These programs focus on keeping you well, help to identify early preventive measures of treatment and help covered individuals with chronic problems to enjoy lives that are as productive and healthy as possible. These programs may include prenatal educational programs and illness management programs for Conditions such as diabetes, cancer and heart disease. These programs are voluntary and are designed to enhance your ability to make informed choices and decisions for your unique health care needs. You may call the toll free customer service number on your ID card for more information. Your participation in this program is completely voluntary IMPORTANT INFORMATION RELATING TO BCBSF'S BLUEPRINT FOR HEALTH PROGRAMS All decisions that require or pertain to independent professional medical /clinical judgment or training, or the need for medical services, are solely your responsibility and the responsibility of your Physicians and other health care Providers. You and your Physicians are responsible for deciding what medical care should be rendered or received, and when and how that care should be provided. Monroe County BOCC is ultimately responsible for determining whether expenses, which have been or will be incurred for medical care are, or will be, covered under this Booklet. In fulfilling this responsibility, neither BCBSF nor Monroe County BOCC will be deemed to participate in or override the medical decisions of your health care Provider. Please note that the Hospital admission notification requirement and any Blueprint For Health Program may be discontinued or modified at any time without notice to you or your consent. Blueprint for Health Programs 8 -5 Section 9: Eligibility for Coverage Each employee or other individual who is eligible to participate in the Monroe County BOCC Group Health Plan, and who meets and continues to meet the eligibility requirements described in this Booklet, shall be entitled to apply for coverage under this Booklet. These eligibility requirements are binding upon you and /or your eligible family members. No changes in the eligibility requirements will be permitted except as permitted by Monroe County BOCC. Acceptable documentation may be required as proof that an individual meets and continues to meet the eligibility requirements such as a court order naming the Eligible Employee as the legal guardian or appropriate adoption documentation described in the "Enrollment and Effective Date of Coverage" section. Eligibility Requirements for Covered Plan Participants In order to be eligible to enroll as a Covered Plan Participant, an individual must be an Eligible Employee or Eligible Retiree. An Eligible Employee must meet each of the following requirements: 1. The employee must be a bona fide employee of a Monroe County Employer, participating in the Monroe County Group Health Plan; 2. The employee must be actively working 25 hours or more per week on a regular basis; 3. The employee must have completed the applicable Waiting Period of 60 days of continuous service; and 4. The employee must meet any additional eligibility requirement(s) required by Monroe County BOCC. Note: Employees and qualified Dependents are eligible for coverage on the day following the 60 day of continuous service or Waiting Period. Monroe County BOCC's coverage eligibility classifications may be expanded to include: 1. retired employees; 2. additional job classifications; 3. Constitutional Officers or their Employees 4. employees of affiliated or subsidiary companies of Monroe County BOCC; and 5. other individuals as determined by Monroe County BOCC. Monroe County BOCC shall have sole discretion concerning the expansion of eligibility classifications. Eligibility Requirements for Dependent(s) An individual who meets the eligibility criteria specified below is an Eligible Dependent and is eligible to apply for coverage under this Booklet: 1. The Covered Plan Participant's spouse under a legally valid existing marriage. 2. The Covered Plan Participant's natural, newborn, adopted, Foster, or step child(ren) (or a child for whom the Covered Plan Participant has been court - appointed as legal guardian or legal custodian) who has not reached the end of the Calendar Year in which he or she reaches age 26 (or in the case of a Foster Child, is no longer eligible under the Foster Child Program), regardless of the dependent child's student or marital status, financial dependency on the Covered Plan Participant, whether the dependent child resides with the Covered Plan Eligibility For Coverage 9 -1 Participant, or whether the dependent child is eligible for or enrolled in any other group health plan. 3. The newborn child of a Covered Dependent child who has not reached the end of the Calendar Year in which he or she becomes 26. Coverage for such newborn child will automatically terminate 18 months after the birth of the newborn child. Note: If a Covered Dependent child who has reached the end of the Calendar Year in which he or she becomes 26 obtains a dependent of their own (e.g., through birth or adoption) such newborn child will not be eligible for this coverage and the Covered Dependent child will also lose his or her eligibility for this coverage. It is the Covered Plan Participant's sole responsibility to establish that a child meets the applicable requirements for eligibility. This eligibility shall terminate on the last day of the Calendar Year in which the dependent child reaches age 26. Extension of Eligibility for Dependent Children A Covered Dependent child may continue coverage beyond the end of the Calendar Year in which he or she reaches age 26, provided he or she is: 1. unmarried and does not have a dependent; 2. a Florida resident or a full -time or part -time student; 3. not enrolled in any other health coverage policy or group health plan; and 4. not entitled to benefits under Title XVIII of the Social Security Act unless the child is a handicapped dependent child. This eligibility shall terminate on the last day of the Calendar Year in which the dependent child reaches age 30. Handicapped Children In the case of a handicapped dependent child, such child is eligible to continue coverage as a Covered Dependent, beyond the age of 26, if the child is: 1. otherwise eligible for coverage under the Group Health Plan; 2. incapable of self- sustaining employment by reason of mental retardation or physical handicap; and 3. chiefly dependent upon the Covered Plan Participant for support and maintenance provided that the symptoms or causes of the child's handicap existed prior to the child's 26 birthday. This eligibility shall terminate on the last day of the month in which the dependent child no longer meets the requirements for extended eligibility as a handicapped child. Exception for Students on Medical Leave of Absence from School A Covered Dependent child who is a full -time or part -time student at an accredited post- secondary institution, who takes a physician certified medically necessary leave of absence from school, will still be considered a student for eligibility purposes under this Booklet for the earlier of 12 months from the first day of the leave of absence or the date the Covered Dependent would otherwise no longer be eligible for coverage under this Booklet. Eligibility For Coverage 9 -2 Section 10: Enrollment and Effective Date of Coverage Eligible Employees, Eligible Retiree and Eligible Dependents may enroll for coverage according to the provisions below. Employee /Retiree and the employee's spouse under a legally valid existing marriage or Domestic Partner. Any Eligible Employee, Eligible Retiree or Eligible Dependent who is not properly enrolled will not be covered under this Benefit Booklet. Neither BCBSF nor Monroe County BOCC will have any obligation whatsoever to any individual who is not properly enrolled. Any Employee, Eligible Retiree or Eligible Dependent who is eligible for coverage under this Booklet may apply for coverage according to the provisions set forth below. Enrollment Forms /Electing Coverage To apply for coverage, you as the Eligible Employee , Eligible Retiree must: 1. complete and submit, through Monroe County BOCC Benefits Office, the Enrollment Form; 2. provide any additional information needed to determine eligibility, at the request of BCBSF or Monroe County BOCC Benefits Office; 3. pay any required contribution; and 4. complete and submit, through Monroe County BOCC Benefits Office, an Enrollment Form to add Eligible Dependents. When making application for coverage, you must elect one of the types of coverage available under Monroe County BOCC's program. Such types may include: Employee Only Coverage - This type of coverage provides coverage for the Employee /Retiree only. Employee /Spouse Coverage - This type of coverage provides coverage for the Employee /Child(ren) Coverage - This type of coverage provides coverage for the Employee /Retiree and the covered child(ren) only. Employee /Family Coverage - This type of coverage provides coverage for the Employee /Retiree and the Eligible Retiree Covered Dependents. There may be additional contribution amounts for each Covered Dependent based on the coverage selected by Monroe County BOCC. Enrollment Periods The enrollment periods for applying for coverage are as follows: Initial Enrollment Period is the period of time during which an Eligible Employee or Eligible Dependent is first eligible to enroll. It starts on the Eligible Employee's or Eligible Dependent's initial date of eligibility and ends no less than 30 days later. Annual Open Enrollment Period is the period of time during which each Eligible Employee or Eligible Retiree is given an opportunity to select coverage from among the alternatives included in Monroe County BOCC's health benefit program. The period is established by Monroe County BOCC, occurs annually, and will take place when specified by Monroe County BOCC. Special Enrollment Period is the 30 -day period of time (unless otherwise noted) immediately following a special circumstance during which an Eligible Employee or Eligible Dependent may apply for coverage. Special circumstances are described in the Special Enrollment Period subsection. Enrollment and Effective Date of Coverage 10 -1 Employee Enrollment An Eligible Employee who fails to enroll during the Initial Enrollment Period will not be covered and may only enroll under this Benefit Booklet during the next Annual Open Enrollment Period established by Monroe County BOCC, or in the case of a Special Enrollment event, during the Special Enrollment Period. The Effective Date will be the date specified by Monroe County BOCC. Dependent Enrollment An individual may be added upon becoming an Eligible Dependent of a Covered Plan Participant. Below are special rules for certain Eligible Dependents. Newborn Child — To enroll a newborn child who is an Eligible Dependent, the Covered Plan Participant must submit an Enrollment Form to BCBSF through Monroe County BOCC Benefits Office during the 30 -day period immediately following the date of birth. The Effective Date of coverage for a newborn child will be the date of birth. If timely notice is given, no additional contribution will be charged for coverage of the newborn child for not less than 30 days after the birth of the child. If timely notice is not received, the applicable contribution will be charged from the date of birth. The applicable contribution for the child will be charged after the initial 30 -day period in either case. Coverage will not be denied for a newborn child if the Covered Plan Participant provides notice to Monroe County BOCC Benefits Office and an Enrollment Form is received within the 60 -day period of the birth of the child and any applicable contribution is paid back to the date of birth. If the newborn is not enrolled within sixty days of the date of birth, the newborn child will not be covered, and may only be enrolled under this Benefit Booklet during an Annual Open Enrollment Period, or in the case of a Special Enrollment event, during the Special Enrollment Period. Note: For a Covered Dependent child who has reached the end of the Calendar Year in which he or she becomes 26 and the Covered Dependent child obtains a dependent of their own (e.g., through birth or adoption), such newborn child will not be eligible for this coverage and cannot enroll. Further, such Covered Dependent child will also lose his or her eligibility for this coverage. Adopted Newborn Child — To enroll an adopted newborn child, the Covered Plan Participant must submit an Enrollment Form through Monroe County BOCC Benefits Office to BCBSF during the 30 -day period immediately following the date of birth. The Effective Date of coverage for an adopted newborn child, eligible for coverage, will be the moment of birth, provided that a written agreement to adopt such child has been entered into by the Covered Plan Participant prior to the birth of such child, whether or not such an agreement is enforceable. The Covered Plan Participant may be required to provide any information and /or documents that are deemed necessary in order to administer this provision. If timely notice is given, no additional contribution will be charged for coverage of the adopted newborn child for not less than 30 days after the birth of the child. If timely notice is not received, the applicable contribution will be charged from the date of birth. The applicable contribution for the child will be charged after the initial 30 -day period in either case. Coverage will not be denied for an adopted newborn child if the Covered Plan Participant provides notice to Monroe County BOCC Benefits Office and an Enrollment Form is received within the 60 -day period of the birth of the adopted newborn child and any applicable contribution is paid back to the date of birth. If the adopted newborn child is not enrolled within sixty days of the date of birth, the adopted Enrollment and Effective Date of Coverage 10 -2 newborn child will not be covered, and may only be enrolled under this Benefit Booklet during an Annual Open Enrollment Period, or in the case of a Special Enrollment event, during the Special Enrollment Period. If the adopted newborn child is not ultimately placed in the residence of the Covered Plan Participant, there shall be no coverage for the adopted newborn child. It is your responsibility as the Covered Plan Participant to notify Monroe County BOCC Benefits Office within ten calendar days of the date that placement was to occur if the adopted newborn child is not placed in your residence. Adopted /Foster Children — To enroll an adopted or Foster Child, the Covered Plan Participant must submit an Enrollment Form during the 30 -day period immediately following the date of placement. The Effective Date for an adopted or Foster child (other than an adopted newborn child) will be the date such adopted or Foster child is placed in the residence of the Covered Plan Participant in compliance with applicable law. The Covered Plan Participant may be required to provide any information and /or documents deemed necessary in order to properly administer this section. In the event Monroe County BOCC Benefits Office is not notified within 30 days of the date of placement, the child will be added as of the date of placement so long as Covered Plan Participant provides notice to Monroe County BOCC Benefits Office, and we receive the Enrollment Form within 60 days of the placement. If the adopted or Foster Child is not enrolled within sixty days of the date of placement, the adopted or Foster Child will not be covered, and may only be enrolled under this Benefit Booklet during an Annual Open Enrollment Period, or in the case of a Special Enrollment event, during the Special Enrollment Period. For all children covered as adopted children, if the final decree of adoption is not issued, coverage shall not be continued for the proposed adopted Child. Proof of final adoption must be submitted to BCBSF through Monroe County BOCC Benefits Office. It is the responsibility of the Covered Plan Participant to notify BCBSF through Monroe County BOCC Benefits Office if the adoption does not take place. Upon receipt of this notification, we will terminate the coverage of the child as of the Effective Date of the adopted child upon receipt of the written notice. If the Covered Plan Participant's status as a foster parent is terminated, coverage will end for any Foster Child. It is the responsibility of the Covered Plan Participant to notify BCBSF through Monroe County BOCC Benefits Office that the Foster Child is no longer in the Covered Plan Participant's care. Upon receipt of this notification, coverage for the child will be terminated on the date the Covered Plan Participant's status as a foster parent terminated. Marital Status —The Covered Plan Participant may apply for coverage of an Eligible Dependent due to a legally valid existing marriage. To apply for coverage, the Covered Plan Participant must complete the Enrollment Form through Monroe County BOCC Benefits Office and forward it to BCBSF. The Covered Plan Participant must make application for enrollment within 30 days of the marriage. The Effective Date of coverage for an Eligible Dependent who is enrolled as a result of marriage is the date of the marriage. Court Order — The Covered Plan Participant may apply for coverage for an Eligible Dependent outside of the Initial Enrollment Period and Annual Open Enrollment Period if a court has ordered coverage to be provided for a minor child under their group coverage. To apply for coverage, the Covered Plan Participant must complete an Enrollment Form through Monroe County BOCC Benefits Office and forward it to BCBSF. The Covered Plan Participant must make application for enrollment within 30 days of the court order. The Effective Date of coverage for an Eligible Dependent who Enrollment and Effective Date of Coverage 10 -3 is enrolled as a result of a court order is the date required by the court. Annual Open Enrollment Period Eligible Employees and /or Eligible Dependents who did not apply for coverage during the Initial Enrollment Period or a Special Enrollment Period may apply for coverage during an Annual Open Enrollment Period. The Eligible Employee may enroll by completing the Enrollment Form during the Annual Open Enrollment Period. The effective date of coverage for an Eligible Employee and any Eligible Dependent(s) will be the date established by Monroe County BOCC Benefits Office. Eligible Employees who do not enroll or change their coverage selection during the Annual Open Enrollment Period, must wait until the next Annual Open Enrollment Period, unless the Eligible Employee or the Eligible Dependent is enrolled due to a special circumstance as outlined in the Special Enrollment Period subsection of this section. Special Enrollment Period An Eligible Employee and /or the Employee's Eligible Dependent(s) may apply for coverage outside of the Initial Enrollment Period and Annual Enrollment Period as a result of a special enrollment event. To apply for coverage, the Eligible Employee and /or the Employee's Eligible Dependent(s) must complete the applicable Enrollment Form and forward it to the Monroe County BOCC Benefits Office within the time periods noted below for each special enrollment event. An Eligible Employee and /or the Employee's Eligible Dependent(s) may apply for coverage if one of the following special enrollment events occurs and the applicable Enrollment Form is submitted to the Monroe County BOCC Benefits Office within the indicated time periods: 1. If you lose your coverage under another group health benefit plan (as an employee or dependent), or coverage under other health insurance (except in the case of loss of coverage under a Children's Health Insurance Program (CHIP) or Medicaid, see #3 below), or COBRA continuation coverage that you were covered under at the time of initial enrollment provided that: a) when offered coverage under this plan at the time of initial eligibility, you stated, in writing, that coverage under a group health plan or health insurance coverage was the reason for declining enrollment; and b) you lost your other coverage under a group health benefit plan or health insurance coverage (except in the case of loss of coverage under a CHIP or Medicaid, see #3 below) as a result of termination of employment, reduction in the number of hours you work, reaching or exceeding the maximum lifetime of all benefits under other health coverage, the employer ceased offering group health coverage, death of your spouse, divorce, legal separation or employer contributions toward such coverage was terminated; and c) you submit the applicable Enrollment Form to the Group within 30 days of the date your coverage was terminated Note: Loss of coverage for failure to pay your required contribution /premium on a timely basis or for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the prior health coverage) is not a qualifying event for special enrollment. or 2. If when offered coverage under this plan at the time of initial eligibility, you stated, in writing, that coverage under a group health plan or health insurance coverage was the Enrollment and Effective Date of Coverage 10 -4 reason for declining enrollment; and you get married or obtain a dependent through birth, adoption or placement in anticipation of adoption and you submit the applicable Enrollment Form to the Monroe County BOCC Benefits Office within 30 days of the date of the event. or 3. If you or your Eligible Dependent(s) lose coverage under a CHIP or Medicaid due to loss of eligibility for such coverage or become eligible for the optional state premium assistance program and you submit the applicable Enrollment Form to the Monroe County BOCC Benefits Office within 60 days of the date such coverage was terminated or the date you become eligible for the optional state premium assistance program. The Effective Date of coverage for you and your Eligible Dependents added as a result of a special enrollment event is the date of the special enrollment event. Eligible Employees or Eligible Dependents who do not enroll or change their coverage selection during the Special Enrollment Period must wait until the next Annual Open Enrollment Period (See the Dependent Enrollment subsection of this section for the rules relating to the enrollment of Eligible Dependents of a Covered Plan Participant). Other Provisions Regarding Enrollment and Effective Date of Coverage Rehired Employees: Individuals who are rehired as employees of Monroe County BOCC or any of the Constitutional Officers or their Employees are considered newly hired employees for purposes of this section, unless the employer has indicated that the employee qualifies for the exception as described in the federal regulations. The provisions of the Group Health Plan (which includes this Booklet), which are applicable to newly hired employees and their Eligible Dependents (e.g., enrollment, Effective Dates of coverage, Pre - existing Condition exclusionary period, and Waiting Period) are applicable to rehired employees and their Eligible Dependents if the employee does not qualify for the federal exception. Enrollment and Effective Date of Coverage 10 -5 Section 11: Termination of Coverage Termination of a Covered Plan Participant's Coverage A Covered Plan Participant's coverage under this Benefit Booklet will automatically terminate at 12:01 a.m.: 1. on the date the Group Health Plan terminates; 2. on the date the ASO Agreement between BCBSF and Monroe County BOCC terminates; 3. on the last day of the first month that the Covered Plan Participant fails to continue to meet any of the applicable eligibility requirements; 4. on the date specified by Monroe County BOCC that the Covered Plan Participant's coverage is terminated for cause (see the Termination of an Individual Coverage for Cause subsection); or 5. on the date specified by Monroe County BOCC that the Covered Plan Participant's coverage terminates. Termination of a Covered Dependent's Coverage A Covered Dependent's coverage will automatically terminate at 12:01 a.m. on the date: 1. the Group Health Plan terminates; 2. the Covered Plan Participant's coverage terminates for any reason; 3. the Dependent becomes covered under an alternative health benefits plan which is offered through or in connection with the Group Health Plan; 4. last day of the Calendar Year that the Covered Dependent child no longer meets any of the applicable eligibility requirements; 5. date specified by Monroe County BOCC that the Dependent's coverage is terminated for cause (see the Termination of Individual Coverage for Cause subsection). In the event you as the Covered Plan Participant wish to delete a Covered Dependent from coverage, an Enrollment Form must be forwarded to BCBSF through Monroe County BOCC Benefits Office. In the event you as the Covered Plan Participant wish to terminate a spouse's coverage, (e.g., in the case of divorce), you must submit an Enrollment Form to Monroe County BOCC, prior to the requested termination date or within 10 days of the date the divorce is final, whichever is applicable. Termination of an Individual's Coverage for Cause In the event any of the following occurs, Monroe County BOCC may terminate an individual's coverage for cause: 1. fraud, material misrepresentation or omission in applying for coverage or benefits; or 2. the knowing misrepresentation, omission or the giving of false information on Enrollment Forms or other forms completed, by or on your behalf. Notice of Termination It is Monroe County BOCC's responsibility to immediately notify you of your termination or that of your Covered Dependents for any reason. Termination of Coverage 11 -1 Section 12: Continuing Coverage Under COBRA A federal continuation of coverage law, known as the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, may apply to your Group Health Plan. If COBRA applies, you or your Covered Dependents may be entitled to continue coverage for a limited period of time, if you meet the applicable requirements, make a timely election, and pay the proper amount required to maintain coverage. months) if you or your Covered Dependent(s) is /are totally disabled (as defined by the Social Security Administration (SSA)) at the time of your termination, reduction in hours or within the first 60 days of COBRA continuation coverage. The Covered Person must supply notice of the disability determination to Monroe County BOCC Benefits Office within 18 months of becoming eligible for continuation coverage and no later than 60 days after the SSA's You must contact Monroe County BOCC Benefits Office to determine if you or your Covered Dependent(s) are entitled to COBRA continuation of coverage. Monroe County BOCC is solely responsible for meeting all of the obligations under COBRA, including the obligation to notify all Covered Persons of their rights under COBRA. If you fail to meet your obligations under COBRA and this Benefit Booklet, Monroe County BOCC will not be liable for any claims incurred by you or your Covered Dependent(s) after termination of coverage. A summary of your COBRA rights and the general conditions for qualification for COBRA continuation coverage is provided below. The following is a summary of what you may elect, if COBRA applies to Monroe County BOCC and you are eligible for such coverage: 1. You may elect to continue this coverage for a period not to exceed 18 months* in the case of: a) termination of employment of the Covered Plan Participant other than for gross misconduct; or b) reduced hours of employment of the Covered Plan Participant. *Note: You and /or your Covered Dependent(s) are eligible for an 11 month extension of the 18 month COBRA continuation option above (to a total of 29 determination date. 2. Your Covered Dependent(s) may elect to continue their coverage for a period not to exceed 36 months in the case of: a) the Covered Plan Participant's entitlement to Medicare; b) divorce or legal separation of the Covered Plan Participant; c) death of the Covered Plan Participant; d) the employer files bankruptcy (subject to bankruptcy court approval); or e) a dependent child may elect the 36 month extension if the dependent child ceases to be an Eligible Dependent under the terms of Monroe County BOCC's coverage. Children born to or placed for adoption with the Covered Plan Participant during the continuation coverage periods noted above are also eligible for the remainder of the continuation period. Additional requirements applicable to continuation of coverage under COBRA are set forth below: 1. Monroe County BOCC must notify you of your continuation of coverage rights under COBRA within 14 days of the event which creates the continuation option. If coverage would be lost due to Medicare entitlement, Continuing Coverage Under COBRA 12 -1 divorce, legal separation or the failure of a Covered Dependent child to meet eligibility requirements, you or your Covered Dependent must notify Monroe County BOCC Benefits Office, in writing, within 60 days of any of these events. Monroe County BOCC's 14 -day notice requirement runs from the date of receipt of such notice. 2. You must elect to continue the coverage within 60 days of the later of: a) the date that the coverage terminates; or b) the date the notification of continuation of coverage rights is sent by Monroe County BOCC. 3. COBRA coverage will terminate if you become covered under any other group health insurance plan. However, COBRA coverage may continue if the new group health insurance plan contains exclusions or limitations due to a Pre - existing Condition that would affect your coverage. 4. COBRA coverage will terminate if you become entitled to Medicare. 5. If you are totally disabled and eligible and elect to extend your continuation of coverage, you may not continue such extension of coverage more than 30 days after a determination by the Social Security Administration that you are no longer disabled. You must inform Monroe County BOCC Benefits Office of the Social Security Administration's determination within 30 days of such determination. 6. You must meet all contribution requirements, and all other eligibility requirements described in COBRA, and, to the extent not inconsistent with COBRA, in the Group Health Plan. 7. COBRA coverage will terminate on the date Monroe County BOCC ceases to provide group health coverage to its employees. An election by a Covered Plan Participant or Covered Dependent spouse shall be deemed to be an election for any other qualified beneficiary related to that Covered Plan Participant or Covered Dependent spouse, unless otherwise specified in the election form. Note: This section shall not be interpreted to grant any continuation rights in excess of those required by COBRA and /or Section 4980B of the Internal Revenue Code. Additionally, this Benefit Booklet shall be deemed to have been modified, and shall be interpreted, so as to comply with COBRA and changes to COBRA that are mandatory with respect to Monroe County BOCC. Continuing Coverage Under COBRA 12 -2 Section 13: Conversion Pr Eligibility Criteria for Conversion You are entitled to apply for a BCBSF individual insurance conversion policy (hereinafter referred to as a "converted policy" or "conversion policy ") if: 1. you were continuously covered for at least three months under the Group Health Plan, and /or under another group policy that provided similar benefits immediately prior to the Group Health Plan; and 2. your coverage was terminated for any reason, including discontinuance of the Group Health Plan in its entirety and termination of continued coverage under COBRA. Notify BCBSF in writing or by telephone if you are interested in a conversion policy. Within 14 days of such notice, BCBSF will send you a conversion policy application, premium notice and outline of coverage. The outline of coverage will contain a brief description of the benefits and coverage, exclusions and limitations, and the applicable Deductible(s) and Coinsurance provisions. BCBSF must receive a completed application for a converted policy, and the applicable premium payment, within the 63 -day period beginning on the date the coverage under the Group Health Plan terminated. If coverage has been terminated, due to the non - payment of employee contribution by Monroe County BOCC, BCBSF must receive the completed converted policy application and the applicable premium payment within the 63 -day period beginning on the date notice was given that the Group Health Plan terminated. In the event BCBSF does not receive the converted policy application and the initial premium payment within such 63 -day period, your converted policy application will be denied and you will not be entitled to a converted policy. ivilege Additionally, you are not entitled to a converted policy if: 1. you are eligible for or covered under the Medicare program; 2. you failed to pay, on a timely basis, the contribution required for coverage under the Group Health Plan; 3. the Group Health Plan was replaced within 31 days after termination by any group policy, contract, plan, or program, including a self- insured plan or program, that provides benefits similar to the benefits provided under this Booklet; or 4. a) you fall under one of the following categories and meet the requirements of 4.b. below: you are covered under any Hospital, surgical, medical or major medical policy or contract or under a prepayment plan or under any other plan or program that provides benefits which are similar to the benefits provided under this Booklet; or ii. you are eligible, whether or not covered, under any arrangement of coverage for individuals in a group, whether on an insured, uninsured, or partially insured basis, for benefits similar to those provided under this Booklet; or iii. benefits similar to the benefits provided under this Booklet are provided for or are available to you pursuant to or in accordance with the requirements of any state or federal law (e.g., COBRA, Medicaid); and Conversion Privilege 13 -1 b) the benefits provided under the sources referred to in paragraph 4.a.i or the benefits provided or available under the source referred to in paragraph 4.a.ii. and 4.a.iii. above, together with the benefits provided by our converted policy would result in over - insurance in accordance with our over - insurance standards, as determined by us. Neither Monroe County BOCC nor BCBSF has any obligation to notify you of this conversion privilege when your coverage terminates or at any other time. It is your sole responsibility to exercise this conversion privilege by submitting a BCBSF converted policy application and the initial premium payment to us within 63 days of the termination of your coverage under this Benefit Booklet. The converted policy may be issued without evidence of insurability and shall be effective the day following the day your coverage under this Benefit Booklet terminated. Note: Our converted policies are not a continuation of coverage under COBRA or any other states' similar laws. Coverage and benefits provided under a converted policy will not be identical to the coverage and benefits provided under this Booklet. When applying for our converted policy, you have two options: 1) a converted policy providing major medical coverage meeting the requirements of 627.6675(10) Florida Statutes or 2) a converted policy providing coverage and benefits identical to the coverage and benefits required to be provided under a small employer standard health benefit plan pursuant to Section 627.6699(12) Florida Statutes. In any event, we will not be required to issue a converted policy unless required to do so by Florida law. We may have other options available to you. Call the telephone number on your Identification card for more information. Conversion Privilege 13 -2 Section 14: Extension of Benefits Extension of Benefits In the event the Group Health Plan is terminated, coverage will not be provided under this Benefit Booklet for any Service rendered on or after the termination date. The extension of benefits provisions described below only apply when the entire Group Health Plan is terminated. The extension of benefits described in this section do not apply when your coverage terminates if the Group Health Plan remains in effect. The extension of benefits provisions are subject to all of the other provisions, including the limitations and exclusions. Note: It is your sole responsibility to provide acceptable documentation showing that you are entitled to an extension of benefits. In the event you are totally disabled on the termination date of the Group Health Plan as a result of a specific Accident or illness incurred while you were covered under this Booklet, as determined by us, a limited extension of benefits will be provided under this Benefit Booklet for the disabled individual only. This extension of benefits is for Covered Services necessary to treat the disabling Condition only. This extension of benefits will only continue as long as the disability is continuous and uninterrupted. In any event, this extension of benefits will automatically terminate at the end of the 12- month period beginning on the termination date of the Group Health Plan. For purposes of this section, you will be considered "totally disabled" only if, in our or Monroe County BOCC's opinion, you are unable to work at any gainful job for which you are suited by education, training, or experience, and you require regular care and attendance by a Physician. You are totally disabled only if, in our or Monroe County BOCC's opinion, you are unable to perform those normal day -to -day activities which you would otherwise perform and you require regular care and attendance by a Physician. 2. In the event you are receiving covered dental treatment as of the termination date of the Group Health Plan a limited extension of such covered dental treatment will be provided under this Benefit Booklet if: a) a course of dental treatment or dental procedures were recommended in writing and commenced in accordance with the terms specified herein while you were covered under the Group Health Plan; b) the dental procedures were procedures for other than routine examinations, prophylaxis, x -rays, sealants, or orthodontic services; and c) the dental procedures were performed within 90 days after the Group Health Plan terminated. This extension of benefits is for Covered Services necessary to complete the dental treatment only. This extension of benefits will automatically terminate at the end of the 90 -day period beginning on the termination date of the Group Health Plan or on the date you become covered under a succeeding insurance, health maintenance organization or self - insured plan providing coverage or Services for similar dental procedures. You are not required to be totally disabled in order to be eligible for this extension of benefits. Please refer to the Dental Care category of the "What Is Covered ?" section for a description of the dental care Services covered under this Booklet. Extension of Benefits 14 -1 3. In the event you are pregnant as of the termination date of the Group Health Plan, a limited extension of the maternity expense benefits included in this Booklet will be available, provided the pregnancy commenced while the pregnant individual was covered under the Group Health Plan, as determined by us or Monroe County BOCC. This extension of benefits is for Covered Services necessary to treat the pregnancy only. This extension of benefits will automatically terminate on the date of the birth of the child. You are not required to be Totally Disabled in order to be eligible for this extension of benefits. V Extension of Benefits 14 -2 Section 15: The Effect of Medicare Coverage /Medicare Secondary Payer Provisions When you become covered under Medicare and entitlement, then coverage hereunder will continue to be eligible and covered under this remain primary for the ESRD coordination Benefit Booklet, coverage under this Benefit period. If you become eligible for Medicare due Booklet will be primary and the Medicare to ESRD, coverage will be provided, as benefits will be secondary, but only to the extent described in this section, on a primary basis for required by law. In all other instances, coverage 30 months. under this Benefit Booklet will be secondary to any Medicare benefits. To the extent the benefits under this Benefit Booklet are primary, claims for Covered Services should be filed with BCBSF first. Under Medicare, Monroe County BOCC MAY NOT offer, subsidize, procure or provide a Medicare supplement policy to you. Also, Monroe County BOCC MAY NOT induce you to decline or terminate your group health insurance coverage and elect Medicare as primary payer. If you become 65 or become eligible for Medicare due to End Stage Renal Disease ( "ESRD "), you must immediately notify Monroe County BOCC Benefits Office. Individuals With End Stage Renal Disease Disabled Active Individuals If you are entitled to Medicare coverage because of a disability other than ESRD, Medicare benefits will be secondary to the benefits provided under this Benefit Booklet provided that: Monroe County BOCC employed at least 100 or more full -time or part -time employees on 50% or more of its regular business days during the previous Calendar Year. If the Group Health Plan is a multi - employer plan, as defined by Medicare, Medicare benefits will be secondary if at least one employer participating in the plan covered 100 or more employees under the plan on 50% or more of its regular business days during the previous Calendar Year. If you are entitled to Medicare coverage because of ESRD, coverage under this Benefit Booklet will be provided on a primary basis for 30 months beginning with the earlier of: 1. the month in which you became entitled to Medicare Part "A" ESRD benefits; or 2. the first month in which you would have been entitled to Medicare Part "A" ESRD benefits if a timely application had been made. If Medicare was primary prior to the time you became eligible due to ESRD, then Medicare will remain primary (i.e., persons entitled due to disability whose employer has less than 100 employees, retirees and /or their spouses over the age of 65). Also, if coverage under this Benefit Booklet was primary prior to ESRD Miscellaneous 1. This section shall be subject to, modified (if necessary) to conform to or comply with, and interpreted with reference to the requirements of federal statutory and regulatory Medicare Secondary Payer provisions as those provisions relate to Medicare beneficiaries who are covered under this Benefit Booklet. 2. BCBSF will not be liable to Monroe County BOCC or to any individual covered under this Benefit Booklet on account of any nonpayment of primary benefits resulting from any failure of performance of Monroe County BOCC's obligations as described in this section. The Effect of Medicare Coverage/ Medicare Secondary Payer Provisions 15 -1 Section 16: Duplication of Coverage Under Other Health Plans /Programs Coordination of Benefits Coordination of Benefits ( "COB ") is a limitation of coverage and /or benefits to be provided under this Benefit Booklet. COB determines the manner in which expenses will be paid when you are covered under more than one health plan, program, or policy providing benefits for Health Care Services. COB is designed to avoid the costly duplication of payment for Covered Services. It is your responsibility to provide BCBSF and Monroe County BOCC Benefits Office information concerning any duplication of coverage under any other health plan, program, or policy you or your Covered Dependents may have. This means you must notify BCBSF and Monroe County BOCC Benefits Office in writing if you have other applicable coverage or if there is no other coverage. You may be requested to provide this information at initial enrollment, by written correspondence annually thereafter, or in connection with a specific Health Care Service you receive. If the information is not received, claims may be denied and you will be responsible for payment of any expenses related to denied claims. Health plans, programs or policies which may be subject to COB include, but are not limited to, the following which will be referred to as "plan(s)" for purposes of this section: 1. any group or non -group health insurance, group -type self- insurance, or HMO plan; 2. any group plan issued by any Blue Cross and /or Blue Shield organization(s); 3. any other plan, program or insurance policy, including an automobile PIP insurance policy and /or medical payment coverage with which the law permits coordination of benefits; 4. Medicare, as described in "The Effect of Medicare Coverage /Medicare Secondary Payer Provisions" section; and 5. to the extent permitted by law, any other government sponsored health insurance program. The amount of payment, if any, when benefits are coordinated under this section, is based on whether or not the benefits under this Benefit Booklet are primary. When primary, payment will be made for Covered Services without regard to coverage under other plans. When the benefits under this Benefit Booklet are not primary, payment for Covered Services may be reduced so that total benefits under all your plans will not exceed 100 percent of the total reasonable expenses actually incurred for Covered Services. For purposes of this section, in the event you receive Covered Services from an In- Network Provider or an Out -of- Network Provider who participates in the Traditional Program, "total reasonable expenses" shall mean the total amount required to be paid to the Provider pursuant to the applicable agreement BCBSF or another Blue Cross and /or Blue Shield organization has with such Provider. In the event that the primary payer's payment exceeds the Allowed Amount, no payment will be made for such Services. The following rules shall be used to establish the order in which benefits under the respective plans will be determined: 1. This plan always pays secondary to any medical payment, personal injury protection (PIP) coverage or no -fault coverage under any automobile policy. Duplication of Coverage Under Other Health Plans /Programs 16 -1 2. When we cover you as a Covered Dependent and the other plan covers you as other than a dependent, we will be secondary. 3. When we cover you as a dependent child and your parents are married (not separated or divorced): a. the plan of the parent whose birthday, month and day, falls earlier in the year will be primary; b. if both parents have the same birthday, month and day, and the other plan has covered one of the parents longer than us, we will be secondary. 4. When we cover you as a dependent child whose parents are not married, or are separated or divorced: a. if the parent with custody is not remarried, the plan of the parent with custody is primary; b. if the parent with custody has remarried, the plan of the parent with custody is primary; the step - parent's plan is secondary; and the plan of the parent without custody is last; c. regardless of which parent has custody, when a court decree specifies the parent who is financially responsible for the child's health care expenses, the plan of that parent is always primary. 5. When we cover you as a dependent child and the other plan covers you as a dependent child: a. the plan of the parent who is neither laid off nor retired will be primary; b. if the other plan is not subject to this rule, and if, as a result, such plan does not agree on the order of benefits, this paragraph shall not apply. 6. If you have continuation of coverage under COBRA as a result of the purchase of coverage as provided under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, and also under another group plan, the following order of benefits applies: a. first, the plan covering the person as an employee, or as the employee's Dependent; and b. second, the coverage purchased under the plan covering the person as a former employee, or as the former employee's Dependent provided according to the provisions of COBRA. 7. When rules 1 through 6 above do not establish an order of benefits, the plan which has covered the individual the longest shall be primary, unless you are age 65 or older and covered under Medicare Parts A and B. In that case, this Booklet will be secondary to Medicare. 8. If the other plan does not have rules that establish the same order of benefits as under this Booklet, the benefits under the other plan will be determined primary to the benefits under this Booklet. We will not coordinate benefits against an indemnity -type policy, an excess insurance policy, a policy with coverage limited to specified illnesses or accidents, or a Medicare Supplement policy. Non - Duplication of Government Programs and Worker's Compensation The benefits under this Booklet shall not duplicate any benefits to which you or your Covered Dependents are entitled to or eligible for under government programs (e.g., Medicare, Medicaid, Veterans Administration) or Worker's Compensation to the extent allowed by law, or under any extension of benefits of coverage under a prior plan or program which may be provided or required by law. Duplication of Coverage Under Other Health Plans /Programs 16 -2 Section 17: Claims Processing Introduction This section is intended to: • help you understand what you or your treating Providers must do, under the terms of this Benefit Booklet, in order to obtain payment for expenses for Covered Services they have rendered or will render to you; and • provide you with a general description of the applicable procedures we will use for making Adverse Benefit Determinations, Concurrent Care Decisions and for notifying you when we deny benefits. Under no circumstances will we be held responsible for, nor will we accept liability relating to, the failure of your Group Plan's sponsor or plan administrator to: 1) comply with any applicable disclosure requirements; 2) provide you with a Summary Plan Description (SPD); or 3) comply with any other legal requirements. You should contact your plan sponsor or administrator if you have questions relating to your Group Plan's SPD. We are not your Group Plan's sponsor or plan administrator In most cases, a plan's sponsor or plan administrator is the employer who establishes and maintains the plan. Types of Claims For purposes of this Benefit Booklet, there are three types of claims: 1) Pre - Service Claims; 2) Post - Service Claims; and 3) Claims Involving Urgent Care. It is important that you become familiar with the types of claims that can be submitted to us and the timeframes and other requirements that apply. Post - Service Claims How to File a Post - Service Claim We have defined and described the three types of claims that may be submitted to us. Our experience shows that the most common type of claim we will receive from you or your treating Providers will likely be Post - Service Claims. In- Network Providers have agreed to file Post - Service Claims for Services they render to you. In the event a Provider who renders Services to you does not file a Post - Service Claim for such Services, it is your responsibility to file it with us. We must receive a Post - Service Claim within 90 days of the date the Health Care Service was rendered or, if it was not reasonably possible to file within such 90 -day period, as soon as possible. In any event, no Post - Service Claim will be considered for payment if we do not receive it at the address indicated on your ID Card within one year of the date the Service was rendered unless you were legally incapacitated. For Post - Service Claims, we must receive an itemized statement from the health care Provider for the Service rendered along with a completed claim form. The itemized statement must contain the following information: 1. the date the Service was provided; 2. a description of the Service including any applicable procedure code(s); 3. the amount actually charged by the Provider; 4. the diagnosis including any applicable diagnosis code(s); 5. the Provider's name and address; 6. the name of the individual who received the Service; and Claims Processing 17 -1 7. the Covered Plan Participant's name and contract number as they appear on the ID Card. The itemized statement and claim form must be received by us at the address indicated on your ID Card. Note: Special claims processing rules may apply for Health Care Services you receive outside the state of Florida under the BlueCard Program (See the "BlueCard (Out -of- State) Program" section of this Booklet). The Processing of Post - Service Claims We will use our best efforts to pay, contest, or deny all Post - Service Claims for which we have all of the necessary information, as determined by us. Post - Service Claims will be paid, contested, or denied within the timeframes described below. • Payment for Post - Service Claims When payment is due under the terms of this Benefit Booklet, we will use our best efforts to pay (in whole or in part) for electronically submitted Post - Service Claims within 20 days of receipt. Likewise, we will use our best efforts to pay (in whole or in part) for paper Post - Service Claims within 40 days of receipt. You may receive notice of payment for paper claims within 30 days of receipt. If we are unable to determine whether the claim or a portion of the claim is payable because we need more or additional information, we may contest the claim within the timeframes set forth below. • Contested Post - Service Claims In the event we contest an electronically submitted Post - Service Claim, or a portion of such a claim, we will use our best efforts to provide notice, within 20 days of receipt, that the claim or a portion of the claim is contested. In the event we contest a Post - Service Claim submitted on a paper claim form, or a portion of such a claim, we will use our best efforts to provide notice, within 30 days of receipt, that the claim or a portion of the claim is contested. Our notice may identify: 1) the contested portion or portions of the claim; 2) the reason(s) for contesting the claim or a portion of the claim; and 3) the date that we reasonably expect to notify you of the decision. The notice may also indicate whether additional information is needed in order to complete processing of the claim. If we request additional information, we must receive it within 45 days of our request for the information. If we do not receive the requested information, the claim or a portion of the claim will be adjudicated based on the information in our possession at the time and may be denied. Upon receipt of the requested information, we will use our best efforts to complete the processing of the Post - Service Claim within 15 days of receipt of the information. • Denial of Post - Service Claims In the event we deny a Post - Service Claim submitted electronically, we will use our best efforts to provide notice, within 20 days of receipt, that the claim or a portion of the claim is denied. In the event we deny a paper Post - Service Claim, we will use our best efforts to provide notice, within 30 days of receipt, that the claim or a portion of the claim is denied. The notice may identify the denied portion(s) of the claim and the reason(s) for denial. It is your responsibility to ensure that we receive all information determined by us as necessary to adjudicate a Post - Service Claim. If we do not receive the necessary information, the claim or a portion of the claim may be denied. A Post - Service Claim denial is an Adverse Benefit Determination and is subject to the Adverse Benefit Determination standards and appeal procedures described in this section. Additional Processing Information for Post - Service Claims In any event, we will use our best efforts to pay or deny all: 1) electronic Post - Service Claims within 90 days of receipt of the completed claim; Claims Processing 17 -2 and 2) Post - Service paper claims within 120 days of receipt of the completed claim. Claims processing shall be deemed to have been completed as of the date the notice of the claims decision is deposited in the mail by us or otherwise electronically transmitted. Any claims payment relating to a Post - Service Claim that is not made by us within the applicable timeframe is subject to the payment of simple interest at the rate established by the Florida Insurance Code. We will investigate any allegation of improper billing by a Provider upon receipt of written notification from you. If we determine that you were billed for a Service that was not actually performed, any payment amount will be adjusted and, if applicable, a refund will be requested. In such a case, if payment to the Provider is reduced due solely to the notification from you, we will pay you 20 percent of the amount of the reduction, up to a total of $500. Pre - Service Claims How to File a Pre - Service Claim This Benefit Booklet may condition coverage, benefits, or payment (in whole or in part), for a specific Covered Service, on the receipt by us of a Pre - Service Claim as that term is defined herein. In order to determine whether we must receive a Pre - Service Claim for a particular Covered Service, please refer to the "What Is Covered?' section and other applicable sections of this Benefit Booklet. You may also call the customer service number on your ID card for assistance. We are not required to render an opinion or make a coverage or benefit determination with respect to a Service that has not actually been provided to you unless the terms of this Benefit Booklet require (or condition payment upon) approval by us for the Service before it is received. Benefit Determinations on Pre - Service Claims Involving Urgent Care For a Pre - Service Claim Involving Urgent Care, we will use our best efforts to provide notice of our determination (whether adverse or not) as soon as possible, but not later than 72 hours after receipt of the Pre - Service Claim unless additional information is required for a coverage decision. If additional information is necessary to make a determination, we will use our best efforts to provide notice within 24 hours of: 1) the need for additional information; 2) the specific information that you or your Provider may need to provide; and 3) the date that we reasonably expect to provide notice of the decision. If we request additional information, we must receive it within 48 hours of our request. We will use our best efforts to provide notice of the decision on your Pre - Service Claim within 48 hours after the earlier of: 1) receipt of the requested information; or 2) the end of the period you were afforded to provide the specified additional information as described above. Benefit Determinations on Pre - Service Claims that Do Not Involve Urgent Care We will use our best efforts to provide notice of a decision on a Pre - Service Claim not involving urgent care within 15 days of receipt provided additional information is not required for a coverage decision. This 15 -day determination period may be extended by us one time for up to an additional 15 days. If such an extension is necessary, we will use our best efforts to provide notice of the extension and reasons for it. We will use our best efforts to provide notification of the decision on your Pre - Service claim within a total of 30 days of the initial receipt of the claim, if an extension of time was taken by us. If additional information is necessary to make a determination, we will use our best efforts to: 1) provide notice of the need for additional information, prior to the expiration of the initial 15 -day period; 2) identify the specific information Claims Processing 17 -3 that you or your Provider may need to provide; and 3) inform you of the date that we reasonably expect to notify you of our decision. If we request additional information, we must receive it within 45 days of our request for the information. We will use our best efforts to provide notification of the decision on your Pre - Service Claim within 15 days of receipt of the requested information. A Pre - Service Claim denial is an Adverse Benefit Determination and is subject to the Adverse Benefit Determination standards and appeal procedures described in this section. Concurrent Care Decisions Reduction or Termination of Coverage or Benefits for Services A reduction or termination of coverage or benefits for Services will be considered an Adverse Benefit Determination when: • we have approved in writing coverage or benefits for an ongoing course of Services to be provided over a period of time or a number of Services to be rendered; and • the reduction or termination occurs before the end of such previously approved time or number of Services; and • the reduction or termination of coverage or benefits by us was not due to an amendment of this Benefit Booklet or termination of your coverage as provided by this Benefit Booklet. We will use our best efforts to notify you of such reduction or termination in advance so that you will have a reasonable amount of time to have the reduction or termination reviewed in accordance with the Adverse Benefit Determination standards and procedures described below. In no event shall we be required to provide more than a reasonable period of time within which you may develop your appeal before we actually terminate or reduce coverage for the Services. Requests for Extension of Services Your Provider may request an extension of coverage or benefits for a Service beyond the approved period of time or number of approved Services. If the request for an extension is for a Claim Involving Urgent Care, we will use our best efforts to notify you of the approval or denial of such requested extension within 24 hours after receipt of your request, provided it is received at least 24 hours prior to the expiration of the previously approved number or length of coverage for such Services. We will use our best efforts to notify you within 24 hours if: 1) we need additional information; or 2) you or your representative failed to follow proper procedures in your request for an extension. If we request additional information, you will have 48 hours to provide the requested information. We may notify you orally or in writing, unless you or your representative specifically request that it be in writing. A denial of a request for extension of Services is considered an Adverse Benefit Determination and is subject to the Adverse Benefit Determination review procedure below. Standards for Adverse Benefit Determinations Manner and Content of a Notification of an Adverse Benefit Determination We will use our best efforts to provide notice of any Adverse Benefit Determination in writing. Notification of an Adverse Benefit Determination will include (or will be made available to you free of charge upon request): 1. the date the Service or supply was provided; 2. the Provider's name; 3. the dollar amount of the claim, if applicable; 4. the diagnosis codes included on the claim (e.g., ICD -9, DSM -IV), including a description of such codes; 5. the standardized procedure code included on the claim (e.g., Current Procedural Claims Processing 17 -4 Terminology), including a description of such codes; 6. the specific reason or reasons for the Adverse Benefit Determination, including any applicable denial code; 7. a description of the specific Benefit Booklet provisions upon which the Adverse Benefit Determination is based, as well as any internal rule, guideline, protocol, or other similar criterion that was relied upon in making the Adverse Benefit Determination; 8. a description of any additional information that might change the determination and why that information is necessary; 9. a description of the Adverse Benefit Determination review procedures and the time limits applicable to such procedures; 10. if the Adverse Benefit Determination is based on the Medical Necessity or Experimental or Investigational limitations and exclusions, a statement telling you how to obtain the specific explanation of the scientific or clinical judgment for the determination; and 11. You have the right to an independent external review through an external review organization for certain appeals, as provided in the Patient Protection and Affordable Care Act of 2010. If the claim is a Claim Involving Urgent Care, we may notify you orally within the proper timeframes, provided we follow -up with a written or electronic notification meeting the requirements of this subsection no later than three days after the oral notification. How to Appeal an Adverse Benefit Determination Except as described below, only you, or a representative designated by you in writing, have the right to appeal an Adverse Benefit Determination. An appeal of an Adverse Benefit Determination will be reviewed using the review process described below. Your appeal must be submitted to us in writing for an internal appeal within 365 days of the original Adverse Benefit Determination, except in the case of Concurrent Care Decisions which may, depending upon the circumstances, require you to file within a shorter period of time from notice of the denial. The following guidelines are applicable to reviews of Adverse Benefit Determinations: • We must receive your appeal of an Adverse Benefit Determination in person or in writing; • You may request to review pertinent documents, such as any internal rule, guideline, protocol, or similar criterion relied upon to make the determination, and submit issues or comments in writing; • If the Adverse Benefit Determination is based on the lack of Medical Necessity of a particular Service or the Experimental or Investigational exclusion, you may request, free of charge, an explanation of the scientific or clinical judgment relied upon, if any, for the determination, that applies the terms of this Benefit Booklet to your medical circumstances; • During the review process, the Services in question will be reviewed without regard to the decision reached in the initial determination; • We may consult with appropriate Physicians, as necessary; • Any independent medical consultant who reviews your Adverse Benefit Determination on our behalf will be identified upon request; • If your claim is a Claim Involving Urgent Care, you may request an expedited appeal orally or in writing in which case all necessary information on review may be transmitted between you and us by telephone, facsimile or other available expeditious method; and Claims Processing 17 -5 • If you wish to give someone else permission to appeal an Adverse Benefit Determination on your behalf, we must receive a completed Appointment of Representative form signed by you indicating the name of the person who will represent you with respect to the appeal. An Appointment of Representative form is not required if your Physician is appealing an Adverse Benefit Determination relating to a Claim Involving Urgent Care. Appointment of Representative forms are available at www.floridablue.com or by calling the number on the back of your BCBSF ID Card. Timing of Our Appeal Review on Adverse Benefit Determinations We will use our best efforts to review your appeal of an Adverse Benefit Determination and communicate the decision in accordance with the following time frames: • Pre - Service Claims -- within 30 days of the receipt of your appeal; or • Post - Service Claims -- within 60 days of the receipt of your appeal; or • Claims Involving Urgent Care (and requests to extend concurrent care Services made within 24 hours prior to the termination of the Services) -- within 72 hours of receipt of your request. If additional information is necessary we will notify you within 24 hours and we must receive the requested additional information within 48 hours of our request. After we receive the additional information, we will have an additional 48 hours to make a final determination. Note: The nature of a claim for Services (i.e. whether it is "urgent care" or not) is judged as of the time of the benefit determination on review, not as of the time the Service was initially reviewed or provided. You, or a Provider acting on your behalf, who has had a claim denied as not Medically Necessary has the opportunity to appeal the claim denial. The appeal may be directed to an employee of BCBSF who is a licensed Physician responsible for Medical Necessity reviews. The appeal may be by telephone and the Physician will respond to you, within a reasonable time, not to exceed 15 business days. Requests for an internal appeal should be sent to the address below: Blue Cross and Blue Shield of Florida, Inc. Attention: Member Appeals P.O. Box 44197 Jacksonville, Florida 32231 -4197 How to Request External Review of Our Appeal Decision If we deny your appeal and our decision involves • medical judgment, including, but not limited to, • decision based on Medical Necessity, appropriateness, health care setting, level of care or effectiveness of the Health Care Service or treatment you requested or a determination that the treatment is Experimental or Investigational, you are entitled to request an independent, external review of our decision. Your request will be reviewed by an independent third party with clinical and legal expertise ( "External Reviewer ") who has no association with us. If you have any questions or concerns during the external review process, please contact us at the phone number listed on your ID card or visit www.floridablue.com You may submit additional written comments to External Reviewer. A letter with the mailing address will be sent to you when you file an external review. Please note that if you provide any additional information during the external review process it will be shared with us in order to give us the opportunity to reconsider the denial. Submit your request in writing on the External Review Request form within four months after receipt of your denial to the below address: Blue Cross and Blue Shield of Florida Attention: Member External Reviews DCC9 -5 Post Office Box 44197 Jacksonville, FL 32231 -4197 Claims Processing 17 -6 If you have a medical Condition where the timeframe for completion of a standard external review would seriously jeopardize your life, health or ability to regain maximum function, you may file a request for an expedited external review. Generally, an urgent situation is one in which your health may be in serious jeopardy, or in the opinion of your Physician, you may experience pain that cannot be adequately controlled while you wait for a decision on the external review of your claim. Moreover expedited external reviews may be requested for an admission, availability of care, continued stay or Health Care Service for which you received Emergency Services, but have not been discharged from a facility. Please be sure your treating Physician completes the appropriate form to initiate this request type. If you have any questions or concerns during the external review process, please contact us at the phone number listed on your ID card or visit www.floridablue.com You may submit additional written comments to the External Reviewer. A letter with the mailing address will be sent to you when you file an external review. Please note that if you provide any additional information during the external review process it will be shared with us in order to give us the opportunity to reconsider the denial. If you believe your situation is urgent, you may request an expedited review by sending your request to the address above or by fax to 904 - 565 -6637. If the External Reviewer decides to overturn our decision, we will provide coverage or payment for your health care item or Service. You or someone you name to act for you may file a request for external review. To appoint someone to act on your behalf, please complete an Appointment of Representative form. You are entitled to receive, upon written request and free of charge, reasonable access to, and copies of all documents relevant to your appeal including a copy of the actual benefit provision, guideline protocol or other similar criterion on which the appeal decision was based. You may request and we will provide the diagnosis and treatment codes, as well as their corresponding meanings, applicable to this notice, if available. Additional Claims Processing Provisions 1. Release of Information /Cooperation: In order to process claims, we may need certain information, including information regarding other health care coverage you may have. You must cooperate with us in our effort to obtain such information by, among other ways, signing any release of information form at our request. Failure by you to fully cooperate with us may result in a denial of the pending claim and we will have no liability for such claim. 2. Physical Examination: In order to make coverage and benefit decisions, we may, at our expense, require you to be examined by a health care Provider of our choice as often as is reasonably necessary while a claim is pending. Failure by you to fully cooperate with such examination shall result in a denial of the pending claim and we shall have no liability for such claim. 3. Legal Actions: No legal action arising out of or in connection with coverage under this Benefit Booklet may be brought against us within the 60 -day period following our receipt of the completed claim as required herein. Additionally, no such action may be brought after expiration of the applicable statute of limitations. 4. Fraud, Misrepresentation or Omission in Applying for Benefits: We rely on the information provided on the itemized statement and the claim form when processing a claim. All such information, Claims Processing 17 -7 therefore, must be accurate, truthful and complete. Any fraudulent statement, omission or concealment of facts, misrepresentation, or incorrect information may result, in addition to any other legal remedy we may have, in denial of the claim or cancellation or rescission of your coverage. 5. Explanation of Benefits Form: All claims decisions, including denial and claims review decisions, will be communicated to you in writing either on an explanation of benefits form or some other written correspondence. This form may indicate: a) The specific reason or reasons for the Adverse Benefit Determination; b) Reference to the specific Benefit Booklet provisions upon which the Adverse Benefit Determination is based as well as any internal rule, guideline, protocol, or other similar criterion that was relied upon in making the Adverse Benefit Determination; c) A description of any additional information that would change the initial determination and why that information is necessary; d) A description of the applicable Adverse Benefit Determination review procedures and the time limits applicable to such procedures; and e) If the Adverse Benefit Determination is based on the Medical Necessity or Experimental or Investigational limitations and exclusions, a statement telling you how you can obtain the specific explanation of the scientific or clinical judgment for the determination. 6. Circumstances Beyond Our Control: To the extent that natural disaster, war, riot, civil insurrection, epidemic, or other emergency or similar event not within our control, results in facilities, personnel or our financial resources being unable to process claims for Covered Services, we will have no liability or obligation for any delay in the payment of claims for Covered Services, except that we will make a good faith effort to make payment for such Services, taking into account the impact of the event. For the purposes of this paragraph, an event is not within our control if we cannot effectively exercise influence or dominion over its occurrence or non - occurrence. Claims Processing 17 -8 Section 18: Relationship Between the Parties BCBSF /Monroe County BOCC and Health Care Providers Neither BCBSF nor Monroe County BOCC nor any of their officers, directors or employees provides Health Care Services to you. Rather, BCBSF and Monroe County BOCC are engaged in making coverage and benefit decisions under this Booklet. By accepting the Group health care coverage and benefits, you agree that making such coverage and benefit decisions does not constitute the rendering of Health Care Services and that health care Providers rendering those Services are not employees or agents of BCBSF or Monroe County BOCC. In this regard, we and Monroe County BOCC hereby expressly disclaim any agency relationship, actual or implied, with any health care Provider. BCBSF and Monroe County BOCC do not, by virtue of making coverage, benefit, and payment decisions, exercise any control or direction over the medical judgment or clinical decisions of any health care Provider. Any decisions made under the Group Health Plan concerning appropriateness of setting, or whether any Service is Medically Necessary, shall be deemed to be made solely for purposes of determining whether such Services are covered, and not for purposes of recommending any treatment or non - treatment. Neither BCBSF nor Monroe County BOCC will assume liability for any loss or damage arising as a result of acts or omissions of any health care Provider. Non Liability of BCBSF and Monroe County BOCC Neither Monroe County BOCC nor any person covered under this Booklet is BCBSF's agent or representative, and neither shall be liable for any acts or omissions by BCBSF's agents, servants, employees, or us. Additionally, neither BCBSF nor Monroe County BOCC will be liable, whether in tort or contract or otherwise, for any acts or omissions of any other person or organization with which BCBSF has made or hereafter makes arrangements for the provision of Covered Services. BCBSF is not your agent, servant, or representative nor is BCBSF an agent, servant, or representative of Monroe County BOCC and BCBSF will not be liable for any acts or omissions, or those of Monroe County BOCC, its agents, servants, employees, or any person or organization with which Monroe County BOCC has entered into any agreement or arrangement. By acceptance of coverage and benefits hereunder, you agree to the foregoing. Medical Treatment Decisions - Responsibility of Your Physician, Not BCBSF Any and all decisions that require or pertain to independent professional medical judgment or training, or the need for medical Services or supplies, must be made solely by your family and your treating Physician in accordance with the patient /physician relationship. It is possible that you or your treating Physician may conclude that a particular procedure is needed, appropriate, or desirable, even though such procedure may not be covered. Relationship Between the Parties 18 -1 Section 19: General Provisions Access to Information BCBSF and Monroe County BOCC have the right to receive, from you and any health care Provider rendering Services to you, information that is reasonably necessary, as determined by BCBSF and Monroe County BOCC, in order to administer the coverage and benefits provided, subject to all applicable confidentiality requirements listed below. By accepting coverage, you authorize every health care Provider who renders Services to you, to disclose to BCBSF and Monroe County BOCC or to affiliated entities, upon request, all facts, records, and reports pertaining to your care, treatment, and physical or mental Condition, and to permit BCBSF and /or Monroe County BOCC to copy any such records and reports so obtained. Right to Receive Necessary Information In order to administer coverage and benefits, BCBSF or Monroe County BOCC may, without the consent of, or notice to, any person, plan, or organization, obtain from any person, plan, or organization any information with respect to any person covered under this Booklet or applicant for enrollment which BCBSF or Monroe County BOCC deem to be necessary. Right to Recovery Whenever the Group Health Plan has made payments in excess of the maximum provided for under this Booklet, BCBSF or Monroe County BOCC will have the right to recover any such payments, to the extent of such excess, from you or any person, plan, or other organization that received such payments. Compliance with State and Federal Laws and Regulations The terms of coverage and benefits to be provided under this Benefit Booklet shall be deemed to have been modified and shall be interpreted, so as to comply with applicable state or federal laws and regulations dealing with benefits, eligibility, enrollment, termination, or other rights and duties. Confidentiality Except as otherwise specifically provided herein, and except as may be required in order for us to administer coverage and benefits, specific medical information concerning you, received by Providers, shall be kept confidential by us in conformity with applicable law. Such information may be disclosed to third parties for use in connection with bona fide medical research and education, or as reasonably necessary in connection with the administration of coverage and benefits, specifically including BCBSF's quality assurance and Blueprint for Health Programs. Additionally, we may disclose such information to entities affiliated with us or other persons or entities we utilize to assist in providing coverage, benefits or services under this Booklet. Further, any documents or information which are properly subpoenaed in a judicial proceeding, or by order of a regulatory agency, shall not be subject to this provision. BCBSF's arrangements with a Provider may require that we release certain claims and medical information about persons covered under this Booklet to that Provider even if treatment has not been sought by or through that Provider. By accepting coverage, you hereby authorize us to release to Providers claims information, including related medical information, pertaining to you in order for any such Provider to evaluate your financial responsibility under this Booklet. General Provisions 19 -1 Benefit Booklet You have been provided with this Benefit Booklet and an Identification Card as evidence of your coverage under this Benefit Booklet. Modification of Provider Network and the Participation Status NetworkBlue and the Traditional Provider Program, and the participation status of individual Providers available through BCBSF, are subject to change at any time by BCBSF without prior notice to you or your approval or that of Monroe County BOCC. Additionally, BCBSF may, at any time, terminate or modify the terms of any Provider contract and may enter into additional Provider contracts without prior notice to you, or your approval or that of Monroe County BOCC. It is your responsibility to determine whether a health care Provider is an In- Network Provider at the time the Health Care Service is rendered. Under this Booklet, your financial responsibility may vary depending upon a Provider's participation status. Cooperation Required of You and Your Covered Dependents You must cooperate with BCBSF and Monroe County BOCC, and must execute and submit to us any consents, releases, assignments, and other documents requested in order to administer, and exercise any rights hereunder. Failure to do so may result in the denial of claims and will constitute grounds for termination for cause (See the Termination of an Individual's Coverage for Cause subsection in the Termination Of Coverage section). Non - Waiver of Defaults Any failure by BCBSF or Monroe County BOCC at any time, or from time to time, to enforce or to require the strict adherence to any of the terms or conditions described herein, will in no event constitute a waiver of any such terms or conditions. Further, it will not affect BCBSF's or Monroe County BOCC's right at any time to enforce any terms or conditions under this Benefit Booklet. Notices Any notice required or permitted hereunder will be deemed given if hand delivered or if mailed by United States Mail, postage prepaid, and addressed as listed below. Such notice will be deemed effective as of the date delivered or so deposited in the mail. If to BCBSF: To the address printed on the Identification Card. If to you: To the latest address provided by you or to your latest address on Enrollment Forms actually delivered to us. You must notify Monroe County BOCC Benefits Office immediately of any address change. If to Monroe County BOCC: To the address indicated by Monroe County BOCC. Our Obligations Upon Termination Upon termination of your coverage for any reason, there will be no further liability or responsibility to you under the Group Health Plan, except as specifically described herein. Promissory Estoppel No oral statements, representations, or understanding by any person can change, alter, delete, add, or otherwise modify the express written terms of this Booklet. General Provisions 19 -2 Florida Agency for Health Care Administration Performance Data The performance outcome and financial data published by the Agency for Health Care Administration (AHCA), pursuant to Florida Statute 408.05, or any successor statute, located at the web site address www.floridahealthfinder.gov may be accessed through the link provided on the Blue Cross and Blue Shield of Florida corporate web site at www.floridablue.com Subrogation and Right of Recovery The provisions of this section apply to all current or former plan participants and also to the parents, guardian, or other representative of a dependent child who incurs claims and is or has been covered by the plan. The plan's right to recover (whether by subrogation or reimbursement) shall apply to the personal representative of your estate, your decedents, minors, and incompetent or disabled persons. "You" or "your" includes anyone on whose behalf the plan pays benefits. No adult Covered Person hereunder may assign any rights that it may have to recover medical expenses from any tortfeasor or other person or entity to any minor child or children of said adult covered person without the prior express written consent of the Plan. The plan's right of subrogation or reimbursement, as set forth below, extend to all insurance coverage available to you due to an injury, illness or condition for which the plan has paid medical claims (including, but not limited to, liability coverage, uninsured motorist coverage, underinsured motorist coverage, personal umbrella coverage, medical payments coverage, workers compensation coverage, no fault automobile coverage or any first party insurance coverage). For the purpose of determining payment of benefits, your health plan is always secondary to automobile no -fault coverage, personal injury protection coverage, or medical payments coverage. By accepting benefits under this Booklet, you specifically acknowledge our right of subrogation and reimbursement. These rights apply to any claim or potential claim made by you or on your behalf from the following sources, jncluding but not limited to: • Payments made by a Third Party or any insurance company on behalf of the Third Party; • Any payments or awards under an uninsured or underinsured motorist coverage policy; • Any Workers' Compensation or disability award or settlement; • Medical payments under any automobile, homeowners' or premises liability policy; and • Any other payments from any source intended to compensate you for injuries resulting from an accident or alleged negligence. By accepting benefits under this Booklet, you also agree to: • Notify us promptly and in writing when notice is given to any party of the intention to investigate or pursue a claim, or of settlement negotiations with Third Parties, prior to entering into any settlement agreement; and • Notify us promptly of any amounts recovered from Third Parties, by way of settlement or judgment, and do not distribute the settlement or judgment proceeds without Monroe County's prior written consent. No disbursement of any settlement proceeds or other recovery funds from any insurance coverage or other source will be made until the General Provisions 19 -3 health plan's subrogation and reimbursement interest are fully satisfied. No waiver, release of liability or other documents executed by you without prior notice to the consent from Monroe County BOCC will be binding on the Monroe County BOCC. Subrogation The right of subrogation means the plan is entitled to pursue any claims that you may have in order to recover the benefits paid by the plan. Immediately upon paying or providing any benefit under the plan, the plan shall be subrogated to (stand in the place of) all of your rights of recovery with respect to any claim or potential claim against any party, due to an injury, illness or condition to the full extent of benefits provided or to be provided by the Plan. The Plan may assert a claim or file suit in your name and take appropriate action to assert its subrogation claim, with or without your consent. The plan is not required to pay you part of any recovery it may obtain, even if it files suit in your name. Reimbursement If you receive any payment as a result of an injury, illness or condition, you agree to reimburse the plan first from such payment for all amounts the plan has paid and will pay as a result of that injury, illness or condition, up to and including the full amount of your recovery. Constructive Trust By accepting benefits (whether the payment of such benefits is made to you or made on your behalf to any provider) you agree that if you receive any payment as a result of an injury, illness or condition, you will serve as a constructive trustee over those funds. Failure to hold such funds in trust will be deemed a breach of your fiduciary duty to the plan. No disbursement of any settlement proceeds or other recovery funds from any insurance coverage or other source will be made until the health plan's subrogation and reimbursement interest are fully satisfied. Lien Rights Further, the plan will automatically have a lien to the extent of benefits paid by the plan for the treatment of the illness, injury or condition upon any recovery whether by settlement, judgment or otherwise, related to treatment for any illness, injury or condition for which the plan paid benefits. The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by the plan including, but not limited to, you, your representative or agent, and /or any other source that possessed or will possess funds representing the amount of benefits paid by the plan. Assignment In order to secure the plan's recovery rights, you agree to assign to the plan any benefits or claims or rights of recovery you have under any automobile policy or other coverage, to the full extent of the plan's subrogation and reimbursement claims. This assignment allows the plan to pursue any claim you may have, whether or not you choose to pursue the claim. First - Priority Claim By accepting benefits from the plan, you acknowledge that the plan's recovery rights are a first priority claim and are to be repaid to the plan before you receive any recovery for your damages. The plan shall be entitled to full reimbursement on a first - dollar basis from any payments, even if such payment to the plan will result in a recovery which is insufficient to make you whole or to compensate you in part or in whole for the damages sustained. The plan is not required to participate in or pay your court costs or attorney fees to any attorney you hire to pursue your damage claim. General Provisions 19 -4 Applicability to All Settlements and Judgments The terms of this entire subrogation and right of recovery provision shall apply and the plan is entitled to full recovery regardless of whether any liability for payment is admitted and regardless of whether the settlement or judgment identifies the medical benefits the plan provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses. The plan is entitled to recover from any and all settlements or judgments, even those designated as pain and suffering, non - economic damages and /or general damages only. The plan's claim will not be reduced due to your own negligence. Cooperation You agree to cooperate fully with the plan's efforts to recover benefits paid. It is your duty to notify the plan within 30 days of the date when any notice is given to any party, including an insurance company or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury, illness or condition. You and your agents agree to provide the plan or its representative's notice of any recovery you or your agents obtain prior to receipt of such recovery funds or within 5 days if no notice was given prior to receipt. Further, you and your agents agree to provide notice prior to any disbursement of settlement or any other recovery funds obtained. You and your agents shall provide all information requested by the plan, the Claims Administrator or its representative including, but not limited to, completing and submitting any applications or other forms or statements as the plan may reasonably request and all documents related to or filed in personal injury litigation. Failure to provide this information, failure to assist the plan in pursuit of its subrogation rights or failure to reimburse the plan from any settlement or recovery you receive may result in the denial of any future benefit payments or claim until the plan is reimbursed in full, termination of your health benefits or the institution of court proceedings against you. You shall do nothing to prejudice the plan's subrogation or recovery interest or prejudice the plan's ability to enforce the terms of this plan provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the plan or disbursement of any settlement proceeds or other recovery prior to fully satisfying the health plan's subrogation and reimbursement interest. You acknowledge that the plan has the right to conduct an investigation regarding the injury, illness or condition to identify potential sources of recovery. The plan reserves the right to notify all parties and his /her agents of its lien. Agents include, but are not limited to, insurance companies and attorneys. You acknowledge that the plan has notified you that it has the right pursuant to the Health Insurance Portability & Accountability Act ( "HIPAA" ), 42 U.S.C. Section 1301 et seq, to share your personal health information in exercising its subrogation and reimbursement rights. Interpretation In the event that any claim is made that any part of this subrogation and right of recovery provision is ambiguous or questions arise concerning the meaning or intent of any of its terms, the Claims Administrator for the plan shall have the sole authority and discretion to resolve all disputes regarding the interpretation of this provision. Jurisdiction By accepting benefits from the Plan, you agree that any court proceeding with respect to this General Provisions 19 -5 provision may be brought in any court of competent jurisdiction as the plan may elect. By accepting such benefits, you hereby submit to each such jurisdiction, waiving whatever rights may correspond by reason of your present or future domicile. By accepting such benefits, you also agree to pay all attorneys' fees the plan incurs in successful attempts to recover amounts the plan is entitled to under this section. Third Party Beneficiary The terms and provisions of the Group Health Plan shall be binding solely upon, and inure solely to the benefit of, Monroe County BOCC and individuals covered under the terms of this Benefit Booklet, and no other person shall have any rights, interest or claims thereunder, or under this Benefit Booklet, or be entitled to sue for a breach thereof as a third -party beneficiary or otherwise. Monroe County BOCC hereby specifically expresses its intent that health care Providers that have not entered into contracts with BCBSF to participate in BCBSF's Provider networks shall not be third -party beneficiaries under the terms of the Monroe County BOCC Group Health Plan or this Benefit Booklet. Customer Rewards Programs From time to time, we may offer programs to our customers that provide rewards for following the terms of the program. We will tell you about any available rewards programs in general mailings, member newsletters and /or on our website. Your participation in these programs is completely voluntary and will in no way affect the coverage available to you under this Benefit Booklet. We reserve the right to offer rewards in excess of $25 per year as well as the right to discontinue or modify any reward program features or promotional offers at any time without your consent. General Provisions 19 -6 Section 20: Definitions The following definitions are used in this Benefit Booklet. Other definitions may be found in the particular section or subsection where they are used. Accident means an unintentional, unexpected event, other than the acute onset of a bodily infirmity or disease, which results in traumatic injury. This term does not include injuries caused by surgery or treatment for disease or illness. Accidental Dental Injury means an injury to sound natural teeth (not previously compromised by decay) caused by a sudden, unintentional, and unexpected event or force. This term does not include injuries to the mouth, structures within the oral cavity, or injuries to natural teeth caused by biting or chewing, surgery, or treatment for a disease or illness. Administrative Services Only Agreement or ASO Agreement means an agreement between Monroe County BOCC and BCBSF. Under the Administrative Services Only Agreement, BCBSF provides claims processing and payment services, customer service, utilization review services and access to BCBSF's NetworkBlue and BCBSF's network of Traditional Insurance Providers. Adverse Benefit Determination means any denial, reduction or termination of coverage, benefits, or payment (in whole or in part) under the Benefit Booklet with respect to a Pre - Service Claim or a Post - Service Claim. Any reduction or termination of coverage, benefits, or payment in connection with a Concurrent Care Decision, as described in this section, shall also constitute an Adverse Benefit Determination. Allowed Amount means the maximum amount upon which payment will be based for Covered Services. The Allowed Amount may be changed at any time without notice to you or your consent. In the case of an In- Network Provider located in Florida, this amount will be established in accordance with the applicable agreement between that Provider and BCBSF. 2. In the case of an In- Network Provider located outside of Florida, this amount will generally be established in accordance with the negotiated price that the on -site Blue Cross and /or Blue Shield Plan ( "Host Blue ") passes on to us, except when the Host Blue is unable to pass on its negotiated price due to the terms of its Provider contracts. See the BlueCard (Out -of- State) Program section for more details. 3. In the case of Out -of- Network Providers located in Florida who participate in the Traditional Program, this amount will be established in accordance with the applicable agreement between that Provider and BCBSF. 4. In the case of Out -of- Network Providers located outside of Florida who participate in the BlueCard (Out -of- State) Traditional Program, this amount will generally be established in accordance with the negotiated price that the Host Blue passes on to us, except when the Host Blue is unable to pass on its negotiated price due to the terms of its Provider contracts. See the BlueCard (Out -of- State) Program section for more details. 5. In the case of an Out -of- Network Provider that has not entered into an agreement with BCBSF to provide access to a discount from the billed amount of that Provider for the specific Covered Services provided to you, the Allowed Amount will be the lesser of that Provider's actual billed amount for the specific Covered Services or an amount established by BCBSF that may be based on several factors including (but not Definitions 20 -1 necessarily limited to): (i) payment for such Services under the Medicare and /or Medicaid programs; (ii) payment often accepted for such Services by that Out -of- Network Provider and /or by other Providers, either in Florida or in other comparable market(s), that BCBSF determines are comparable to the Out -of- Network Provider that provided the specific Covered Services (which may include payment accepted by such Out -of- Network Provider and /or by other Providers as participating providers in other provider networks of third -party payers which may include, for example, other insurance companies and /or health maintenance organizations); (iii) payment amounts which are consistent, as determined by BCBSF, with BCBSF's provider network strategies (e.g., does not result in payment that encourages Providers participating in a BCBSF network to become non - participating); and /or, (iv) the cost of providing the specific Covered Services. In the case of an Out -of- Network Provider that has not entered into an agreement with another Blue Cross and /or Blue Shield organization to provide access to discounts from the billed amount for the specific Covered Services under the BlueCard (Out - of- State) Program, the Allowed Amount for the specific Covered Services provided to you may be based upon the amount provided to BCBSF by the other Blue Cross and /or Blue Shield organization where the Services were provided at the amount such organization would pay non - participating Providers in its geographic area for such Services. You may obtain an estimate of the Allowed Amount for particular Services by calling the customer service telephone number included in this Booklet or on your Identification Card. The fact that we may provide you with such information does not mean that the particular Service is a Covered Service. All terms and conditions included in your Booklet apply. You should refer to the "What is Covered ?" section of your Booklet and the Schedule of Benefits to determine what is covered and how much will be paid. Please specifically note that, in the case of an Out -of- Network Provider that has not entered into an agreement with BCBSF to provide access to a discount from the billed amount of that Provider, the Allowed Amount for particular Services is often substantially below the amount billed by such Out -of- Network Provider for such Services. You will be responsible for any difference between such Allowed Amount and the amount billed for such Services by any such Out -of- Network Provider. Ambulance means a ground or water vehicle, airplane or helicopter properly licensed pursuant to Chapter 401 of the Florida Statutes, or a similar applicable law in another state. Ambulatory Surgical Center means a facility properly licensed pursuant to Chapter 395 of the Florida Statutes, or a similar applicable law of another state, the primary purpose of which is to provide elective surgical care to a patient, admitted to, and discharged from such facility within the same working day. Applied Behavior Analysis means the design, implementation and evaluation of environmental modifications, using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including, but not limited to, the use of direct observation, measurement and functional analysis of the relations between environment and behavior. Approved Clinical Trial means a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other Life - Threatening Disease or Condition and meets one of the following criteria: Definitions 20 -2 1. The study or investigation is approved or funded by one or more of the following: a. The National Institutes of Health. b. The Centers for Disease Control and Prevention. c. The Agency for Health Care Research and Quality. d. The Centers for Medicare and Medicaid Services. e. Cooperative group or center of any of the entities described in clauses (i) through (iv) or the Department of Defense or the Department of Veterans Affairs. A qualified non - governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants. g. Any of the following if the conditions described in paragraph (2) are met: i. The Department of Veterans Affairs. ii. The Department of Defense. iii. The Department of Energy. 2. The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration. 3. The study or investigation is a drug trial that is exempt from having such an investigational new drug application. For a study or investigation conducted by a Department the study or investigation must be reviewed and approved through a system of peer review that the Secretary determines: (1) to be comparable to the system of peer review of studies and investigations used by the National Institutes of Health, and (2) assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review. For purposes of this definition, the term "Life - Threatening Disease or Condition" means any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted. Artificial Insemination (AI) means a medical procedure in which sperm is placed into the female reproductive tract by a qualified health care provider for the purpose of producing a pregnancy. Autism Spectrum Disorder means any of the following disorders as defined in the diagnostic categories of the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD -9 CM), or their equivalents in the most recently published version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders: 1. Autistic disorder; 2. Asperger's syndrome; 3. Pervasive developmental disorder not otherwise specified; and 4. Childhood Disintegrative Disorder. Benefit Period means a consecutive period of time, specified by BCBSF and the Group, in which benefits accumulate toward the satisfaction of Deductibles, out -of- pocket maximums and any applicable benefit maximums. Your Benefit Period is listed on your Schedule of Benefits, and will not be less than 12 months unless indicated as such. Birth Center means a facility or institution, other than a Hospital or Ambulatory Surgical Center, which is properly licensed pursuant to Chapter 383 of the Florida Statutes, or a similar applicable law of another state, in which births are planned to occur away from the mother's usual residence following a normal, uncomplicated, low -risk pregnancy. Definitions 20 -3 BlueCard (Out -of- State) Program means a national Blue Cross and Blue Shield Association program available through Blue Cross and Blue Shield of Florida, Inc. Subject to any applicable BlueCard (Out -of- State) Program rules and protocols, you may have access to the Provider discounts of other participating Blue Cross and /or Blue Shield plans. See the BlueCard (Out -of- State) Program section for more details. BlueCard (Out -of- State) PPO Program means a national Blue Cross and Blue Shield Association program available through Blue Cross and Blue Shield of Florida, Inc. Subject to any applicable BlueCard (Out -of- State) Program rules and protocols, you may have access to the BlueCard (Out -of- State) PPO Program discounts of other participating Blue Cross and /or Blue Shield plans. BlueCard (Out -of- State) Traditional Program means a national Blue Cross and Blue Shield Association program available through Blue Cross and Blue Shield of Florida, Inc. Subject to any applicable BlueCard (Out -of- State) Program rules and protocols, you may have access to the BlueCard (Out -of- State) Traditional Program discounts of other participating Blue Cross and /or Blue Shield plans. BlueCard (Out -of- State) PPO Program Provider means a Provider designated as a BlueCard (Out -of- State) PPO Program Provider by the Host Blue. BlueCard (Out -of- State) Traditional Program Provider means a Provider designated as a BlueCard (Out -of- State) Traditional Program Provider by the Host Blue. Bone Marrow Transplant means human blood precursor cells administered to a patient to restore normal hematological and immunological functions following ablative or non - ablative therapy with curative or life- prolonging intent. Human blood precursor cells may be obtained from the patient in an autologous transplant, or an allogeneic transplant from a medically acceptable related or unrelated donor, and may be derived from bone marrow, the circulating blood, or a combination of bone marrow and circulating blood. If chemotherapy is an integral part of the treatment involving bone marrow transplantation, the term "Bone Marrow Transplant" includes the transplantation as well as the administration of chemotherapy and the chemotherapy drugs. The term "Bone Marrow Transplant" also includes any Services or supplies relating to any treatment or therapy involving the use of high dose or intensive dose chemotherapy and human blood precursor cells and includes any and all Hospital, Physician or other health care Provider Health Care Services which are rendered in order to treat the effects of, or complications arising from, the use of high dose or intensive dose chemotherapy or human blood precursor cells (e.g., Hospital room and board and ancillary Services). Calendar Year begins January 1st and ends December 31st. Cardiac Therapy means Health Care Services provided under the supervision of a Physician, or an appropriate Provider trained for Cardiac Therapy, for the purpose of aiding in the restoration of normal heart function in connection with a myocardial infarction, coronary occlusion or coronary bypass surgery. Care Coordination means organized, information - driven patient care activities intended to facilitate the appropriate responses to a Covered Person's health care needs across the continuum of care. Care Coordinator Fee means a fixed amount paid by a Blue Cross and /or Blue Shield Licensee to Providers periodically for Care Coordination under a Value -Based Program. Certified Nurse Midwife means a person who is licensed pursuant to Chapter 464 of the Florida Statutes, or a similar applicable law of another state, as an advanced nurse practitioner V Definitions 20 -4 and who is certified to practice midwifery by the American College of Nurse Midwives. Certified Registered Nurse Anesthetist means a person who is a properly licensed nurse who is a certified advanced registered nurse practitioner within the nurse anesthetist category pursuant to Chapter 464 of the Florida Statutes, or a similar applicable law of another state. Claim Involving Urgent Care means any request or application for coverage or benefits for medical care or treatment that has not yet been provided to you with respect to which the application of time periods for making non - urgent care benefit determinations: (1) could seriously jeopardize your life or health or your ability to regain maximum function; or (2) in the opinion of a Physician with knowledge of your Condition, would subject you to severe pain that cannot be adequately managed without the proposed Services being rendered. Coinsurance means your share of health care expenses for Covered Services. After your Deductible requirement is met, a percentage of the Allowed Amount will be paid for Covered Services, as listed in the Schedule of Benefits. The percentage you are responsible for is your Coinsurance. Concurrent Care Decision means a decision by us to deny, reduce, or terminate coverage, benefits, or payment (in whole or in part) with respect to a course of treatment to be provided over a period of time, or a specific number of treatments, if we had previously approved or authorized in writing coverage, benefits, or payment for that course of treatment or number of treatments. As defined herein, a Concurrent Care Decision shall not include any decision to deny, reduce, or terminate coverage, benefits, or payment under the personal case management Program as described in the "Blueprint For Health Programs" section of this Benefit Booklet. Condition means a disease, illness, ailment, injury, or pregnancy. Convenient Care Center means a properly licensed ambulatory center that: 1) treats a limited number of common, low- intensity illnesses when ready access to the patient's primary physician is not possible; 2) shares clinical information about the treatment with the patient's primary physician; 3) is usually housed in a retail business; and 4) is staffed by at least one master's level nurse (ARNP) who operates under a set of clinical protocols that strictly circumscribe the conditions the ARNP can treat. Although no physician is present at the Convenient Care Center, medical oversight is based on a written collaborative agreement between a supervising physician and the ARNP, Copayment means the dollar amount established solely by BCBSF and Monroe County BOCC which is required to be paid to a health care Provider by you at the time certain Covered Services are rendered by that Provider Cost Share means the dollar or percentage amount established solely by us, which must be paid to a health care Provider by you at the time Covered Services are rendered by that Provider. Cost Share may include, but is not limited to Coinsurance, Copayment, Deductible and /or Per Admission Deductible (PAD) amounts. Applicable Cost Share amounts are identified in your Schedule of Benefits. Covered Dependent means an Eligible Dependent who meets and continues to meet all applicable eligibility requirements and who is enrolled, and actually covered, under the Group Health Plan other than as a Covered Plan Participant (See the "Eligibility Requirements for Dependent(s)" subsection of the "Eligibility for Coverage" section). Covered Person means a Covered Plan Participant or a Covered Dependent. V Definitions 20 -5 Covered Plan Participant means an Eligible Employee or other individual who meets and continues to meet all applicable eligibility requirements and who is enrolled, and actually covered, under this Benefit Booklet other than as a Covered Dependent. Covered Services means those Health Care Services which meet the criteria listed in the "What Is Covered ?" section. Custodial or Custodial Care means care that serves to assist an individual in the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, and using the toilet, preparation of special diets, and supervision of medication that usually can be self- administered. Custodial Care essentially is personal care that does not require the continuing attention of trained medical or paramedical personnel. In determining whether a person is receiving Custodial Care, consideration is given to the frequency, intensity and level of care and medical supervision required and furnished. A determination that care received is Custodial is not based on the patient's diagnosis, type of Condition, degree of functional limitation, or rehabilitation potential. Deductible means the amount of charges, up to the Allowed Amount, for Covered Services that are your responsibility. The term, Deductible, does not include any amounts you are responsible for in excess of the Allowed Amount, or any Coinsurance /Copay amounts, if applicable. Detoxification means a process whereby an alcohol or drug intoxicated, or alcohol or drug dependent, individual is assisted through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors or alcohol in combination with drugs as determined by a licensed Physician or Psychologist, while keeping the physiological risk to the individual at a minimum. Diabetes Educator means a person who is properly certified pursuant to Florida law, or a similar applicable law of another state, to supervise diabetes outpatient self- management training and educational services. Dialysis Center means an outpatient facility certified by the Centers for Medicare and Medicaid Services (CMMS) and the Florida Agency for Health Care Administration (or a similar regulatory agency of another state) to provide hemodialysis and peritoneal dialysis services and support. Dietitian means a person who is properly licensed pursuant to Florida law or a similar applicable law of another state to provide nutrition counseling for diabetes outpatient self- management services. Down syndrome means a chromosomal disorder caused by an error in cell division which results in the presence of an extra whole or partial copy of chromosome 21. Durable Medical Equipment means equipment furnished by a supplier or a Home Health Agency that: 1) can withstand repeated use; 2) is primarily and customarily used to serve a medical purpose; 3) not for comfort or convenience; 4) generally is not useful to an individual in the absence of a Condition; and 5) is appropriate for use in the home. Durable Medical Equipment Provider means a person or entity that is properly licensed, if applicable, under Florida law (or a similar applicable law of another state) to provide home medical equipment, oxygen therapy services, or dialysis supplies in the patient's home under a Physician's prescription. Effective Date means, with respect to individuals covered under this Benefit Booklet, 12:01 a.m. on the date Monroe County BOCC specifies that the coverage will commence as further described in the "Enrollment and V Definitions 20 -6 Effective Date of Coverage" section of this Benefit Booklet. Eligible Dependent means an individual who meets and continues to meet all of the eligibility requirements described in the Eligibility Requirements for Dependent(s) subsection of the Eligibility for Coverage section in this Benefit Booklet, and is eligible to enroll as a Covered Dependent. Eligible Employee means an active employee or retiree individual who meets and continues to meet all of the eligibility requirements described in the Eligibility Requirements for Covered Plan Participant subsection of the Eligibility for Coverage section in the Benefit Booklet and is eligible to enroll as a Covered Plan Participant. Any individual who is an Eligible Employee is not a Covered Plan Participant until such individual has actually enrolled with, and been accepted for coverage as a Covered Plan Participant by Monroe County BOCC. Emergency Medical Condition means a medical or psychiatric Condition or an injury manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described as (i) placing the health of the individual in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part. Emergency Services means, with respect to an Emergency Medical Condition: 1. a medical screening examination (as required under Section 1867 of the Social Security Act) that is within the capability of the emergency department of a Hospital, including ancillary Services routinely available to the emergency department to evaluate such Emergency Medical Condition; and 2. within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatment as are required under Section 1867 of such Act to Stabilize the patient. Endorsement means an amendment to the Group Health Plan or this Booklet. Enrollment Date means the date of enrollment of the individual under the Group Health Plan or, if earlier, the first day of the Waiting Period of such enrollment. Enrollment Forms means those forms, electronic (where available) or paper, which are used to maintain accurate enrollment files under this Benefit Booklet. Experimental or Investigational means any evaluation, treatment, therapy, or device which involves the application, administration or use, of procedures, techniques, equipment, supplies, products, remedies, vaccines, biological products, drugs, pharmaceuticals, or chemical compounds if, as determined solely by BCBSF or Monroe County BOCC: 1. such evaluation, treatment, therapy, or device cannot be lawfully marketed without approval of the United States Food and Drug Administration or the Florida Department of Health and approval for marketing has not, in fact, been given at the time such is furnished to you; or 2. such evaluation, treatment, therapy, or device is provided pursuant to a written protocol which describes as among its objectives the following: determinations of safety, efficacy, or efficacy in comparison to the standard evaluation, treatment, therapy, or device; or 3. such evaluation, treatment, therapy, or device is delivered or should be delivered subject to the approval and supervision of V Definitions 20 -7 an institutional review board or other entity as required and defined by federal regulations; or 4. credible scientific evidence shows that such evaluation, treatment, therapy, or device is the subject of an ongoing Phase I or II clinical investigation, or the experimental or research arm of a Phase III clinical investigation, or under study to determine: maximum tolerated dosage(s), toxicity, safety, efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the Condition in question; or 5. credible scientific evidence shows that the consensus of opinion among experts is that further studies, research, or clinical investigations are necessary to determine: maximum tolerated dosage(s), toxicity, safety, efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the Condition in question; or 6. credible scientific evidence shows that such evaluation, treatment, therapy, or device has not been proven safe and effective for treatment of the Condition in question, as evidenced in the most recently published Medical Literature in the United States, Canada, or Great Britain, using generally accepted scientific, medical, or public health methodologies or statistical practices; or 7. there is no consensus among practicing Physicians that the treatment, therapy, or device is safe and effective for the Condition in question; or 8. such evaluation, treatment, therapy, or device is not the standard treatment, therapy, or device utilized by practicing Physicians in treating other patients with the same or similar Condition. "Credible scientific evidence" shall mean (as determined by BCBSF or Monroe County BOCC): 1. records maintained by Physicians or Hospitals rendering care or treatment to you or other patients with the same or similar Condition; 2. reports, articles, or written assessments in authoritative medical and scientific literature published in the United States, Canada, or Great Britain; 3. published reports, articles, or other literature of the United States Department of Health and Human Services or the United States Public Health Service, including any of the National Institutes of Health, or the United States Office of Technology Assessment; 4. the written protocol or protocols relied upon by the treating Physician or institution or the protocols of another Physician or institution studying substantially the same evaluation, treatment, therapy, or device; 5. the written informed consent used by the treating Physician or institution or by another Physician or institution studying substantially the same evaluation, treatment, therapy, or device; or 6. the records (including any reports) of any institutional review board of any institution which has reviewed the evaluation, treatment, therapy, or device for the Condition in question. Note: Health Care Services which are determined by BCBSF or Monroe County BOCC to be Experimental or Investigational are excluded (see the "What Is Not Covered ?" section). In determining whether a Health Care Service is Experimental or Investigational, BCBSF or Monroe County BOCC may also rely on the predominant opinion among experts, as expressed in the published authoritative literature, that usage of a particular evaluation, treatment, therapy, or device should be substantially confined to research settings or that further studies are necessary in order to define safety, toxicity, Definitions 20 -8 effectiveness, or effectiveness compared with standard alternatives. FDA means the United States Food and Drug Administration. Foster Child means a person who is placed in your residence and care under the Foster Care Program by the Florida Department of Health & Rehabilitative Services in compliance with Florida Statutes or by a similar regulatory agency of another state in compliance with that state's applicable laws. Gamete Intrafallopian Transfer (GIFT) means the direct transfer of a mixture of sperm and eggs into the fallopian tube by a qualified health care provider. Fertilization takes place inside the tube. Generally Accepted Standards of Medical Practice means standards that are based on credible scientific evidence published in peer - reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations, and the views of Physicians practicing in relevant clinical areas and any other relevant factors. Gestational Surrogate means a woman, regardless of age, who contracts, orally or in writing, to become pregnant by means of assisted reproductive technology without the use of an egg from her body. Gestational Surrogacy Contract or Arrangement means an oral or written agreement, regardless of the state or jurisdiction where executed, between the Gestational Surrogate and the intended parent or parents. Group means the employer, labor union, trust, association, partnership, or corporation, department, other organization or entity through which coverage and benefits under this Benefit Booklet are made available to you, and through which you and your Covered Dependents become entitled to coverage and benefits for the Covered Services described herein. Group Health Plan or Group Plan means the plan established and maintained by Monroe County BOCC for the provision of health care coverage and benefits to the individuals covered under this Benefit Booklet. Health Care Services or Services includes treatments, therapies, devices, procedures, techniques, equipment, supplies, products, remedies, vaccines, biological products, drugs, pharmaceuticals, chemical compounds, and other services rendered or supplied, by or at the direction of, Providers. Home Health Agency means a properly licensed agency or organization which provides health services in the home pursuant to Chapter 400 of the Florida Statutes, or a similar applicable law of another state. Home Health Care or Home Health Care Services means Physician- directed professional, technical and related medical and personal care Services provided on an intermittent or part -time basis directly by (or indirectly through) a Home Health Agency in your home or residence. For purposes of this definition, a Hospital, Skilled Nursing Facility, nursing home or other facility will not be considered an individual's home or residence. Hospice means a public agency or private organization which is duly licensed by the State of Florida under applicable law, or a similar applicable law of another state, to provide hospice services. In addition, such licensed entity must be principally engaged in providing pain relief, symptom management, and supportive services to terminally ill persons and their families. Hospital means a facility properly licensed pursuant to Chapter 395 of the Florida Statutes, or a similar applicable law of another state, that: offers services which are more intensive than those required for room, board, personal services and general nursing care; offers facilities and beds for use beyond 24 hours; and V Definitions 20 -9 regularly makes available at least clinical laboratory services, diagnostic x -ray services and treatment facilities for surgery or obstetrical care or other definitive medical treatment of similar extent. The term Hospital does not include: an Ambulatory Surgical Center; a Skilled Nursing Facility; a stand -alone Birthing Center; a Psychiatric Facility; a Substance Abuse Facility; a convalescent, rest or nursing home; or a facility which primarily provides Custodial, educational, or Rehabilitative Therapies. Note: If services specifically for the treatment of a physical disability are provided in a licensed Hospital which is accredited by the Joint Commission on the Accreditation of Health Care Organizations, the American Osteopathic Association, or the Commission on the Accreditation of Rehabilitative Facilities, payment for these services will not be denied solely because such Hospital lacks major surgical facilities and is primarily of a rehabilitative nature. Recognition of these facilities does not expand the scope of Covered Services. It only expands the setting where Covered Services can be performed for coverage purposes. Identification (ID) Card means the card(s) issued to Covered Plan Participants under the BlueOptions Group Health Plan. The card is not transferable to another person. Possession of such card in no way guarantees that a particular individual is eligible for, or covered under, this Benefit Booklet. Independent Clinical Laboratory means a laboratory properly licensed pursuant to Chapter 483 of the Florida Statutes, or a similar applicable law of another state, where examinations are performed on materials or specimens taken from the human body to provide information or materials used in the diagnosis, prevention, or treatment of a Condition. Independent Diagnostic Testing Facility means a facility, independent of a Hospital or Physician's office, which is a fixed location, a mobile entity, or an individual non - Physician practitioner where diagnostic tests are performed by a licensed Physician or by licensed, certified non - Physician personnel under appropriate Physician supervision. An Independent Diagnostic Testing Facility must be appropriately registered with the Agency for Health Care Administration and must comply with all applicable Florida law or laws of the State in which it operates. Further, such an entity must meet BCBSF's criteria for eligibility as an Independent Diagnostic Testing Facility. In- Network means, when used in reference to Covered Services, the level of benefits payable to an In- Network Provider as designated on the Schedule of Benefits under the heading 1n- Network". Otherwise, In- Network means, when used in reference to a Provider, that, at the time Covered Services are rendered, the Provider is an In- Network Provider under the terms of this Booklet. In- Network Provider means any health care Provider who, at the time Covered Services were rendered to you, was under contract with BCBSF to participate in BCBSF's NetworkBlue and included in the panel of providers designated by BCBSF as "In- Network" for your specific plan. (Please refer to your Schedule of Benefits). For payment purposes under this Benefit Booklet only, the term In- Network Provider also refers, when applicable, to any health care Provider located outside the state of Florida who or which, at the time Health Care Services were rendered to you, participated as a BlueCard (Out -of- State) PPO Program Provider under the Blue Cross Blue Shield Association's BlueCard (Out -of- State) Program. Intensive Outpatient Treatment means treatment in which an individual receives at least 3 clinical hours of institutional care per day (24- hour period) for at least 3 days a week and Definitions 20 -10 returns home or is not treated as an inpatient during the remainder of that 24 -hour period. A Hospital shall not be considered a "home" for purposes of this definition. In Vitro Fertilization (IVF) means a process in which an egg and sperm are combined in a laboratory dish to facilitate fertilization. If fertilized, the resulting embryo is transferred to the woman's uterus. Licensed Practical Nurse means a person properly licensed to practice practical nursing pursuant to Chapter 464 of the Florida Statues, or a similar applicable law of another state. Massage Therapist means a person properly licensed to practice Massage, pursuant to Chapter 480 of the Florida Statutes, or a similar applicable law of another state. Massage or Massage Therapy means the manipulation of superficial tissues of the human body using the hand, foot, arm, or elbow. For purposes of this Benefit Booklet, the term Massage or Massage Therapy does not include the application or use of the following or similar techniques or items for the purpose of aiding in the manipulation of superficial tissues: hot or cold packs; hydrotherapy; colonic irrigation; thermal therapy; chemical or herbal preparations; paraffin baths; infrared light; ultraviolet light; Hubbard tank; or contrast baths. Mastectomy means the removal of all or part of the breast for Medically Necessary reasons as determined by a Physician. Medical Literature means scientific studies published in a United States peer- reviewed national professional journal. Medical Pharmacy Physician- administered Prescription Drugs which are rendered in a Physician's office. Medically Necessary or Medical Necessity means that, with respect to a Health Care Service, a Provider, exercising prudent clinical judgment, provided, or is proposing or recommending to provide the Health Care Service to you for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that the Health Care Service was /is: 1. in accordance with Generally Accepted Standards of Medical Practice; 2. clinically appropriate, in terms of type, frequency, extent, site of Service, duration, and considered effective for your illness, injury, or disease or symptoms; 3. not primarily for your convenience, your family's convenience, your caregiver's convenience or that of your Physician or other health care Provider, and 4. not more costly than the same or similar Service provided by a different Provider, by way of a different method of administration, an alternative location (e.g., office vs. inpatient), and /or an alternative Service or sequence of Services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your illness, injury, disease or symptoms. When determining whether a Service is not more costly than the same or similar Service as referenced above, we may, but are not required to, take into consideration various factors including, but not limited to, the following: a. the Allowed Amount for Service at the location for the delivery of the Service versus an alternate setting; b. the amount we have to pay to the proposed particular Provider versus the Allowed Amount for a Service by another Provider including Providers of the same and /or different licensure and /or specialty; and /or, c. an analysis of the therapeutic and /or diagnostic outcomes of an alternate Definitions 20 -11 treatment versus the recommended or performed procedure including a comparison to no treatment. Any such analysis may include the short and /or long -term health outcomes of the recommended or performed treatment versus alternate treatments including an analysis of such outcomes as the ability of the proposed procedure to treat comorbidities, time to disease recurrence, the likelihood of additional Services in the future, etc. Note: The distance you have to travel to receive a Health Care Service, time off from work, overall recovery time, etc. are not factors that we are required to consider when evaluating whether or not a Health Care Service is not more costly than an alternative Service or sequence of Services. Reviews we perform of Medical Necessity may be based on comparative effectiveness research, where available, or on evidence showing lack of superiority of a particular Service or lack of difference in outcomes with respect to a particular Service. In performing Medical Necessity reviews, we may take into consideration and use cost data which may be proprietary. It is important to remember that any review of Medical Necessity by us is solely for the purpose of determining coverage or benefits under this Booklet and not for the purpose of recommending or providing medical care. In this respect, we may review specific medical facts or information pertaining to you. Any such review, however, is strictly for the purpose of determining, among other things, whether a Service provided or proposed meets the definition of Medical Necessity in this Booklet as determined by us. In applying the definition of Medical Necessity in this Booklet, we may apply our coverage and payment guidelines then in effect. You are free to obtain a Service even if we deny coverage because the Service is not Medically Necessary; however, you will be solely responsible for paying for the Service. Medicare means the federal health insurance provided under Title XVIII of the Social Security Act and all amendments thereto. Medication Guide for the purpose of this Benefit Booklet means the guide then in effect issued by us where you may find information about Specialty Drugs, Prescription Drugs that require prior coverage authorization and Self - Administered Prescription Drugs that may be covered under this plan. Note: The Medication Guide is subject to change at any time. Please refer to our website at www.floridablue.com for the most current guide or you may call the customer service phone number on your Identification Card for current information. Mental Health Professional means a person properly licensed to provide mental health Services, pursuant to Chapter 491 of the Florida Statutes, or a similar applicable law of another state. This professional may be a clinical social worker, mental health counselor or marriage and family therapist. A Mental Health Professional does not include members of any religious denomination who provide counseling services. Mental and Nervous Disorder means any disorder listed in the diagnostic categories of the International Classification of Disease (ICD -9 CM or ICD 10 CM), or their equivalents in the most recently published version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, regardless of the underlying cause, or effect, of the disorder. Midwife means a person properly licensed to practice midwifery pursuant to Chapter 467 of the Florida Statutes, or a similar applicable law of another state. NetworkBlue means, or refers to, the preferred provider network established and so designated by BCBSF which is available to individuals covered under this Benefit Booklet. Please note Definitions 20 -12 that BCBSF's Preferred Patient Care (PPC) preferred provider network is not available to individuals covered under this Benefit Booklet. Occupational Therapist means a person properly licensed to practice Occupational Therapy pursuant to Chapter 468 of the Florida Statutes, or a similar applicable law of another state. Occupational Therapy means a treatment that follows an illness or injury and is designed to help a patient learn to use a newly restored or previously impaired function. Orthotic Device means any rigid or semi -rigid device needed to support a weak or deformed body part or restrict or eliminate body movement. Out -of- Network means, when used in reference to Covered Services, the level of benefits payable to an Out -of- Network Provider as designated on the Schedule of Benefits under the heading "Out -of- Network ". Otherwise, Out - of- Network means, when used in reference to a Provider, that, at the time Covered Services are rendered, the Provider is not an In- Network Provider under the terms of this Booklet. Out -of- Network Provider means a Provider who, at the time Health Care Services were rendered: 1. did not have a contract with us to participate in NetworkBlue but was participating in our Traditional Program; or 2. did not have a contract with a Host Blue to participate in its local PPO Program for purposes of the BlueCard (Out -of- State) PPO Program but was participating, for purposes of the BlueCard (Out -of- State) Program, as a BlueCard (Out -of- State) Traditional Program Provider; or 3. did have a contract to participate in NetworkBlue but was not included in the panel of Providers designated by us to be In- Network for your Plan; or 4. did not have a contract with us to participate in NetworkBlue or our Traditional Program; or 5. did not have a contract with a Host Blue to participate for purposes of the BlueCard (Out -of- State) Program as a BlueCard (Out - of State) Traditional Program Provider. Outpatient Rehabilitation Facility means an entity which renders, through providers properly licensed pursuant to Florida law or the similar law or laws of another state: outpatient physical therapy; outpatient speech therapy; outpatient occupational therapy; outpatient cardiac rehabilitation therapy; and outpatient Massage for the primary purpose of restoring or improving a bodily function impaired or eliminated by a Condition. Further, such an entity must meet BCBSF's criteria for eligibility as an Outpatient Rehabilitation Facility. The term Outpatient Rehabilitation Facility, as used herein, shall not include any Hospital including a general acute care Hospital, or any separately organized unit of a Hospital, which provides comprehensive medical rehabilitation inpatient services, or rehabilitation outpatient services, including, but not limited to, a Class III "specialty rehabilitation hospital" described in Chapter 59A, Florida Administrative Code or the similar law or laws of another state. Pain Management includes, but is not limited to, Services for pain assessment, medication, physical therapy, biofeedback, and /or counseling. Pain rehabilitation programs are programs featuring multidisciplinary Services directed toward helping those with chronic pain to reduce or limit their pain. Partial Hospitalization means treatment in which an individual receives at least 6 clinical hours of institutional care per day (24 -hour period) for at least 5 days per week and returns home or is not treated as an inpatient during the remainder of that 24 -hour period. A Hospital shall not be considered a "home" for purposes of this definition. V Definitions 20 -13 Physical Therapy means the treatment of disease or injury by physical or mechanical means as defined in Chapter 486 of the Florida Statutes or a similar applicable law of another state. Such therapy may include traction, active or passive exercises, or heat therapy. Physical Therapist means a person properly licensed to practice Physical Therapy pursuant to Chapter 486 of the Florida Statutes, or a similar applicable law of another state. Physician means any individual who is properly licensed by the state of Florida, or a similar applicable law of another state, as a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of Chiropractic (D.C.), Doctor of Dental Surgery or Dental Medicine (D.D.S. or D.M.D.), or Doctor of Optometry (O.D.). Physician Assistant means a person properly licensed pursuant to Chapter 458 of the Florida Statutes, or a similar applicable law of another state. Physician Specialty Society means a United States medical specialty society that represents diplomates certified by a board recognized by the American Board of Medical Specialties. Post - Service Claim means any paper or electronic request or application for coverage, benefits, or payment for a Service actually provided to you (notjust proposed or recommended) that is received by us on a properly completed claim form or electronic format acceptable to us in accordance with the provisions of this section. Pre - Service Claim means any request or application for coverage or benefits for a Service that has not yet been provided to you and with respect to which the terms of the Benefit Booklet condition payment for the Service (in whole or in part) on approval by us of coverage or benefits for the Service before you receive it. A Pre - Service Claim may be a Claim Involving Urgent Care. As defined herein, a Pre - Service Claim shall not include a request for a decision or opinion by us regarding coverage, benefits, or payment for a Service that has not actually been rendered to you if the terms of the Benefit Booklet do not require (or condition payment upon) approval by us of coverage or benefits for the Service before it is received. Prescription Drug means any medicinal substance, remedy, vaccine, biological product, drug, pharmaceutical or chemical compound which can only be dispensed with a Prescription and /or which is required by state law to bear the following statement or similar statement on the label: "Caution: Federal law prohibits dispensing without a Prescription ". Preventive Services Guide means the guide then in effect issued by us that contains a listing of Preventive Health Services covered under your plan. Note: The Preventive Services Guide is subject to change Please refer to our website at www.FloridaBlue.com /healthresources for the most current guide. Prosthetist /Orthotist means a person or entity that is properly licensed, if applicable, under Florida law, or a similar applicable law of another state, to provide services consisting of the design and fabrication of medical devices such as braces, splints, and artificial limbs prescribed by a Physician. Prosthetic Device means a device which replaces all or part of a body part or an internal body organ or replaces all or part of the functions of a permanently inoperative or malfunctioning body part or organ. Provider means any facility, person or entity recognized for payment by BCBSF under this Booklet. Provider Incentive means an additional amount of compensation paid to a health care Provider by a Blue Cross and /or Blue Shield Plan, based on the Provider's compliance with agreed -upon V Definitions 20 -14 procedural and /or outcome measures for a particular population of covered persons. Psychiatric Facility means a facility properly licensed under Florida law, or a similar applicable law of another state, to provide for the Medically Necessary care and treatment of Mental and Nervous Disorders. For purposes of this Booklet, a psychiatric facility is not a Hospital or a Substance Abuse Facility, as defined herein. Psychologist means a person properly licensed to practice psychology pursuant to Chapter 490 of the Florida Statutes, or a similar applicable law of another state. Registered Nurse means a person properly licensed to practice professional nursing pursuant to Chapter 464 of the Florida Statutes, or a similar applicable law of another state. Registered Nurse First Assistant (RNFA) means a person properly licensed to perform surgical first assisting services pursuant to Chapter 464 of the Florida Statutes or a similar applicable law of another state. Rehabilitation Services means Services for the purpose of restoring function lost due to illness, injury or surgical procedures including but not limited to cardiac rehabilitation, pulmonary rehabilitation, Occupational Therapy, Speech Therapy, Physical Therapy and Massage Therapy. Rehabilitative Therapies means therapies the primary purpose of which is to restore or improve bodily or mental functions impaired or eliminated by a Condition, and include, but are not limited to, Physical Therapy, Speech Therapy, Pain Management, pulmonary therapy or Cardiac Therapy. Residential Treatment Facility means a facility properly licensed under Florida law or a similar applicable law of another state, to provide care and treatment of Mental and Nervous Disorders and Substance Dependency and meets all of the following requirements: • Has Mental Health Professionals on -site 24 hours per day and 7 days per week; • Provides access to necessary medical services 24 hours per day and 7 days per week; • Provides access to at least weekly sessions with a behavioral health professional fully licensed for independent practice for individual psychotherapy; • Has individualized active treatment plan directed toward the alleviation of the impairment that caused the admission; • Provides a level of skilled intervention consistent with patient risk; • Is not a wilderness treatment program or any such related or similar program, school and /or education service. With regard to Substance Dependency treatment, in addition to the above, must meet the following: • If Detoxification Services are necessary, provides access to necessary on -site medical services 24 hours per day and 7 days per week, which must be actively supervised by an attending physician; • Ability to assess and recognize withdrawal complications that threaten life or bodily function and to obtain needed Services either on site or externally; • Is supervised by an on -site Physician 24 hours per day and 7 days per week with evidence of close and frequent observation Residential Treatment Services means treatment in which an individual is admitted by a Physician overnight to a Hospital, Psychiatric Hospital or Residential Treatment Facility and receives daily face to face treatment by a Mental Health Professional for at least 8 hours per day, V Definitions 20 -15 each day. The Physician must perform the admission evaluation with documentation and treatment orders within 48 hours and provide evaluations at least weekly with documentation. A multidisciplinary treatment plan must be developed within 3 days of admission and must be updated weekly. Self- Administered Prescription Drug means an FDA - approved Prescription Drug that you may administer to yourself, as recommended by a Physician. Skilled Nursing Facility means an institution or part thereof which meets BCBSF's criteria for eligibility as a Skilled Nursing Facility and which: 1) is licensed as a Skilled Nursing Facility by the state of Florida or a similar applicable law of another state; and 2) is accredited as a Skilled Nursing Facility by the Joint Commission on Accreditation of Healthcare Organizations or recognized as a Skilled Nursing Facility by the Secretary of Health and Human Services of the United States under Medicare, unless such accreditation or recognition requirement has been waived by BCBSF. Sound Natural Teeth means teeth that are whole or properly restored (restoration with amalgams, resin or composite only); are without impairment, periodontal, or other conditions; and are not in need of Services provided for any reason other than an Accidental Dental Injury. Teeth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated with endodontics, are not Sound Natural Teeth. Specialty Drug means an FDA - approved Prescription Drug that has been designated, solely by us, as a Specialty Drug due to special handling, storage, training, distribution requirements and /or management of therapy. Specialty Drugs may be Provider administered or self - administered and are identified with a special symbol in the Medication Guide. Specialty Pharmacy means a Pharmacy that has signed a Participating Pharmacy Provider Agreement with us to provide specific Prescription Drug products, as determined by us. In- Network Specialty Pharmacies are listed in the Medication Guide. Speech Therapy means the treatment of speech and language disorders by a Speech Therapist including language assessment and language restorative therapy services. Speech Therapist means a person properly licensed to practice Speech Therapy pursuant to Chapter 468 of the Florida Statutes, or a similar applicable law of another state. Stabilize means, with respect to an emergency medical condition described above, to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during. 1) A the transfer of the individual from a facility; or, 2) with respect to an emergency medical condition as described above. Standard Reference Compendium means: 1) the United States Pharmacopoeia Drug Information; 2) the American Medical Association Drug Evaluation; or 3) the American Hospital Formulary Service Hospital Drug Information. Substance Abuse Facility means a facility properly licensed under Florida law, or a similar applicable law of another state, to provide necessary care and treatment for Substance Dependency. For the purposes of this Booklet a Substance Abuse Facility is not a Hospital or a Psychiatric Facility, as defined herein. Substance Dependency means a Condition where a person's alcohol or drug use injures his or her health; interferes with his or her social or economic functioning; or causes the individual to lose self - control. V Definitions 20 -16 Traditional Program means, or refers to, BCBSF's provider contracting programs called Payment for Physician Services (PPS) and Payment for Hospital Services (PHS). For purposes of this Benefit Booklet, the term Traditional Program also refers, when applicable, to the traditional Provider contracting programs of other Blue Cross and /or Blue Shield organizations as designated under the Blue Cross and Blue Shield Association's BlueCard Program. Traditional Program Providers means, or refers to, those health care Providers who are not NetworkBlue Providers, but who, or which, at the time you received Services from them were participating in the Traditional Program. For purposes of payment under this Benefit Booklet only, the term Traditional Program Provider also refers, when applicable, to any health care Provider located outside the state of Florida who or which, at the time Health Care Services were rendered to you, participated as a BlueCard Traditional Provider under the Blue Cross and Blue Shield Association's BlueCard Program Traditional Program Providers are considered out of network for benefit calculation purposes; however, does not balance bill the member. Urgent Care Center means a facility properly licensed that: 1) is available to provide Services to patients at least 60 hours per week with at least twenty -five (25) of those available hours after 5:00 p.m. on weekdays or on Saturday or Sunday; 2) posts instructions for individuals seeking Health Care Services, in a conspicuous public place, as to where to obtain such Services when the Urgent Care Center is closed; 3) employs or contracts with at least one or more Board Certified or Board Eligible Physicians and Registered Nurses (RNs) who are physically present during all hours of operation. Physicians, RNs, and other medical professional staff must have appropriate training and skills for the care of adults and children; and 4) maintains and operates basic diagnostic radiology and laboratory equipment in compliance with applicable state and /or federal laws and regulations. For purposes of this Benefit Booklet, an Urgent Care Center is not a Hospital, Psychiatric Facility, Substance Abuse Facility, Skilled Nursing Facility or Outpatient Rehabilitation Facility. Value -Based Program means an outcomes - based payment arrangement and /or a coordinated care model facilitated with one or more local Providers that is evaluated against cost and quality metrics /factors and is reflected in Provider payment. Waiting Period means the length of time established by Monroe County BOCC which must be met by an individual before that individual becomes eligible for coverage under this Benefit Booklet. Zygote Intrafallopian Transfer (ZIFT) means a process in which an egg is fertilized in the laboratory and the resulting zygote is transferred to the fallopian tube at the pronuclear stage (before cell division takes place). The eggs are retrieved and fertilized on one day and the zygote is transferred the following day. Definitions 20 -17 Domestic Partner Coverage Endorsement This Endorsement is to be attached to and made a part of the current Benefit Booklet and any Endorsements attached thereto. The Benefit Booklet is amended as described below to provide coverage for a Domestic Partner of a Covered Employee (employee only) and, if applicable, the dependent child(ren) of a Domestic Partner. Glossary of Terms Domestic Partner means a person of the same or opposite sex with whom the Covered Employee (employee only) has established a Domestic Partnership. 6. the Covered Employee has completed and submitted any required forms to the Group and the Group has determined the Domestic Partnership eligibility requirements have been met. Eligibility for Coverage Domestic Partner and Dependent Children) of Domestic Partners Eligibility The following individuals are eligible to apply for coverage under the Benefit Booklet: 1. the Covered Employee's (employee only) present Domestic Partner; Domestic Partnership means a relationship between a Covered Employee (employee only) and one other person of the same or opposite sex who meet at a minimum, the following eligibility requirements: 1. both individuals are each other's sole Domestic Partner and intend to remain so indefinitely; 2. individuals are not related by blood to a degree of closeness (e.g., siblings) that would prohibit legal marriage in the state in which they legally reside; 3. both individuals are unmarried, at least 18 years of age, and are mentally competent to consent to the Domestic Partnership; 4. both individuals are financially interdependent and have resided together continuously in the same residence for at least six months prior to applying for coverage under the Benefit Booklet and intend to continue to reside together indefinitely; 5. the Covered Employee has submitted to the Group acceptable proof of evidence of common residence and joint financial responsibility; and 2. the Covered Domestic Partner's dependent child(ren), who is under the limiting age, who meets all of the following eligibility requirements, and the eligibility requirements under the Benefit Booklet: a. resides regularly with the Covered Employee and the Domestic Partner, or the Domestic Partner is required to provide coverage for the child(ren) by court order; or b. the child(ren) qualifies as the Domestic Partner's dependent(s) for tax purposes under the federal guidelines; and c. the child(ren) meets and continues to meet the eligibility requirements as outlined in the Eligibility Requirements for Dependent(s) subsection of the Benefit Booklet. Domestic Partner Enrollment Forms/ Electing Coverage When an Eligible Employee is making application for coverage for his /her Domestic Partner and the Domestic Partner's dependent child(ren), the Eligible Employee must complete ASO Dom Part with Dep END Plan 03559 and submit through the Group any required Enrollment Forms. When an Eligible Employee is electing coverage for his /her self and his /her Domestic Partner, and Employee /Spouse Coverage is available under the Group's program, Employee /Spouse Coverage is redefined as Employee /Domestic Partner Coverage. Domestic Partner Enrollment Periods An Eligible Employee may make application for an eligible Domestic Partner and the Domestic Partner's dependent child(ren) during the following enrollment periods and as outlined in the Benefit Booklet: 1. employee's Initial Enrollment Period; 2. Annual Open Enrollment Period; 3. Special Enrollment Period; or 4. within the 30 -day period immediately following the satisfaction of the eligibility requirements of the Domestic Partnership. Termination of a Domestic Partner's and /or Domestic Partner's Dependent Child(ren)'s Coverage In addition to the provisions stated in the Termination of a Covered Dependent's Coverage subsection of the Benefit Booklet, the Covered Domestic Partner's and the Covered Domestic Partner's Covered Dependent child(ren)'s coverage under the Benefit Booklet will terminate at 12:01 a.m. on the date that the Domestic Partnership terminates or the date of death of the Covered Domestic Partner. The Covered Employee must notify the Group within 30 days of when Domestic Partnership eligibility requirements are no longer met or within 30 days of the death of the Covered Domestic Partner. COBRA Continuation of Coverage Covered Domestic Partners are not entitled to COBRA continuation of coverage but are eligible under Monroe County employment /personnel rules to apply for continuation of coverage under the MCBCC Group Health Plan. Miscellaneous The term Eligible Dependent is modified to also include the reference to Domestic Partner when spouse is referenced. This Endorsement shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions, limitations, or conditions contained in the Benefit Booklet, other than as specifically stated in the provisions contained in this Endorsement. In the event of any inconsistencies between the provisions contained in this Endorsement and the provisions contained in the Benefit Booklet, the provisions contained in this Endorsement shall control to the extent necessary to effectuate the intent as expressed herein. Serviced By Blue Cross and Blue Shield of Florida, Inc. ASO Dom Part with Dep END Plan 03559 2 Company: MONROE COUNTY BOCC Croup: B0611 Current Service Period: From 10 ?2015 to' €2x'20117 Current Paid Period: From 1012015 to 1212017 C.7.e I This Florida Blue report is proprietary and confidential. Report Run: 01/16/2018 2:06 PM Page 1 of 1 Oct2015 $520,204.62 $520,204.62 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 Nov2015 $964,534.70 $546,500.78 $418,033.92 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 Dec2015 $1,067,587.00 $35,678.84 $494098.22' $537,809.94 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 Jan2016 $725,906.40 $9,468.92 $44,934.67 $270,081.09 $401,421.72 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.0 Feb2016 $815,683.43 $9,801.00 $26865.33' $60,029.02 $351,076.94 $367,911.14 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.0 Mar2016 $1,255,904.80 $9,858.33 $3795.16'. $54,071.39 $30,214.12 $511,918.73 $646,047.07 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 Apr2016 $758,747.26 $8,239.70 $11,464.49 $660.90 $14,471.70 $27,361.32 $349,034.83 $347,514.32 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 May2016 $1,193,121.75 ($718.92) $2092.97' ($1,933.70) $8,403.52 $14696.35 $140,390.56 $562,352.48 $467,838.49 $0.00 $0.00 $0.00 $0.00 $O.0 Jun2016 $1,254,088.64 ($145.82) ($1,584.32)' $499.58 $397,027.07 $10728.98 $40,844.06 $30,356.73 $343,489.85 $432,872.51 $0.00 $0.00 $0.00 $O.0 Ju12016 $1,077,679.99 ($943.94) $37,364.03 ($8,680.48) ($7,954.80) ($6,052.55) $3,255.13 $8,952.54 $63,552.40 $472,550.18 $515,637.48 $0.00 $0.00 $O.0 Aug2016 $1,361,595.74 $4,624.85 $3241.65' $12,370.16 $6,490.62 $7975.47' $5,194.23 $2,526.80 $11,869.75 $364,340.03 $403,707.17 $539,255.01 $0.00 $O.0 Sep2016 $1,066,264.49 $154.10 $5739.68' ($2,583.60) $778.02 $8056.04 $179.92 $8,729.51 $51,295.18 $11,302.04 $49,184.00 $497,439.43 $435,990.17 $O.0 Oct2016 $958,735.50 $0.00 ($2,397.53)', ($467.28) $3,828.30 $804.64 $1,090.05 $3,639.92 $2,624.88 $36,844.15 $9,211.97 $81,415.73 $337,313.25 $484,827.4 Nov2016 $1,066,196.92 $53.20 $1346.70' $628.09 $2,664.86 $81.92 $654.59 $797.67 $1,427.64 $4,750.05 $2,187.34 $18,788.06 $61,221.10 $441,795 Dec2016 $1,307,718.63 $228.76 $776.23' $125.17 $1,217.51 $394.88 $31.91 ($342.00) $390.65 $2,581.91 $8,122.69 $207,631.00 $19,306.01 $49,118.E Jan2017 $1,278,220.18 $0.00 $0.00' $407.19 $33.31 ($403.98) $350.26 $1,312.67 $1,447.86' ($3,556.59) $23,682.98 $4,176.29 $20,989.98 $39,629.1 Feb2017 $307,643.06 $6.19 $19.08' $527.53 $264.68 $5.73 $1,402.13 $167.46 $369.63 $8,493.45 $3,580.31 $2,860.99 $10,657.32 $18,149.7 Mar2017 $1,662,471.63 $147.00 $0.00' $1,911.37 $102.96 $443.75' $67.80 $21,604.69 $1,240.56' $188.33 $196.17 $172,051.51 $21,253.08 $9,476.0 Apr2017 $1,117,881.58 $701.61 $156.00' $394.91 $757.75 $3310.96 $761.30 $730.39 $773.02 $1,384.87 $10,071.68 $569.47 ($2,690.29) $534.7 May2017 $1,185,342.50 $0.00 $38.37' $16.68 $0.00 $20.65 $0.00 $359.46 $268.37 $1,479.73 $18.04 $181.42 $1,865.29 $726.2 Jun2017 $1,205,645.46 $0.00 $0.00' $0.00 $0.00 $55.09 $148.46 $0.00 $40.41 $863.94 $1,615.68 $589.11 $6,462.65 $8,605.E Ju12017 $955,813.63 $0.00 $0.00' $0.00 $0.00 $0.00 $12.72 $0.00 ($90.44) $329.50 $172.06 $4,378.04 $4,630.75 $63.E Aug2017 $1,258,515.10 $0.00 $0.00' $12.36 $0.00 $0.00 $22.38 $0.00 ($76.15) $9,811.08 ($317.78) $0.00 $119.28 $8,603.4 Sep2017 $565,955.21 $0.00 $0.00' $0.00 $18.46 $1214.18 $185.49 $3,034.79 $90.27 ($649.10) $0.00 $26.59 $391.24 ($52.9" Oct2017 $925,654.43 ($1,042.18) $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $4,633.04 $23.03 $14.11 $0.00 ($120.71) $1,632.2 Nov2017 $764,306.60 $0.00 $0.00' ($6,578.07) $0.00 ($47.25) $0.00 $0.00 $0.00 $117.00 ($118.78 ) $76.57 $0.00 ($7,240.4: Dec2017 $975,413.56 $0.00 $0.00' $0.00 $0.00 $0.00 $196.96 $0.00 $0.00 $0.00 ($1,030.23) $204.65 ($112.87) $4,826.7 Total $27,596,832.81 $1,142,817.04 $1,045,984.65' $919,302.25 $1,210,816.74 $948,476.05' $1,189,869.85 $991,737.43 $951,185.41 $1,343,726.11 $1,025,934.89 $1,529,643.87 $917,276.25 $1,060,696.E Nate: Excludes Pharmacy and Capitation Data I This Florida Blue report is proprietary and confidential. Report Run: 01/16/2018 2:06 PM Page 1 of 1 Oct2015 Nov2015 Dec2015 Jan2016 Feb2016 Mar2016 Apr2016 May2016 Jun2016 Ju12016 Aug2016 Sep2016 Oct2016 Nov2016 Dec2016 Jan2017 Feb2017 Mar2017 Apr2017 May2017 Jun2017 Ju12017 Aug2017 Sep2017 Oct2017 Nov2017 $0.00 Dec2017 $0.00: ...... Total $0.00 Note: Excludes Medical and Capitation Data mommmommm $0.00', $0.00', $0.00', $0.00', $0.00 $0.00', $0.00', $0.00', $o.c $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 A $0.00 $0.00 $0.00' $0.00 $0.00r $0.00' $0.00 $0.00' $O.0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 F $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 $0.00'. $0.00'. $0.00'. $0.00 $0.001 $0.00'. $0.00. $0.00'. $O.0 $0.00 $O.OD $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 .` $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 E- $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.c W $0.00 $0.00' $0.00' $0.00 $0.00: $0.00' $0.00 $0.00' $O.0 J $0.00 $O.OD $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 $0.00 $O.OD $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 z w $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 sox $0.00 ......... $0.00 $0.00 $0.00 $0.00 ...... ...... $0.00 $O.0 J $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 mi $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 J $0.00 $0.00' $0.00' $0.00 $0.001 $0.00' $0.00 $0.00' $O.0 U $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 $0.00 $O.OD $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 W $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 ' $0.00 $O.OD' $0.00' $0.00 $0.00` $0.00' $0.00 $0.00' $O.0 $0.00 $O.OD $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 $0.00 $O.OD $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 U $0.00 $O.OD $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $O.0 $0.00 $O.OD $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $o.c $0.00 $O.OD ' $0.00' $0.00 $0.00 $0.00' $0.00 $0.00' $O.0 N $0.00 $0.00' $0.00' $0.00 $0.00 $0.00' $0.00 $0.00' $0.0 Z.; c E s C! Q This Florida Blue report is proprietary and confidential. Report Run: 01/16/2018 2:06 PM Page 1 oft $O.0 $O.0 r $O.0 $O.0 +n $O.0 $O.0 $O.0 $O.0 O $0.0 ? $O.0 E— $O.0 Uj $484,827.4 J $441,7955 O $49118.8 $39,629.1 $18,149.7 J $9,476.0 U) $534.7 $726.2 U $8,605.E $63.E $8,603.4 UJ ($52.9; $1,632.2 ($7,240.4: z $4,826.7 $1,060,696.8 F F 4 r N c .0 ct Q This Florida Blue report is proprietary and confidential. Report Run: 01/16/2018 2:06 PM Page 1 of 1 C.7.e This Florida Blue report is proprietary and confidential. 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Report Run: 01/16/2018 2:06 PM Pagel of 1 $0.00 $0.00' $0.00 $0.00' $0.00' $0.00' $0.00'; $0.00' $0.00' $0.00' $0.00'; $0.00 $0.00' $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $529,799.78 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00', $0.00 $0.00 $0.00' $0.00 $0.00 $0.00 $0.00' $417,456.55 $600,678.47 $0.00 $0.00 $0.00 $0.00 $0.00', $0.00 $0.00 $0.00', $0.00 $0.00 $0.00 $0.00' $136,757.76 $693,753.05 $359,640.22 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00' $0.00' $20,839.58 $52,647.89 $120,223.21 $67,428.18 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00' $0.00' $42,354.17 $9,014.14 $346,251.23 $619,227.36 $416,941.44 $0.00 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00' $0.00' $7,662.09 $20,183.20 $17,369.70 $26,456.82 $585,468.80 $443,284.53 $0.00 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00' $0.00' $11,514.93 $2,144.10 $1,179.87 $12,559.00 $151,319.68 $620,128.43 $381,522.23 $0.00 $0.00 $0.00' $0.00 $0.00 $0.00' $0.00' $1,324.90 $2,073.34 $7,265.76 $19,056.67 $8,688.88 $38,619.48 $641,777.92' $468,457.49 $0.00 $0.00' $0.00 $0.00 $0.00' $0.00' $208.84 $11,554.31 $14,444.22 $27,187.27 $17,119.00 $47,884.11 $99,102.44' $370,751.63 $358,065.33 $0.00 $0.00 $0.00 $0.00' $0.00' $1,378.98 ($1,037.28) $2,631.59 $93.80 $2,790.61 $291,346.49 $13,428.27' $29,675.01 $390,067.81 $509,965.18' $0.00 $0.00 $0.00' $0.00' $1,294.25 ($149.32) $1,352.93 ($29.01) $1,319.57 $1,082.89 $9,912.33' $9,740.43 $33,758.89 $341,125.34' $162,287.96 $0.00 $0.00' $0.00' $189.22 $584.86 $1,865.47 $1,283.17 $2,833.31 $1,289.58 $29,458.37'. $4,534.27 $54,461.27 $177,833.40'. $313,773.16 $332,408.82 $0.00' $0.00'. $360.88 $310.34 ($1,554.65) $8,809.64 $2,897.79 $219.82 $11,071.49' $4,864.80 $5,797.72 $55,947.69' $37,154.96 $235,716.48 $416,500.60' $0.00' $1,187.95 $177.67 $1,759.80 $757.65 ($13.41) $1,623.03 ($7,921.75)', $1,313.69 ($3,820.26) $28,650.56' $18,544.02 $101,671.65 $489,644.61' $337,753.06' $1,172,329.88 $1,391,934.77 $872,429.35 $782,830.55 $1,189,365.67 $1,445,478.36 $1,178,351.30' $889,337.32 $838,330.76 $1,113,522.17' $531,760.10 $669,796.95 $906,145.21' $337,753.06' This Florida Blue report is proprietary and confidential. Report Run: 01/16/2018 2:06 PM Pagel of 1 C.7.f High Cost Claims Detail w Company: MONROE COUNTY BOCCGroup: B0611High Cost Claims Threshold: 50000CUrrent Service Period: From 10/2016 to 12 /2017CUrrent Paid Period: From 01/2017 to 1212017 Member ID Paid Date Service Date Received Date Procedure [ode Procedure Desc Dgns Cade Dgns Desc Utilization Dose Patient Patient Di! Paid Am[ Billed Amt Mbr Gendi Relationship Div Subr Location RX Drug Product Name Praduc[ Plan Code � Admt Date yj 1/4/2017 12/24/2016 1/3/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, ZO1818 ENCOUNTER FOR OTHER PROFESSIONAL $1].59 $42.00 FEMALE SUBSCRIBER 1 CCC 3559 FRONTAL AND LATERAL; PREPROCEDURAL OUTPATIENT /HOSPITAL EXAMINATION 1/4/2017 12/27/2016 12/30/2016 * * * ** " " " "" * * " ** " " " *" " " " "" $1,056.00 $2,218.04 FEMALE SUBSCRIBER 1 CCC 3559 1/5/2017 12/27/2016 1/4/2017 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING N17989 OTHER SPECIFIED SOFT PROFESSIONAL $58.38 $142.00 FEMALE SUBSCRIBER 1 CCC 3559 RESPONSES TO COMPRESSION AND OTHER MANEUVERS; TISSUE DISORDERS DUTPATIENT /HOSPITAL COMPLETE BILATERAL STUDY 1/5/2017 12/28/2016 1/3/2017 - - C50912 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $3,991.93 $3,991.93 FEMALE SUBSCRIBER 1 CCC 3559 } OF UNSPECIFIED SITE OF a LEFT FEMALE BREAST Q, 1/9/2017 12/30/2016 1/5/2017 * * * ** *' *** * * * ** fk #fii *' * ** $888.00 $3,134.48 FEMALE SUBSCRIBER 1 CCC 3559 Q, 1/27/2017 12/1/2016 12/8/2016 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $89.24 $219.98 FEMALE SUBSCRIBER 1 CCC 3559 OR DIAGN0515(SPECIFY SUBSTANCE OR DRUG); OF LOWER -INNER ADDITIONAL SEQUENTIAL INFUSION OFA NEW QUADRANT OF LEFT DRUG /SUBSTANCE, UPT01 HOUR (LISTSEPARATELY IN FEMALE BREAST rf ADDITION TO CODE FOR PRIMARY PROCEDURE) F 112712017 12/1/2016 12/8/2016 96375 Therapeutic, prophylactic, or diagnostic injection (specify C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $31.17 $76.85 FEMALE SUBSCRIBER 1CCC 3559 UJI subs tanc eord rug);eachadditionalsequential intravenous OF LOWER -INNER h push ofa new substance /dr,g(Lint separately In a ddlion QUADRANT OF LEFT D to code for ori,,, oroced urel FEMALE BREAST 1/27/2017 12/1/2016 12/8/2016 91,413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $200.46 $494.20 FEMALE SUBSCRIBER 1 CCC 3559 INFUSION TEC HNIQUE ; UPTO I HOUR, SINGLEOR INITIAL OF LOWER -INNER SUBSTANCE /DRUG QUADRANT OF LEFT 1/27/2017 12/1/2016 12/8/2016 96417 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C50312 FEMALE BREAST MALIGNANT NEOPLASM PROFESSIONAL OFFICE $99.28 $244.77 FEMALE SUBSCRIBER 1 CCC 3559 IL INFUSIDNTECHNIQUE; EACH ADDITIONAL SEQUENTIAL OF LOWER -INNER INFUSION (DIFFERENT SUBSTANCE /DRUG), LETO 1 HOUR QUADRANT OF LEFT HUSTSEPARATELY IN ADDITION TO CODE FOR PRIMARY FEMALE BREAST PRDCEDIIRFI 1/27/2017 12/1/2016 12/8/2016 J1100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, I MG C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.30 $3.20 FEMALE SUBSCRIBER 1 CCC 3559 OF LOWER -INNER J QUADRANT OF LEFT W FEMALE BREAST 1/27/2017 12/1/2016 12/8/201611200 INJECTION, DIPHENHYDRAMINE HCL, UPT050MG C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.55 $3.35 FEMALE SUBSCRIBER 1 CCC 3559 OF LOWER INNER QUADRANT OF LEFT J FEMALE BREAST 1/27/2017 12/1/2016 12/8/2016 J2469 PALONOSETRDN HCL C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $192.60 $594.40 FEMALE SUBSCRIBER 1 CCC 3559 (, OF LOWER -INNER QUADRANT of LEFT FEMALE BREAST W 1/27/2017 12/1/2016 12/8/2016 J9070 CYCLOPHOSPHAMIDE, 100 MG C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $668.70 $827.40 FEMALE SUBSCRIBER 1CCC 3559 OF LOWER -INNER QUADRANT OF LEFT U FEMALE BREAST F 1/27/2017 12/1/2016 12/8/2016 J9171 INJECTION, DDCETAXEH I MG CS0312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $8,358.00 FEMALE SUBSCRIBER 1CCC 3559 OF LOWER -INNER QUADRANT OF LEFT N FEMALE BREAST fy 1/30/2017 1/3/2017 1/6/2017 - - C50312 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $340.49 $1,565.52 FEMALE SUBSCRIBER 1 CCC 3559 OF LOWER INNER C QUADRANT OF LEFT 03 FEMALE BREAST 1/30/2017 1/12/2017 1/16/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1,989.84 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF LOWER -INNER 1 CCC $0.00 PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY QUADRANT OF LEFT 1 CCC $0.00 COMPONENTS: AN EXPANDED PROBLEM FOCUSED FEMALE BREAST 1 CCC $300.41 HISTORY; AN EXPANDED PROBLEM FOCUSED SUBSCRIBER 1 CCC EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 1/30/2017 1/16/2017 1/17/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R05 COUGH PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 21112017 1/9/2017 1/27/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1069 ACUTE UPPER OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED RESPIRATORY INFECTION, PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY UNSPECIFIED COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 2/9/2017 12/24/2016 2/7/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 ZO1818 ENCOUNTER FOR OTHER PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY PREPROCEDURAL OUTPATIENT /HOSPITAL EXAMINATION 2/13/2017 1/25/2017 2/7/2017 19307 MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILIARY C50312 MALIGNANT NEOPLASM PROFESSIONAL LYMPH NODES, WITH OR WITHOUT PECTORALS MINOR OF LOWER INNER OUTPATIENT /HOSPITAL MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE QUADRANT OF LEFT FEMALE BREAST 2/20/2017 1/25/2017 2/15/20173260F REPAIR OF LOW IMPERFORATE ANUS; WITH AN0PERINEAL C50912 MALIGNANT NEOPLASM PROFESSIONAL FISTULA ( "CUT - BACK" PROCEDURE) OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL LEFT FEMALE BREAST 2/20/2017 1125/2017 2/15/20173395F QUANTITATIVE NON -HER2 IMMUN0HIST0CHEMISTRY C50912 MALIGNANT NEOPLASM PROFESSIONAL (IHC) EVALUATION OF BREAST CANCER(EG, TESTING FOR OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL ESTROGEN OR PROGESTERONE RECEPTORS AER /PRA ") LEFT FEMALE BREAST PERFORMED (PATH) 2/20/2017 1/25/2017 2/15/2017 88307 LEVELV- SURGICAL PATHOLOGY, GROSS AND C50912 MALIGNANT NEOPLASM PROFESSIONAL MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENT(S), PATHOLOGIC LEFT FEMALE BREAST FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT 2/20/2017 1/25/2017 2115/2017 88309 LEVELVI- SURGICAL PATHOLOGY, GROSS AND C50912 MALIGNANT NEOPLASM PROFESSIONAL MICROSCOPIC EXAMINATION BONE RESECTION, BREAST, OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL MASTECTOMY - WITH REGIONAL LYMPH NODES, COLON, LEFT FEMALE BREAST SEGMENTAL RESECTION FOR TUMOR, COLON, TOTAL RESECTION, ESOPHAGUS, PARTIAL/TOTAL RESECTION, EXTREMITY, DISARTICULATION, FETUS, WITH DISSECTION, LARYNX,P 2120/2017 1/25/2017 2/15/2017 88342 IMMUN0HIST0C HEK115TRY 0R IMMUN0 CYT0CHEMISTRY, C50912 MALIGNANT NEOPLASM PROFESSIONAL PER SPECIMEN; INITIAL SINGLE ANTIBODY STAIN OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL PROCEDURE LEFT FEMALE BREAST $70.63 $235.75 FEMALE SUBSCRIBER 1 CCC $96.61 $160.00 FEMALE SUBSCRIBER 1 CCC $175.00 $300.00 FEMALE SUBSCRIBER 1 CCC $11.04 $70.00 FEMALE SUBSCRIBER 1 CCC $1,989.84 $3,076.00 FEMALE SUBSCRIBER 1 CCC $0.00 $0.01 FEMALE SUBSCRIBER 1 CCC $0.00 $0.01 FEMALE SUBSCRIBER 1 CCC $300.41 $533.00 FEMALE SUBSCRIBER 1 CCC $530.84 $678.00 FEMALE SUBSCRIBER 1 CCC $0.00 $267.00 FEMALE SUBSCRIBER 1 CCC C.7.f 3559 ®' WE 3559 3559 3559 3559 III gm 2/20/2017 1/25/2017 2/15/2017 88360 MORPHOMETR I C ANALYSIS, TUMOR C50912 MALIGNANT NEOPLASM PROFESSIONAL 1 CCC IMMUNOHISTOCHEMISTRY(EG , HER - 2 /NEU, ESTROGEN $565.54 FEMALE SUBSCRIBER OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL $512.61 FEMALE SUBSCRIBER RECEPTOR /PROG ESTE RON E RECEPTOR), QUANTITATIVE $106.40 LEFT FEMALE BREAST 1 CCC ($1,949.84) OR SE M I QUANTITATIVE, PER SPECIMEN, EACH SINGLE 1 CCC $0.00 1$0.011 FEMALE SUBSCRIBER 1 CCC ANTIBODY STAIN PROCEDURE; MANUAL (50.01 FEMALE SUBSCRIBER 1 CCC 212712017 2/16/2017 212012017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF LOWER -INNER PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY QUADRANT OF LEFT COMPONENTS: AN EXPANDED PROBLEM FOCUSED FEMALE BREAST HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY, COUNSELING AND COLRD 3/3/2017 2/20/2017 2/23/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C50312 MALIGNANT NEOPLASM PROFE55IONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF LOWER -INNER PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY QUADRANT OF LEFT COMPONENTS: A PROBLEM FOCUSED HISTORY; A FEMALE BREAST PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 3/13/2017 2/14/2017 211812017- - C50312 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 3/14/2017 1/27/2017 2/2/2017- - C50912 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF UNSPECIFIED SITE OF LEFT FEMALE BREAST 3/16/2017 3/8/2017 3/10/2017 77263 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE COMPLEX OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 3/16/2017 3/8/2017 3110/2017 77334 TREATMENT DEVICES, DESIGN AND CONSTRUCTION; CS0312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, OF LOWER INNER COMPENSATORS, WEDGES, MOLDS OR CASTS) QUADRANT OF LEFT FEMALE BREAST 3/16/2017 12/28/2016 3/15/2017 93306 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH Z01818 ENCOUNTER FOR OTHER PROFESSIONAL IMAGE DOCUMENTATION (2D), INCLUDES M -MODE PREPROCEDURAL OUTPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH EXAMINATION SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 3/17/2017 1/2S/2017 2/7/2017 19307 MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILIARY C50312 MALIGNANT NEOPLASM PROFESSIONAL LYMPH NODES, WITH OR WITHOUT PECTORALS MINOR OF LOWER -INNER OUTPATIENT /HOSPITAL MUSCLE, BUT EXCLUDING PECTORALS MAJOR MUSCLE QUADRANT OF LEFT FEMALE BREAST 3/17/2017 1/25/2017 2/15/2017326OF REPAIR OF LOW IMPERFORATE ANUS; WITH ANOPERINEAL C50912 MALIGNANT NEOPLASM PROFESSIONAL FISTULA ( "CUT - BACK" PROCEDURE) OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL LEFT FEMALE BREAST 3/17/2017 1/25/2017 2/15/20173395F QUANTITATIVE NDN -HER2 IMMUNOHISTOCHEMISTRY C50912 MALIGNANT NEOPLASM PROFESSIONAL HHC) EVALUATION OF BREAST CANCER(EG, TESTING FOR OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL ESTROGEN OR PROGESTERONE RECEPTORS AER /PRA' - ) LEFT FEMALE BREAST PERFORMED (PATH) $382.00 $382.00 FEMALE SUBSCRIBER 1 CCC $95.63 $235.75 FEMALE SUBSCRIBER 1 CCC $57.62 $142.05 FEMALE SUBSCRIBER 1 CCC $850.21 $850.21 FEMALE SUBSCRIBER 1 CCC $0.00 $113,159.00 FEMALE SUBSCRIBER 1 CCC $172.06 $565.54 FEMALE SUBSCRIBER 1 CCC $155.95 $512.61 FEMALE SUBSCRIBER 1 CCC $106.40 $216.00 FEMALE SUBSCRIBER 1 CCC ($1,949.84) ($3,076.00) FEMALE SUBSCRIBER 1 CCC $0.00 1$0.011 FEMALE SUBSCRIBER 1 CCC $0.00 (50.01 FEMALE SUBSCRIBER 1 CCC C.7.f 3559 im mm 3559 3559 3559 3559 9MMI 3559 3559 3559 C.7.f 3/17/2017 1/25/2017 2/15/2017 88307 LEVEL V- SORG I CAL PATH DOGGY, GROSS AND C50912 MALIGNANT NEOPLASM PROFESSIONAL '($300.811 (.$533.00) FEMALE SUBSCRIBER 1 CCC 3559 MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL 14 - BIOPSY /CURETTINGS BONE FRAGMENT(S) ,PATHOLOGIC LEFT FEMALE BREAST 411 FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR N RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT 3/17/2017 1/25/2017 2/15/2017 88309 LEVEL VI- SURGICAL PATHOLOGY, GROSS AND 050912 MALIGNANT NEOPLASM PROFESSIONAL ($50.81) i$8J8.O0) FEMALE SUBSCRIBER 1 CCC 3559 MICROSCOPIC EXAMINATION BONE RESECTION, BREAST, OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL MASTECTOMY - WITH REGIONAL LYMPH NODES, COLON, LEFT FEMALE BREAST SEGMENTAL RESECTION FOR TUMOR, COLON, TOTAL RESECTION, ESOPHAGUS, PARTIAL/TOTAL RESECTION, EXTREMITY, DISARTICUTATION, FETUS, WITH DISSECTION, } wamx, P L a 3/1]/201] 1/25/2017 2/15/2017 88342 IMMUNOHISTOCHEMISTRY ORIMMUNOCYTOCHEMISTRV, [50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 {$26J.001 FEMALE SUBSCRIBER 1 CCC 3559 Q, PERSPECIMEN; INITIAL SINGLE ANTIBODY STAIN OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL Q PROCEDURE LEFT FEMALE BREAST 3/17/2017 1/25/2017 2/15/2017 88360 MORPHOMETRIC ANALYSIS, TUMOR C50912 MALIGNANT NEOPLASM PROFESSIONAL }38200) x,382.00) FEMALE SUBSCRIBER 1 CCC 3559 Q IMMUNOHISTOCHEMISTRY (EG, HER- 2 /NEU,ESTROGEN OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL RECEPTOR /PROG ESTE RONE RECEPTOR), QUANTITATIVE LEFT FEMALE BREAST OR SEMIQUANTITATIVE, PER SPECIMEN, EACH SINGLE Lij ~ ANTIBODY STAIN PROCEDURE; MANUAL D 3/17/2017 1/25/2017 3/15/2017 19307 MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILIARY C50312 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $3,076.00 FEMALE SUBSCRIBER 1 CCC 3559 LYMPH NODES, WITH OR WITHOUT PECTORALS MINOR OF LOWER -INNER OUTPATIENT /HOSPITAL MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE QUADRANT OF LEFT FEMALE BREAST 3/17/2017 1/25/2017 3/15/20173260F REPAIR OF LOW IMPERFORATE ANUS; WITH ANOPERINEAL C50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER 1CCC 3559 U' FISTULA ( "CUT- BACK "PROCEDURE) OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL Q LEFT FEMALE BREAST {i 3/17/2017 1/2S/2017 3115/2017 3395F QUANTITATIVE NON -HER2 IMMUNDHISTOCHEMISTRY CS0912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER 1 CCC 3559 U`J (IHC) EVALUATION OF BREAST CANCER(EG, TESTING FOR OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL ESTROGEN OR PROGESTERONE RECEPTORS.AER /PRA ") LEFT FEMALE BREAST PERFORMED (PATH) W 3/17/2017 1/25/2017 3/15/2017 88307 LEVELV - SURGICAL PATHOLOGY, GROSS AND C50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $533.00 FEMALE SUBSCRIBER 1 CCC 3559 MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL � - BIOPSY /CURETTINGS BONE FRAGMENT(S) ,PATHOLOGIC LEFT FEMALE BREAST J FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR RESECTION BREAST, EXCISION OF LESION, REQUIRING v MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT W 3/17/2017 1/25/2017 3/15/2017 88309 LEVEL VI- SURGICAL PATHOLOGY, GROSS AND C50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $678.00 FEMALE SUBSCRIBER 1 CCC 3559 MICROSCOPIC EXAMINATION BONE RESECTION, BREAST, OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL MASTECTOMY - WITH REGIONAL LYMPH NODES, COLON, LEFT FEMALE BREAST (' SEGMENTAL RESECTION FOR TUMOR, COLON, TOTAL RESECTION, ESOPHAGUS, PARTIAL/TOTAL RESECTION, EXTREMITY, DISARTICUTATION, FETUS, WITH DISSECTION, LARYNX,P N 3/17/2017 1/25/2017 3/15/2017 883421MMUNOHISTO CHEMISTRY OR IMMUNOCYTOCHEMISTRY, C50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $267.00 FEMALE SUBSCRIBER 1 CCC 3559 N PERSPECIMEN; INITIAL SINGLE ANTIBODY STAIN OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL = PROCEDURE LEFT FEMALE BREAST ❑i 3/17/2017 1/25/2017 3/15/2017 3/20/2017 112712017 2/7/2017 3/23/2017 3/16/2017 3122/2017 3/30/2017 3/16/2017 3/29/2017 3/30/2017 3/21/2017 3/29/2017 3/30/2017 3/21/2017 3/29/2017 3/30/2017 3/21/2017 3/29/2017 3/30/2017 3/27/2017 3129/2017 3/31/2017 3/27/2017 3/30/2017 G6015 4/3/2017 3/28/2017 3/31/2017 G6015 4/4/2017 3/29/2017 4/3/2017 G6015 41 3/30/2017 4/4/2017 G6015 4/7/2017 3/27/2017 4/5/2017 4/7/2017 3/31/2017 4/5/2017 88360 MORPHOMETR I C ANALYSIS, TUMOR C50912 MALIGNANT NEOPLASM PROFESSIONAL IMMUNOHISTOCHEMISTRY HEG , HER - 2 /NEU, ESTROGEN $162,577.00 FEMALE OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL RECEPTOR /PROG ESTE RON E RECEPTOR), QUANTITATIVE $2,932.71 FEMALE LEFT FEMALE BREAST 1 CCC OR SE M I QUANTITATIVE, PER SPECIMEN, EACH SINGLE $224.00 FEMALE SUBSCRIBER 1 DEC ANTIBODY STAIN PROCEDURE; MANUAL $2,047.59 FEMALE SUBSCRIBER 1 CCC - C50912 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $71.29 $169.84 FEMALE SUBSCRIBER OF UNSPECIFIED SITE OF LEFT FEMALE BREAST - C50312 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 71250 COMPUTED TOMOGRAPHY, THORAX; WITHOUT C50912 MALIGNANT NEOPLASM PROFESSIONAL CONTRAST MATERIAL OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL LEFT FEMALE BREAST 77300 BASIC RADIATION D0SIMETRY CALCULATION, CENTRAL C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE AXIS DEPTH DOSE CALCULATION, TIDE, NSD, GAP OF LOWER -INNER CALCULATION, OFF AXIS FACTOR, TISSUE QUADRANT OF LEFT INHOMOGENEITY FACTORS, CALCULATION OF NOW FEMALE BREAST IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN PRESCRIBED BY THE TREATING 77301 INTENSITY MODULATED RADIOTHERAPY PLAN, C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE INCLUDING DOSE - VOLUME HISTOGRAMS FOR TARGET OF LOWER -INNER AND CRITICAL STRUCTURE PARTIAL TOLERANCE QUADRANT OF LEFT SPECIFICATIONS FEMALE BREAST 77338 Multi leaf collimator (MILE) device(s) for intensity C50312 MALIGNANT N EOPLASM PROFESSIONAL OFFICE modulated radiation therapy TMRT), design and OF LOWER -INNER ca nstru coon per IMRT plan QUADRANT OF LEFT FEMALE BREAST 77280 THERAPEUTIC RADIOLOGY SIMUTATION- AIDED FIELD CS0312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE SETTING; SIMPLE OF LOWER INNER QUADRANT OF LEFT FEMALE BREAST RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST RADIATION TX DELIVERY HURT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 77427 RADIATION TREATMENT MANAGEMENT, FIVE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE TREATMENTS OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF LOWER -INNER QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF QUADRANT OF LEFT PATIENT TREATMENT DOCUMENTATION IN SUPPORTOF FEMALE BREAST THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY $0.00 $382.00 FEMALE SUBSCRIBER 1 CCC $91,062.85 $162,577.00 FEMALE SUBSCRIBER 1 CCC $2,932.71 $2,932.71 FEMALE SUBSCRIBER 1 CCC $84.17 $224.00 FEMALE SUBSCRIBER 1 DEC $860.67 $2,047.59 FEMALE SUBSCRIBER 1 CCC $2,839.50 $6,769.90 FEMALE SUBSCRIBER 1 CCC $65438 $1,55736 FEMALE SUBSCRIBER 1 CCC $25536 $610.61 FEMALE SUBSCRIBER 1 CCC $753.71 $1,259.04 FEMALE SUBSCRIBER 1 CCC $753.71 $1,259.04 FEMALE SUBSCRIBER 1 CCC $753.71 $1,259.04 FEMALE SUBSCRIBER 1 CCC $753.71 $1,259.04 FEMALE SUBSCRIBER 1 CCC $254.69 $597.63 FEMALE SUBSCRIBER 1 CCC $71.29 $169.84 FEMALE SUBSCRIBER 1 CCC C.7.f 3559 w Z N Q! 3559 3559 W } 3559 E. CL CL Q 3559 v Q F W h 3559 3559 nm 3559 3559 3559 3559 3559 WbS] will 41712017 3/31/2017 4/5/2017 G6015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE 1 CCC $125.00 $613.00 FEMALE SUBSCRIBER 1 CCC OF LOWER -INNER $1,259.04 FEMALE SUBSCRIBER 1 CCC $753.71 $1,259.04 FEMALE SUBSCRIBER QUADRANT OF LEFT $121.61 $160.00 FEMALE SUBSCRIBER 1 CCC $84.96 $250.00 FEMALE FEMALE BREAST 1 CCC 4/10/2017 4/3/2017 4/6/201766015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER INNER QUADRANT OF LEFT FEMALE BREAST 4/11/2017 3/21/2017 4/10/2017 93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING 182622 ACUTE EMBOLISM AND OTHER MEDICAL RESPONSES TO COMPRESSION AND OTHER MANEUVERS; THROMBOSIS OF DEEP UNILATERAL OR LIMITED STUDY VEINS OF LEFT UPPER EXTREMITY 4/11/2017 4/4/2017 4/10/201766015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER INNER QUADRANT OF LEFT FEMALE BREAST 411112017 4/5/2017 411012017 G6015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/11/2017 4/5/2017 4/10/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 14540 MODERATE PERSISTENT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED ASTHMA, PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY UNCOMPLICATED COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/13/2017 4/3/2017 4/12/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE TREATMENTS OF LOWER INNER QUADRANT OF LEFT FEMALE BREAST 4/13/2017 4/6/2017 4/12/201766015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/13/2017 417/2017 4/12/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF LOWER -INNER QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF QUADRANT OF LEFT PATIENT TREATMENT DOCUMENTATION IN SUPPORTOF FEMALE BREAST THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY 4/13/2017 4/7/2017 4/12/2017 G6015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/14/2017 4/10/2017 4/13/2017 G6015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/14/2017 4/11/2017 4/13/201766015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/17/2017 4/10/2017 4/14/2017 - - 1972 POSTMASTECTOMY HOSPITAL OUTPATIENT LYMPHEDEMA SYNDROME 4118/2017 4/10/2017 4/17/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE TREATMENTS OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST $753.71 $1,259.04 FEMALE SUBSCRIBER 1 FCC $753.71 $1,259.04 FEMALE SUBSCRIBER 1 CCC $125.00 $613.00 FEMALE SUBSCRIBER 1 CCC $75171 $1,259.04 FEMALE SUBSCRIBER 1 CCC $753.71 $1,259.04 FEMALE SUBSCRIBER 1 CCC $121.61 $160.00 FEMALE SUBSCRIBER 1 CCC $254.69 $597.63 FEMALE SUBSCRIBER 1 CCC $75331 $1,259.04 FEMALE SUBSCRIBER 1 CCC $71.29 $169.84 FEMALE SUBSCRIBER 1 CCC $753.71 $1,259.04 FEMALE SUBSCRIBER 1 ECG $753.71 $1,259.04 FEMALE SUBSCRIBER 1 OCT $753.71 $1,259.04 FEMALE SUBSCRIBER 1 ECG $84.96 $250.00 FEMALE SUBSCRIBER 1 CCC $254.69 $597.63 FEMALE SUBSCRIBER 1 CCC 4/18/2017 4/12/2017 4/17/2017 G6015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1 FCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/19/2017 4/3/2017 4/18/2017 - - 1972 POSTMASTECTOMY HOSPITAL OUTPATIENT $88.08 $235.00 FEMALE SUBSCRIBER 1 CCC LYMPHEDEMA SYNDROME 4/19/2017 4/12/2017 4/18/2017 - - 1972 POSTMASTECTOMY HOSPITAL OUTPATIENT $67.20 $200.00 FEMALE SUBSCRIBER 1 CCC LYMPHEDEMA SYNDROME 4/20/2017 4/13/2017 4/19/201766015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $75171 $1,259.04 FEMALE SUBSCRIBER 1CCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/20/2017 4/14/2017 4/19/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $71.29 $169.84 FEMALE SUBSCRIBER 1 CCC INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF LOWER INNER QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF QUADRANT OF LEFT PATIENT TREATMENT DOCUMENTATION IN SUPPORTOF FEMALE BREAST THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY 4/20/2017 4/14/2017 4/19/2017 G6002 STEREOSCOPIC X -RAY GUIDANCE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $132.25 $293.64 FEMALE SUBSCRIBER 1 DEC OF LOWER INNER QUADRANT OF LEFT FEMALE BREAST 4/20/2017 4/14/2017 4/19/201766015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER ICCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/21/2017 4/14/2017 4/20/2017 - - 1972 POSTMASTECTOMY HOSPITAL OUTPATIENT $84.96 $250.00 FEMALE SUBSCRIBER 1 DEC LYMPHEDEMA SYNDROME 4/24/2017 4/17/2017 4/21/201766015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1CCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/24/2017 411712017 4/21/2017 - - 1972 POSTMASTECTOMY HOSPITAL OUTPATIENT $68.16 $200.00 FEMALE SUBSCRIBER 1 CCC LYMPHEDEMA SYNDROME 4/24/2017 4118/2017 4/21/201766015 RADIATION TX DELIVERI IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1CCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/26/2017 4/17/2017 4/25/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $254.69 $597.63 FEMALE SUBSCRIBER 1 CCC TREATMENTS OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/26/2017 4/19/2017 4/25/2017 - - 1972 POSTMASTECTOMY HOSPITAL OUTPATIENT $67.20 $200.00 FEMALE SUBSCRIBER 1 CCC LYMPHEDEMA SYNDROME 4/26/2017 4/19/2017 4/25/2017 G6015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1 CCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/26/2017 4/20/2017 4/25/201766015 RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $75171 $1,259.04 FEMALE SUBSCRIBER 1CCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 4/26/2017 4/21/2017 4/25/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $71.29 $169,84 FEMALE SUBSCRIBER 1 CCC INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF LOWER -INNER QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF QUADRANT OF LEFT PATIENT TREATMENT DOCUMENTATION IN SUPPORTOF FEMALE BREAST THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY 4/26/2017 4/21/2017 4/25/2017 G6015 4/27/2017 4/21/2017 4/26/2017 - 4/28/2017 1/25/2017 4/19/2017 4/28/2017 4/24/2017 4/27/2017 G6002 4/28/2017 4/24/2017 4/27/2017 G6015 5/1/2017 4/24/2017 4/28/2017 - 5/1/2017 4/25/2017 4/28/2017 G6002 5/1/2017 4/25/2017 4/28/2017 G6015 5/2/2017 4/26/2017 5/1/2017 G6015 5/3/2017 4/24/2017 5/2/2017 5/3/2017 4/26/2017 5/2/2017 - 5/3/2017 4/27/2017 5/2/2017 G6015 5/4/2017 4/28/2017 5/3/201 - 5/4/2017 4/28/2017 5/3/2017 5/4/2017 4/28/2017 5/3/2017 66015 5/9/2017 5/2 /2017 5/8/2017 - RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE 1 FCC $67.20 OF LOWER -INNER SUBSCRIBER 1 CCC QUADRANT OF LEFT $5,474.00 FEMALE SUBSCRIBER FEMALE BREAST - 1972 POSTMASTECTOMY HOSPITAL OUTPATIENT 1 CCC $753.71 LYMPHEDEMA SUBSCRIBER 1 CCC SYNDROME 1610 AN ESTH ES IA FO R ALL P ROCEDU R ES ON N ERVES, M USCLES, C50912 MALIG NAST N EOPLASM OTHER MEDICAL TENDONS, FASCIA, AND BURSAE OF SHOULDER AND $293.64 FEMALE OF UNSPECIFIED SITE OF AXILLA $753.71 LEFT FEMALE BREAST STEREOSCOPIC% -RAY GUIDANCE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1,259.04 FEMALE SUBSCRIBER OF LOWER INNER $254.69 $597.63 FEMALE QUADRANT OF LEFT 1 CCC $84.96 FEMALE BREAST RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1,259.04 FEMALE SUBSCRIBER OF LOWER -INNER $34.56 $100.00 FEMALE QUADRANT OF LEFT 1 CCC $71.29 FEMALE BREAST - 1972 POSTMASTECTOMY HOSPITAL OUTPATIENT $1,259.04 FEMALE SUBSCRIBER LYMPHEDEMA $34.56 $100.00 FEMALE SYNDROME STEREOSCOPIC X -RAY GUIDANCE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 77427 RADIATION TREATMENT MANAGEMENT, FIVE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE TREATMENTS OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST - 1972 POSTMASTECTOMY HOSPITAL OUTPATIENT LYMPHEDEMA SYNDROME RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST - 1972 POSTMASTECTOMY HOSPITAL OUTPATIENT LYMPHEDEMA SYNDROME 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF LOWER -INNER QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF QUADRANT OF LEFT PATIENT TREATMENT DOCUMENTATION IN SUPPORTOF FEMALE BREAST THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY RADIATION TX DELIVERY IMRT C50312 MALIGNANT NEOPLASM PROFE55IONAL OFFICE OF LOWER INNER QUADRANT OF LEFT FEMALE BREAST - 1972 POSTMASTECTOMY HOSPITAL OUTPATIENT LYMPHEDEMA SYNDROME $753.71 $1,259.04 FEMALE SUBSCRIBER 1 FCC $67.20 $200.00 FEMALE SUBSCRIBER 1 CCC $0.00 $5,474.00 FEMALE SUBSCRIBER 1 CCC $132.25 $293.64 FEMALE SUBSCRIBER 1 CCC $753.71 $1,259.04 FEMALE SUBSCRIBER 1 CCC $6144 $185.00 FEMALE SUBSCRIBER 1 CCC $132.25 $293.64 FEMALE SUBSCRIBER 1 CCC $753.71 $1,259.04 FEMALE SUBSCRIBER 1 CCC $753.71 $1,259.04 FEMALE SUBSCRIBER 1 CCC $254.69 $597.63 FEMALE SUBSCRIBER 1 CCC $84.96 $250.00 FEMALE SUBSCRIBER 1 CCC $753.71 $1,259.04 FEMALE SUBSCRIBER 1 CCC $34.56 $100.00 FEMALE SUBSCRIBER 1 CCC $71.29 $169.84 FEMALE SUBSCRIBER 1 DEC $75171 $1,259.04 FEMALE SUBSCRIBER 1 CCC $34.56 $100.00 FEMALE SUBSCRIBER 1 CCC C.7.f 3559 w O1 N 3559 A Q! 3559 3559 W } fl 3559 L CL CL Q 3559 Q 3559 W D 3559 3559 d W IX 3559 (/1 3559 3559 3559 3559 WE 5/11/2017 5/1/2017 5/10/2017 77280 TH E RAP EUTI C RADI OLOGY SI M U LATI ON -AI DED F EED C50312 MALIG NANT N EOPLASM PROFESSIONAL OFFICE $255.56 $702.20 FEMALE SUBSCRIBER 1 CCC SETTING; SIMPLE OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 5/11/2017 5/1/2017 5/10/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $254.69 $687.27 FEMALE SUBSCRIBER 1 CCC TREATMENTS OF LOWER INNER QUADRANT OF LEFT FEMALE BREAST 5/11/2017 5/1/2017 5/10/2017 G6012 RADIATION TREATMENT DELIVERY C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $34039 $870.62 FEMALE SUBSCRIBER 1 CCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 5/11/2017 5/2/2017 5/10/201766012 RADIATION TREATMENT DELIVERY C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $34039 $870.62 FEMALE SUBSCRIBER 1CCC OF LOWER INNER QUADRANT OF LEFT FEMALE BREAST 5/11/2017 5/3/2017 5/10/2017 G6012 RADIATION TREATMENT DELIVERY C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $340.39 $870.62 FEMALE SUBSCRIBER 1 CCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 5/11/2017 5/4/2017 5/10/2017 G6012 RADIATION TREATMENT DELIVERY C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $340.39 $870.62 FEMALE SUBSCRIBER 1 CCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 5/11/2017 5/5/2017 5/10/2017 G6012 RADIATION TREATMENT DELIVERY C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $340.39 $870.62 FEMALE SUBSCRIBER 1 CCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 5/16/2017 1/25/2017 5/2/2017 15734 MUSCLE, MYDCUTANEOUS, DR FASCIOCUTANEOUS FLAP; C50912 MALIGNANT NEOPLASM PROFESSIONAL $1,627.49 $4,279.00 FEMALE SUBSCRIBER 1 CCC TRUNK OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL LEFT FEMALE BREAST 5/16/2017 1/25/2017 5/2/2017 15717 IMPLANTATION OF BIOLOGIC IMPLANT(EG, ACELLULAR C50912 MALIGNANT NEOPLASM PROFESSIONAL $267.52 $662.75 FEMALE SUBSCRIBER 1 CCC DERMALMATRIX) FORSOFTTISSUE REINFORCEMENT (IC, OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL BREAST,TRUNK) (LIST SEPARATELY IN ADDITIONTOCODE LEFT FEMALE BREAST FOR PRIMARY PROCEDURE) 5/16/2017 1/25/2017 5/2/2017 19318 REDUCTION MAMMAPLASTY C50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $3,275.60 FEMALE SUBSCRIBER 1 CCC OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL LEFT FEMALE BREAST 5/19/2017 1/25/2017 2/7/2017 19307 MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILIARY C50312 MALIGNANT NEOPLASM PROFESSIONAL I$?989.84) $3,076.00 FEMALE SUBSCRIBER 1000 LYMPH NODES ,WITH ORWITHOUTPECFORAUS MINOR OF LOWER -INNER OUTPATIENT /HOSPITAL MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE QUADRANT OF LEFT FEMALE BREAST 512012017 1/25/2017 2/15/2017 88307 LEVELV- SURGICAL PATHOLOGY, GROSS AND C50912 MALIGNANT NEOPLASM PROFESSIONAL [51,213251 $533.00 FEMALE SUBSCRIBER 1 CCC MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENTS ), PATHOLOGIC LEFT FEMALE BREAST FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT 5/24/2017 5/15 /2017 5/23/2017 - - C50312 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $843.61 $843.61 FEMALE SUBSCRIBER 1 CCC OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 5126/2017 5/24/2017 5/25/2017 ' * * "' ' * "* * " "" °fi * *' * * "' $127.40 $265.00 FEMALE SUBSCRIBER 1 CCC 5/30/2017 5/18/2017 5/26/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1,125.00 FEMALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 CCC OF LOWER -INNER $175.00 FEMALE SUBSCRIBER PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY $232.38 QUADRANT OF LEFT SUBSCRIBER 1 CCC COMPONENTS: A DETAILED HISTORY; A DETAILED FEMALE BREAST EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/1/2017 5/23/2017 5/31/2017 93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING R600 LOCALIZED EDEMA OTHER MEDICAL RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 6/8/2017 5/25/2017 6/6/2017 36590 REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS Z853 PERSONAL HISTORY OF PROFESSIONAL OFFICE DEVICE, WITH SUBCUTANEOUS PORTOR PUMP, CENTRAL MALIGNANT NEOPLASM OR PERIPHERAL INSERTION OF BREAST 6/13/2017 6/8/2017 6/12/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z853 PERSONAL HISTORY OF PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MALIGNANT NEOPLASM PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY OF BREAST COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 6/14/2017 6/1/2017 6/13/2017 77066 Diagnostic mammography, 'mdl ding compute .Ided Z1231 ENCOUNTER FOR PROFESSIONAL detection (CAD) when performed; bilateral SCREENING OUTPATIENT /HOSPITAL MAMMOGRAM FOR MALIGNANT NEOPLASM OF BREAST 6/15/2017 5/23/2017 6/14/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF LOWER -INNER PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY QUADRANT OF LEFT COMPONENTS: A DETAILED HISTORY; A DETAILED FEMALE BREAST EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/16/2017 1/25/2017 4/19/2017 1610 ANESTHESIA FOR ALL PROCEDURES ON NERVES, MUSCLES, C50912 MALIGNANT NEOPLASM OTHER MEDICAL TENDONS, FASCIA, AND BURSAE OF SHOULDER AND OF UNSPECIFIED SITE OF AXILIA LEFT FEMALE BREAST 6/16/2017 1/25/2017 4/19/2017 1610 ANESTHESIA FOR ALL PROCEDURES ON NERVES, MUSCLES, C50912 MALIGNANT NEOPLASM OTHER MEDICAL TENDONS, FASCIA, AND BURSAE OF SHOULDER AND OF UNSPECIFIED SITE OF AXILLA LEFT FEMALE BREAST 6/16/2017 6/1/2017 6/15/2017- - Z853 PERSONAL HISTORY OF HOSPITAL OUTPATIENT MALIGNANT NEOPLASM OF BREAST 6/16/2017 6/13/2017 6/15/2017 99396 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z01419 ENCOUNTER FOR PROFE55IONAL OFFICE REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL GYNECOLOGICAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION (GENERAL) EXAMINATION, COUNSELING /ANTICIPATORY (ROUTINE) WITHOUT GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ABNORMAL FINDINGS ANDTHE ORDERING OF LABORATORV /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; 40 -64 YEARS 7/20/2017 7/3/2017 7/18/2017 71020 RADIOLDGIC EXAMINATION, CHEST, TWO VIEWS, R0789 OTHER CHEST PAIN OTHER MEDICAL FRONTAL AND LATERAL; $163.14 $250.00 FEMALE SUBSCRIBER 1 CCC $125.00 $613.00 FEMALE SUBSCRIBER 1 CCC $474.26 $1,125.00 FEMALE SUBSCRIBER 1 CCC $109.22 $175.00 FEMALE SUBSCRIBER 1 CCC $79.76 $183.00 FEMALE SUBSCRIBER 1 CCC $14130 $348.35 FEMALE SUBSCRIBER 1 CCC $3,260.54 $5,474.00 FEMALE SUBSCRIBER 1 CCC $0.00 ($5,474.00) FEMALE SUBSCRIBER 1 CCC $657.00 $657.00 FEMALE SUBSCRIBER 1 OCT $232.38 $255.00 FEMALE SUBSCRIBER 1 CCC $0.00 $164.00 FEMALE SUBSCRIBER 1 CCC C.7.f 3559 3559 3559 3559 gm WE 3559 3559 3559 3559 712012017 7/3/2017 7/18/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R0789 OTHER CHEST PAIN OTHER MEDICAL $3,076.00 FEMALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 CCC $843.61 $843.61 FEMALE SUBSCRIBER PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $11,379.00 $16,99100 FEMALE SUBSCRIBER 1 CCC COMPONENTS: AN EXPANDED PROBLEM FOCUSED $348.35 FEMALE SUBSCRIBER 1 CCC HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 8/14/2017 1/25/2017 3/15/2017 19307 MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY C50312 MALIGNANT NEOPLASM PROFESSIONAL LYMPH NODES, WITH DR WITHOUT PECTORALIS MINOR OF LOWER -INNER OUTPATIENT /HOSPITAL MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE QUADRANT OF LEFT FEMALE BREAST 8/14/2017 1/25/2017 3/15/2017 19307 MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY C50312 MALIGNANT NEOPLASM PROFESSIONAL LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR OF LOWER INNER OUTPATIENT /HOSPITAL MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE QUADRANT OF LEFT FEMALE BREAST 8/18/2017 8/5/2017 8/17/2017- - C50312 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 8/23/2017 8/12/2017 8/17/2017 - - 75111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 8/23/2017 8/16/2017 8/22/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C50312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF LOWER -INNER PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY QUADRANT OF LEFT COMPONENTS: A DETAILED HISTORY; A DETAILED FEMALE BREAST EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 9/1/2017 8/30/2017 8/31/2017 * *' ** * * * ** '• * ** * * * ** * * * ** 9/11/2017 1/25/2017 9/1/2017 88307 LEVELV - SURGICALPATHDLOGY,GROSSAND C10912 MALIGNANT NEOPLASM PROFESSIONAL MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENTS) , PATHOLOGIC LEFT FEMALE BREAST FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT 9/22/2017 8/12/2017 9/21/2017 78815 POSITRON EMISSION TOMOGRAPHY(PET)WITH C50912 MALIGNANT NEOPLASM PROFESSIONAL CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL )CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LEFT FEMALE BREAST LOCALIZATION IMAGING; SKULL BASE TO MID THIGH 10/6/2017 1/25/2017 3/15/20173260F REPAIR OF LOW IMPERFORATE ANUS; WITH ANOPERINEAL C50912 MALIGNANT NEOPLASM PROFESSIONAL FISTULA ) "CUT - BACK" PROCEDURE) OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL LEFT FEMALE BREAST 10/6/2017 1/25/2017 3/15/20173395F QUANTITATIVE NOWHER2 IMMUNOHISTOCHEMISTRY C50912 MALIGNANT NEOPLASM PROFESSIONAL )IHC) EVALUATION OF BREAST CANCER(EG, TESTING FOR OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL ESTROGEN OR PRDGESTERONE RECEPTORS AER /PRA - ) LEFT FEMALE BREAST PERFORMED )PATH) 10/6/2017 1/25/2017 3/15/2017 88307 LEVELV - SURGICAL PATHOLOGY, GROSS AND C50912 MALIGNANT NEOPLASM PROFE55IONAL MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENT(S), PATHOLOGIC LEFT FEMALE BREAST FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT $225.00 $300.00 FEMALE SUBSCRIBER 1 CCC $0.00 ($3,075.00) FEMALE SUBSCRIBER 1 CCC $1,989.84 $3,076.00 FEMALE SUBSCRIBER 1 CCC $843.61 $843.61 FEMALE SUBSCRIBER 1 CCC $11,379.00 $16,99100 FEMALE SUBSCRIBER 1 CCC $141.30 $348.35 FEMALE SUBSCRIBER 1 CCC $23.57 $110.00 FEMALE SUBSCRIBER 1 CCC $0.00 $533.00 FEMALE SUBSCRIBER 1 CCC C.7.f 3559 3559 3559 3559 3559 3559 Is $194.31 $477.00 FEMALE SUBSCRIBER 1 CCC 3559 $0.00 i$0,017 FEMALE SUBSCRIBER 1 CCC 3559 $0.00 ;$0.011 FEMALE SUBSCRIBER 1 DEC 3559 $0.00 (.$533.001 FEMALE SUBSCRIBER 1 CCC 3559 10/6/2017 1/25/2017 3/15/2017 88309 LEVEL VI - SURG ICA L PATH OLOGY, GROSS AND C50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 (5618.001 FEMALE SUBSCRIBER 1 CCC MICROSCOPIC EXAMINATION BONE RESECTION, BREAST, OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL MASTECTOMY - WITH REGIONAL LYMPH NODES, COLON, LEFT FEMALE BREAST SEGMENTAL RESECTION FOR TUMOR, COLON, TOTAL RESECTION, ESOPHAGUS, PARTIAL/TOTAL RESECTION, EXTREMITY, DISARTICULATION, FETUS, WITH DISSECTION, LARYNX,P 10/6/2017 1/25/2017 3/15/2017 883421MMUNOHISTO CHEMISTRY OR IMMUNOCYTOCHEMISTRY, C50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 ($267.00j FEMALE SUBSCRIBER 1 CCC PERSPECIMEN; INITIAL SINGLE ANTIBODY STAIN OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL PROCEDURE LEFT FEMALE BREAST 10/6/2017 1/25/2017 3/15/2017 88360 MORPHOMETRIC ANALYSIS, TUMOR C50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 ($382.001 FEMALE SUBSCRIBER 1 CCC IMMUNOHISTOCHEMISTRY(EG, HER -2 /NEU, ESTROGEN OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL RECEPTOR / FROG ESTE RON E RECEPTOR), QUANTITATIVE LEFT FEMALE BREAST OR SEMIQUANTITATIVE, PER SPECIMEN, EACH SINGLE ANTIBODY STAIN PROCEDURE; MANUAL 10/6/2017 1/25/2017 3/15/2017326OF REPAIROF LOW IMPERFORATE ANUS; WITH ANOPERINEAL C50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER 1COE FISTULA ( "CUT - BACK" PROCEDURE) OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL LEFT FEMALE BREAST 10/6/2017 1/25/2017 3/15/2017 3395F QUANTITATIVE NON -HER2 IMMUNOHISTOCHEMISTRY C50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER 1 CCC (IHC) EVALUATION OF BREAST CANCER(EG, TESTING FOR OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL ESTROGEN OR PRDGESTERONE RECEPTORS AER /PRA - ) LEFT FEMALE BREAST PERFORMED (PATH) 10/6/2017 1/25/2017 3/15/2017 88307 LEVELV- SURGICAL PATHOLOGY, GROSS AND C50912 MALIGNANT NEOPLASM PROFESSIONAL $300.41 $533.00 FEMALE SUBSCRIBER 1 CCC MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENT(S), PATHOLOGIC LEFT FEMALE BREAST FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT 10/6/2017 1/25/2017 3/15/2017 88309 LEVELVI- SURGICAL PATHOLOGY, GROSS AND C50912 MALIGNANT NEOPLASM PROFESSIONAL $530.84 $678.00 FEMALE SUBSCRIBER 1 CCC MICROSCOPIC EXAMINATION BONE RESECTION, BREAST, OF UNSPECIFIED SITE OF OUTPATIENT/HOSPITAL MASTECTOMY- WITH REGIONAL LYMPH NODES, COLON, LEFT FEMALE BREAST SEGMENTAL RESECTION FOR TUMOR, COLON, TOTAL RESECTION, ESOPHAGUS, PARTIAL/TOTAL RESECTION, EXTREMITY, DISARTICULATION, FETUS, WITH DISSECTION, LARYNX, P 10/6/2017 1/25/2017 3/15/2017 883421MMUNOHISTOCHEMISTRY OR IMMUNOCYTO CHEMISTRY, C50912 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $267.00 FEMALE SUBSCRIBER 1 CCC PERSPECIMEN; INITIAL SINGLE ANTIBODY STAIN OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL PROCEDURE LEFT FEMALE BREAST 10/6/2017 1/25/2017 3/15/2017 88360 MORPHOMETRIC ANALYSIS, TUMOR C50912 MALIGNANT NEOPLASM PROFESSIONAL $382.00 $382.00 FEMALE SUBSCRIBER 1 CCC IMMUNOHISTDCHEMISTRY(EG , HER -2 /NEU, ESTROGEN OF UNSPECIFIED SITE OF OUTPATIENT /HOSPITAL R ECEPTO R/PROG ESTE RON E RECEPTOR), QUANTITATIVE LEFT FEMALE BREAST OR SEMIQUANTITATIVE, PER SPECIMEN, EACH SINGLE ANTIBODY STAIN PROCEDURE; MANUAL 10/27/2017 10/10/2017 10/25/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z853 PERSONAL HISTORY OF PROFESSIONAL OFFICE $5034 $105.00 FEMALE SUBSCRIBER 1 CCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED MALIGNANT NEOPLASM PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY OF BREAST COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 1012712017 10/25/2017 10/26/2017 ..x.x * * * ** *xx.. " * * ** * * * ** $127.40 $265.00 FEMALE SUBSCRIBER 1 CCC C.7.f 3559 3559 3559 3559 3559 EL{tl I= 3559 3559 WbS] ®' 11/6/2017 10/12/2017 11/3/2017 904711 IMMUNIZATION ADM IN ISTRATI ON (INCLUDES Z23 ENCOUNTER FOR PROFESSIONAL SUBSCRIBER 1 CCC PERCUTAN ED US, I NTRADER MAL, SUBCUTANEOUS, OR $832.00 FEMALE IMMUNIZATION OUTPATIENT /HOSPITAL $0.00 $32.00 FEMALE INTRAMUSCULAR INI ECTIONS); 1 VACCINE )SINGLE OR 1 CCC $0.00 $164.00 FEMALE SUBSCRIBER 1 CCC COMBINATION VACCINE /TOX01 D) $99.00 FEMALE SUBSCRIBER 1 CCC 11/6/2017 10/12/2017 11/3/2017 90686 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLITVIRUS, Z23 ENCOUNTER FOR PROFESSIONAL PRESERVATIVE FREE, WHEN ADMINISTERED TO IMMUNIZATION OUTPATIENT /HOSPITAL INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR USE 11/8/2017 1011712017 11/7/2017- - C50312 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF LOWER -INNER QUADRANT OF LEFT FEMALE BREAST 11/14/2017 11/8/2017 11/13/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 701818 ENCOUNTER FOR OTHER OTHER MEDICAL PREPROCEDURAL EXAMINATION 11/14/2017 111812017 11/13/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 201818 ENCOUNTER FOR OTHER OTHER MEDICAL FRONTALAND LATERAL; PREPROCEDURAL EXAMINATION 11/14/2017 11/8/2017 11/13/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, PREPROCEDURAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON EXAMINATION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 11/14/2017 11/8/2017 11/13/2017 81003 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, PREPROCEDURAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, EXAMINATION UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY 11/14/2017 11/8/2017 11113/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, 201818 ENCOUNTER FOR OTHER OTHER MEDICAL HCT, BBC, WBCAND PLATELETCOUNT ) AND AUTOMATED PREPROCEDURAL DIFFERENTIAL W BC COUNT EXAMINATION 11/14/2017 111812017 11/13/2017 93000 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL LEADS; WITH INTERPRETATION AND REPORT PREPROCEDURAL EXAMINATION 11/14/2017 11/8/2017 11/13/2017 99000 HANDLING AND /OR CONVEYANCE OF SPECIMEN FOR Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL TRANSFER FROM THE PHYSICIAN S OFFICETOA PREPROCEDURAL LABORATORY EXAMINATION 11/17/2017 11/14/2017 11/15/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE R0982 POSTNASAL DRIP PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 11/27/2017 11/17/2017 11/22/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE ZO1818 ENCOUNTER FOR OTHER OTHER MEDICAL PREPROCEDURAL EXAMINATION 11127/2017 11/17/2017 11/22/2017 99000 HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR Z01819 ENCOUNTER FOR OTHER OTHER MEDICAL TRANSFER FROM THE PHYSICIAN S OFFICETOA PREPROCEDURAL LABORATORY EXAMINATION $10.00 $10.00 FEMALE SUBSCRIBER 1 CCC $20.00 $25.00 FEMALE SUBSCRIBER 1 CCC $832.00 $832.00 FEMALE SUBSCRIBER 1 CCC $0.00 $32.00 FEMALE SUBSCRIBER 1 CCC $0.00 $164.00 FEMALE SUBSCRIBER 1 CCC $0.00 $99.00 FEMALE SUBSCRIBER 1 CCC $0.00 $36.00 FEMALE SUBSCRIBER 1 CCC $0.00 $58.00 FEMALE SUBSCRIBER 1 CCC $0.00 $120.00 FEMALE SUBSCRIBER 1 CCC $0.00 $41.00 FEMALE SUBSCRIBER 1 CCC $121.61 $160.00 FEMALE SUBSCRIBER 1 CCC $0.00 $32.00 FEMALE SUBSCRIBER 1 CCC $0.00 $41.00 FEMALE SUBSCRIBER 1 CCC 12/1/2017 11/22/2017 11/29/2017 - - 201818 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT SUBSCRIBER 1 CCC $0.00 $164.00 FEMALE PREPROCEDURAL 1 DEC $95.63 $235.75 FEMALE SUBSCRIBER 1 CCC EXAMINATION $88,4fi 1.00 MALE 12/14/2017 12/11/2017 12/12/2017 * * * «* * * * ** * « * ** * " " *" * * * ** 12/21/2017 12/13/2017 12/20/2017 71020 RADIDLOGIC EXAMINATION, CHEST, TWO VIEWS, ZO1818 ENCOUNTER FOR OTHER OTHER MEDICAL $0.00 FRONTAL AND LATERAL; SUBSCRIBER PREPROCEDURAL $748.68 $1,934.00 MALE SUBSCRIBER 1050 EXAMINATION $200.87 12/28/2017 10/24/2017 12/27/2017 99213 OFFICE DR OTHER OUTPATIENT VISIT FOR THE CS0312 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF LOWER -INNER PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY QUADRANT OF LEFT COMPONENTS: AN EXPANDED PROBLEM FOCUSED FEMALE BREAST HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED Sub Total 6250024288 1/3/2017 12/22/2016 12/29/2016 ** * ** 1/6/2017 12/22/2016 1/3/2017 * * * *" 1/612017 12/22/2016 1/4/2017 * * * ** * * *A# * " * ** #k # # * +•** 1/6/2017 12/22/2016 12/29/2016 1/9/2017 12/22/2016 1/6/2017 1/9/2017 12/23/2016 1/6/2017 * * * ** s +. *+ .. * ** • + + ++ s*.** 1/17/2017 12/22/2016 1/13/2017 92928 PERCUTANEOUS TRANSCATHETER PLACEMENT OF 1200 UNSTABLE ANGINA PROFESSIONAL INTRACORONARY STENTES), WITH CORONARY INPATIENT /HOSPITAL ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH 1/17/2017 12/22/2016 1/13/2017 93458 Catheter placement In roronary artery(s)for coronary 1200 UNSTABLE ANGINA PROFESSIONAL angiogmphy,mdLdingmtmproced oral nject YS)for INPATIENT /HOSPITAL nary angIography, imaging supervision and interpretation; with left heart catheterization including i moproced ural injection(,) for left ventriculography, when performed 1/17/2017 12/22/2016 1/13/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1200 UNSTABLE ANGINA PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELI NO AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 1/17/2017 12/23/2016 1/13/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1200 UNSTABLE ANGINA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRESAT LEAST 2 OF TH ESE 3 KEY COMPON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/18/2017 10/28/2016 1/17/2017 75571 Computed tomography, h ear t, without contrast material, Z136 ENCOUNTER FOR PROFESSIONAL with quantitative evaluation of coro nary calcium SCREENING FOR DUTPATIENT /HOSPITAL CARDIOVASCULAR DISORDERS $4,866.60 $8,111.00 FEMALE SUBSCRIBER 1 CCC $127.40 $265.00 FEMALE SUBSCRIBER 1 CCC $0.00 $164.00 FEMALE SUBSCRIBER 1 DEC $95.63 $235.75 FEMALE SUBSCRIBER 1 CCC $151.11 $377.00 MALE SUBSCRIBER 1 050 $78.97 $196.00 MALE SUBSCRIBER 1 OSO $0.00 $49.00 MALE SUBSCRIBER 1 OSO C.7.f 3559 w 3559 3559 111M -I lim M0 W9 $159,354.76 $417,478.48 12/22/2016 ## # ## ### $901.50 $35,671.00 MALE SUBSCRIBER 1 OSO 12/22/2016 ## # # ## ## $0.00 $88,461.00 MALE SUBSCRIBER 1 050 12/22/2016 # # # ## # ## $52,163.74 $88,4fi 1.00 MALE SUBSCRIBER 1 OSO 12/22/2016 # # # # # # ## j$901.SOj !$35,671.001 MALE SUBSCRIBER 1 OSO $0.00 $195.00 MALE SUBSCRIBER 1 0 $0.00 $91.00 MALE SUBSCRIBER 1 0 $748.68 $1,934.00 MALE SUBSCRIBER 1050 $200.87 $972.00 MALE SUBSCRIBER 1 OSO $151.11 $377.00 MALE SUBSCRIBER 1 050 $78.97 $196.00 MALE SUBSCRIBER 1 OSO $0.00 $49.00 MALE SUBSCRIBER 1 OSO C.7.f 3559 w 3559 3559 111M -I lim M0 W9 1/30/2017 1/9/2017 1/11/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1208 OTHER FORMS OF PROFESSIONAL OFFICE W EVALUATION AND MANAGEMENT OF AN ESTABLISHED ANGINA PECTORIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED m EXAMINATION; MEDICAL DECISION MAKING OF Q) MODERATE COMPLEXITY. COUNSELING AND /OR A 4 COORDINATION OF CARE WITH OTHER 2/16/2017 12/22/2016 2/15/2017 #kA "" $61533 * ** * * * ** * * * ** 2/20/2017 2/13/2017 2115/2017 93000 ELEC TROC ARDI OGRAM,ROUTINEECGWITHATLEASTI2 R0789 OTHER CHEST PAIN PROFESSIONAL OFFICE 1 OSO LEADS; WITH INTERPRETATION AND REPORT "a 2/20/2017 2/13/2017 2/15/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R0789 OTHER CHEST PAIN PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED $8712 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SUBSCRIBER 1 0S0 3559 COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR } COORDINATION OF CARE WITH OTHER fl i® 2/27/2017 2/16/2017 212112017 78452 Myocardial perfusion imaging, tomographlc (SPECT) 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE CL (ncluding attenuation correction, qualitative or DISEASE OF NATIVE quantitative wall mot ion, ejection fraction by first pass or CORONARY ARTERY gated technique, additional quantification, when Q WITHOUTANGINA. Performed); multiple studies, at rest and /or PECTORIS $0.00 2/27/2017 2/16/2017 2/21/2017 93015 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, DISEASE OF NATIVE CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, CORONARY ARTERY AND /OR PHARMACOLOGICAL STRESS; WITH PHYSICIAN F WITHOUTANGINA SUPERVISION, WITH INTERPRETATION AND REPORT PECTORIS 2/27/2017 2/16/2017 2121/2017 93306 ECHOCARDIOGRAPHY, TRANSTHDRACIC, REAL -TIME WITH 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE IMAGE DOCUMENTATION (2D), INCLUDES M -MODE DISEASE OF NATIVE D RECORDING, WHEN PERFORMED, COMPLETE, WITH CORONARY ARTERY SPECTRAL DOPPLER ECHOCARDIOGRAPHY , AND WITH $49.89 WITHOUTANGINA SUBSCRIBER 1 0S0 COLOR FLOW DOPPLER ECHOCARDIOGRAPHY PECTORIS 2/27/2017 2/16/2017 2/21/2017 A9500 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE IMAGING AGENT, TECHNETIUM TC 99M DISEASE OF NATIVE CORONARYARTERY O WITHOUTANGINA d $122.52 PECTORIS SUBSCRIBER 3/8/2017 12/22/2016 3/6/2017 99223 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION 1200 UNSTABLEANGINA PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN J $165.44 $590.00 MALE 3/8/2017 12/23/2016 3/6/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE 1200 UNSTABLE ANGINA PROFESSIONAL THAN 3D MINUTES INPATIENT / HDSPITAL 4/4/2017 3/30/2017 4/3/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1252 OLD MYOCARDIAL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED INFARCTION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED J $188.01 $554.00 MALE SUBSCRIBER EXAMINATION; MEDICAL DECISION MAKING OF 3559 p y MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 8/21/2017 12/22/2016 8/18/2017 * *' "* 11 — * * " ** —1- ...s" C.7.f $87.22 $290.00 MALE SUBSCRIBER 1 050 3559 $96.01 $289.00 MALE SUBSCRIBER 1 OSO 3559 $87.22 $290.00 MALE SUBSCRIBER 1 0SO 3559 $0.00 $35.00 MALE SUBSCRIBER 1 OSO 3559 W OR m Q) A 4 $61533 $1,367.00 MALE SUBSCRIBER 1 050 3559 7 $0.00 $92.00 MALE SUBSCRIBER 1 OSO 3559 "a $8712 $290.00 MALE SUBSCRIBER 1 0S0 3559 W } fl i® CL CL Q $0.00 $1,500.00 MALE SUBSCRIBER 1050 3559 F W h D $49.89 $800.00 MALE SUBSCRIBER 1 0S0 3559 O d $122.52 $1,050.00 MALE SUBSCRIBER l OSO 3559 LEI O J $165.44 $590.00 MALE SUBSCRIBER 1 050 3559 IELJ Q J $188.01 $554.00 MALE SUBSCRIBER 1 OSO 3559 p y $96.01 $289.00 MALE SUBSCRIBER 1 OSO 3559 $87.22 $290.00 MALE SUBSCRIBER 1 0SO 3559 $0.00 $35.00 MALE SUBSCRIBER 1 OSO 3559 10/9/2017 12/12/2016 10/6/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1209 ANGINA PECTORIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/12/2017 12/12/2016 12/5/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1209 ANGINA PECTORIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/28/2017 12/12/2016 12/5/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1209 ANGINA PECTORIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/28/2017 12/12/2016 12/21/2016 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 1209 ANGINA PECTORIS, PROFESSIONAL OFFICE LEADS; WITH INTERPRETATION AND REPORT UNSPECIFIED 12/28/2017 12/12/2016 12/21/2016 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1209 ANGINA PECTORIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, UNSPECIFIED W HICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR Sub Total 1.25E +10 1/3/2017 12/18/2016 12/30/2016 71D20 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 80602 SHORTNESS OF BREATH PROFESSIONAL FRONTAL AND LATERAL; OUTPATIENT /HOSPITAL 1/3/2017 12/18/2016 12/31/2016 76770 ULTRASOUND, RETROPERITONEAL(EG, RENAL, AORTA, R109 UNSPECIFIED ABDOMINAL PROFESSIONAL NODES), REALTIME WITH IMAGE DOCUMENTATION; PAIN OUTPATIENT /HOSPITAL COMPLETE 1/3/2017 12/24/2016 12/30/2016 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERIKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 1/3/2017 12/25/2016 12/30/2016 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 1/3/2017 12/26/2016 12/31/2016 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 8079 CHEST PAIN, UNSPECIFIED PROFESSIONAL FRONTAL INPATIENT /HOSPITAL $0.00 $288.00 MALE SUBSCRIBER 1 OSO $0.00 $288.00 MALE SUBSCRIBER 1 050 $107.93 $288.00 MALE SUBSCRIBER 1 0S0 {$12.56) ($92.007 MALE SUBSCRIBER 1 OSO $0.00 (1 MALE SUBSCRIBER 1 PRO $54,937.90 $188,204.00 $1947 $45.00 MALE SUBSCRIBER 1 BCC $64.44 $164.00 MALE SUBSCRIBER 1 BCC $45.62 $110.00 MALE SUBSCRIBER 1 BCC $45.62 $110.00 MALE SUBSCRIBER 1 BCC $15.84 $41.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE 3559 3559 3559 3559 3559 III WE 1/3/2017 12/27/2016 12/30/2016 78452 Myocardial perfusion imaging, tomographlc (SPELT) 1209 ANGINA PECTORIS, PROFESSIONAL $124.64 $449.00 MALE (including attenuation correction, qualitative or UNSPECIFIED INPATIENT /HOSPITAL $124.64 $449.00 MALE qua Mdative all motion, ejection fraction by first pass or 1 BCC 3559 $124.64 $449.00 MALE gated technique, additional quantification, when 1 BCC 3559 $113.25 $113.26 MALE perfarmed); multiple studies, at rest and /or 1 BCC 3559 1/3/2017 12/29/2016 12/31/2016 74000 RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE R109 UNSPECIFIED ABDOMINAL PROFESSIONAL 3559 ANTEROPOSTERIOR VIEW PAIN INPATIENT /HOSPITAL 1/5/2017 12/17/2016 1/4/2017 * * * ** * * * ** * " * ** * * * ** * * * ** 1/5/2017 12/23/2016 1/4/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PO ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/5/2017 12/26/2016 1/4/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM ED ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/5/2017 12/27/2016 1/4/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM ED ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/5/2017 12/28/2016 1/4/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/5/2017 12/29/2016 1/3/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R05 COUGH PROFESSIONAL FRONTAL INPATIENT /HOSPITAL 1/5/2017 12/29/2016 1/4/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT or PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/10/2017 12/19/2016 1/9/2017 *xxxx .xxxx xxxxx . + + *. .xxxx 1/10/2017 12/20/2016 1/9/2017 1/10/2017 12/21/2016 1/9/2017 * * * ** * * * ** * * * ** * * * ** * * * ** 1/10/2017 12/29/2016 '/'/2017 1/11/2017 12/16/2016 1/10/2017 * * * ** 1/11/2017 12/17/2016 1/10/2017 $134.59 $384.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 $15.84 $45.00 MALE SUBSCRIBER 1 BCC 3559 $99234 $1,617.00 MALE SUBSCRIBER 1 BCC 3559 $81.89 $190.00 MALE SUBSCRIBER 1 BCC 3559 $81.89 $190.00 MALE SUBSCRIBER 1 BCC 3559 $81.89 $190.00 MALE SUBSCRIBER 1 BCC 3559 $81.89 $190.00 MALE SUBSCRIBER 1 BCC 3559 $15.84 $41.00 MALE SUBSCRIBER 1 BCC 3559 $81.89 $190.00 MALE SUBSCRIBER 1 BCC 3559 $213.25 $1,196.00 MALE SUBSCRIBER 1 BCC 3559 $124.64 $449.00 MALE SUBSCRIBER 1 BCC 3559 $124.64 $449.00 MALE SUBSCRIBER 1 BCC 3559 $124.64 $449.00 MALE SUBSCRIBER 1 BCC 3559 $113.25 $113.26 MALE SUBSCRIBER 1 BCC 3559 $124.58 $124.58 MALE SUBSCRIBER 1 BCC 3559 1/11/2017 12/22/2016 111012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M726 NECROTIZING FASCIITIS PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/11/2017 12/23/2016 111012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M726 NECROTIZING FASCIITIS PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/11/2017 12/24/2016 111012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M726 NECROTIZING FASCIITIS PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/11/2017 12/26/2016 111012017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1209 ANGINA PECTORIS, PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES UNSPECIFIED INPATIENT /HDSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 1/11/2017 12/27/2016 1/10/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M726 NECROTIZING FASCIITIS PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEV COMPON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/11/2017 12/27/2016 111012017 93016 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR 1209 ANGINA PECTORIS, PROFESSIONAL SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, UNSPECIFIED INPATIENT/HOSPITAL CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND /OR PHARMACOLOGICAL STRESS; PHYSICIAN SUPERVISION ONLY, WITHOUT INTERPRETATION AND REPORT 1/11/2017 12/27/2016 111012017 93018 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR 1209 ANGINA PECTORIS, PROFESSIONAL SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, UNSPECIFIED INPATIENT /HOSPITAL CONTINUOUS ELECTRDCARDIOGRAPHIC MONITORING, AND /OR PHARMACOLOGICAL STRESS; INTERPRETATION AND REPORT ONLY 1/11/2017 12/27/2016 1/10/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1209 ANGINA PECTORIS, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $85.95 $312.00 MALE SUBSCRIBER 1 BCC $8535 $312.00 MALE SUBSCRIBER 1 BCC $85.95 $312.00 MALE SUBSCRIBER 1 BCC $221.18 $555.00 MALE SUBSCRIBER 1 BCC $8535 $312.00 MALE SUBSCRIBER 1 BCC $19.94 $400.00 MALE SUBSCRIBER 1 BCC $13.42 $400.00 MALE SUBSCRIBER 1 BCC $113.66 $284.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 w Z N Q! 3559 7 fl } fl N. CL 3559 Q, Q 4 F W 3559 O d 3559 {j O J W 3559 J v 3559 llJ U Q 3559 1/11/2017 12/28/2016 111012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M726 NECROTIZING FASCIITIS PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/13/2017 12/22/2016 1/12/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N183 CHRONIC KIDNEY DISEASE, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH STAGE 3(MODERATE) INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 111]1201] 12/20/2016 111312017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION N183 CHRONIC KIDNEY DISEASE, PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES STAGE 3(MODERATE) INPATIENT/HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 1/17/2017 12/21/2016 1/16/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N183 CHRONIC KIDNEY DISEASE, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH STAGE 3(MODERATE) INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 1/17/2017 12/23/2016 1/13/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N183 CHRONIC KIDNEY DISEASE, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH STAGE 3(MODERATE) INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 111712017 12/30/2016 111212017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/17/2017 12/31/2016 1/12/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 111812017 12/21/2016 1/17/2017 1118/2017 12/22/2016 1/17/2017 1/18/201] 12/23/2016 1/1]/2017 1/18/201] 12/27/2016 1/1]/2017 1/20/2017 11/11/2016 1/19/2017 99291 CRITICALCARE, EVALUATION AND MANAGEMENT OF THE K922 GASTROINTESTINAL PROFESSIONAL CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST30- HEMORRHAGE, OUTPATIENT /HOSPITAL 74 MINUTES UNSPECIFIED $85.95 $312.00 MALE SUBSCRIBER 1 BCC $66.54 $167.00 MALE SUBSCRIBER 1 BCC $0.00 $313.00 MALE SUBSCRIBER 1 BCC $95.77 $240.00 MALE SUBSCRIBER 1 BCC $66.54 $167.00 MALE SUBSCRIBER 1 BCC $81.89 $190.00 MALE SUBSCRIBER 1 BCC $81.89 $190.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE mm ®' WE ®' $156.88 $395.00 MALE SUBSCRIBER 1 BCC 3559 $64.35 $152.00 MALE SUBSCRIBER 1 BCC 3559 $64.35 $152.00 MALE SUBSCRIBER 1 BCC 3559 $95.06 $130.00 MALE SUBSCRIBER 1 BCC 3559 $792.48 $1,583.00 MALE SUBSCRIBER 1 BCC 3559 112012017 12/22/2016 1/19/2017 99255 INPATIENT CONSULTATION FOR ANEW OR ESTABLISHED M545 LOW BACK PAIN PROFESSIONAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSI 112012017 12/30/2016 1/19/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M545 LOW BACK PAIN PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/25/2017 11/12/2016 112312017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION K922 GASTROINTESTINAL PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES HEMORRHAGE, INPATIENT/HOSPITAL THESE KEY COMPONENTS: A COMPREHENSIVE HISTORY; UNSPECIFIED A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 1/25/2017 11/14/2016 1/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE K922 GASTROINTESTINAL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HEMORRHAGE, INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A UNSPECIFIED DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 1/25/2017 11/15/2016 1/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE K922 GASTROINTESTINAL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HEMORRHAGE, INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A UNSPECIFIED DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 1/25/2017 11/16/2016 112312017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE K922 GASTROINTESTINAL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HEMORRHAGE, INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A UNSPECIFIED DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 1/25/2017 11/17/2016 1/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE K922 GASTROINTESTINAL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HEMORRHAGE, INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A UNSPECIFIED DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $184.62 $425.00 MALE SUBSCRIBER 1 BCC $51.55 $120.00 MALE SUBSCRIBER 1 BCC $188.01 $554.00 MALE SUBSCRIBER 1 BCC $96.12 $283.00 MALE SUBSCRIBER 1 BCC $96.12 $283.00 MALE SUBSCRIBER 1 BCC $96.12 $283.00 MALE SUBSCRIBER 1 BCC $96.12 $283.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE mm ®' WE ®' 1/25/2017 11/18/2016 1/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE K922 GASTROINTESTINAL PROFESSIONAL $154.00 MALE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH 1 BCC HEMORRHAGE, INPATIENT /HOSPITAL SUBSCRIBER REQU I RES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A $6142 UNSPECIFIED SUBSCRIBER 1 BCC DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 1/25/2017 11/19/2016 1/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE K922 GASTROINTESTINAL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HEMORRHAGE, INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A UNSPECIFIED DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 1/25/2017 11/20/2016 112312017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE K922 GASTROINTESTINAL PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH HEMORRHAGE, INPATIENT/HOSPITAL REQUIRESAT LEAST 2 OFTHESE 3 KEY COMPONENTS:A UNSPECIFIED DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 1/25/2017 11/21/2016 1/23/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE K922 GASTROINTESTINAL PROFESSIONAL THAN 3D MINUTES HEMORRHAGE, INPATIENT /HDSPITAL UNSPECIFIED 1/30/2017 11112017 1/5/2017 76870 ULTRASOUND, SCROTUM AND CONTENTS N5089 OTHER SPECIFIED PROFESSIONAL DISORDERS OF THE MALE INPATIENT /HOSPITAL GENITAL ORGANS 1/30/2017 1/1/2017 1/5/2017 93975 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS N5089 OTHER SPECIFIED PROFESSIONAL OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS DISORDERS OF THE MALE INPATIENT /HOSPITAL AND /OR RETROPERITONEAL ORGANS; COMPLETE STUDY GENITAL ORGANS 1/30/2017 11112017 111212017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E675 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/2/2017 1/12/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/3/2017 1/6/2017 76705 ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE R140 ABDOMINAL DISTENSION PROFESSIONAL DOCUMENTATION; LIMITED LEG, SINGLE ORGAN, (GASEOUS) INPATIENT /HOSPITAL QUADRANT, FOLLOW -UP) 1/30/2017 1/3/2017 1/12/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL REQUIRESAT LEAST 2 OF THESE 3 KEY COMPON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR $96.12 $283.00 MALE SUBSCRIBER 1 BCC $96.12 $283.00 MALE SUBSCRIBER 1 BCC $96.12 $283.00 MALE SUBSCRIBER 1 BCC $96.01 $289.00 MALE SUBSCRIBER 1 BCC $0.00 $154.00 MALE SUBSCRIBER 1 BCC $0.00 $382.00 MALE SUBSCRIBER 1 BCC $6142 $190.00 MALE SUBSCRIBER 1 BCC $34.33 $190.00 MALE SUBSCRIBER 1 BCC $0.00 $154.00 MALE SUBSCRIBER 1 BCC $61.42 $190,00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE 3559 3559 3559 3559 3559 3559 1/30/2017 1/4/2017 111212017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERIKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/4/2017 1/16/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E871 HYPO- OSMOLALITY AND PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HYPONATREMIA INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 113012017 1/5/2017 111212017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/5/2017 1/13/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL THERAPEUTIC); WITH IMAGING GUIDANCE INPATIENT /HDSPITAL 1/30/2017 1/5/2017 1/16/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E871 HYPO- OSMOIALITY AND PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HYPONATREMIA INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/6/2017 1/9/2017 72192 COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST R198 OTHER ASCITES PROFESSIONAL MATERIAL INPATIENT /HOSPITAL 1/30/2017 116/2017 1/16/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E871 HYPO- OSMOIS.LITY AND PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HYPONATREMIA INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/6/2017 1/20/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERIKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD N ENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 1/30/2017 1/7/2017 1/12/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D72829 ELEVATED WHITE BLOOD PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH CELL COUNT, INPATIENT /HOSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS: AN UNSPECIFIED EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR $61.42 $190.00 MALE SUBSCRIBER 1 BCC $49.90 $167.00 MALE SUBSCRIBER 1 BCC $61.42 $190.00 MALE SUBSCRIBER 1 BCC $140.92 $422.00 MALE SUBSCRIBER 1 BCC $49.90 $167.00 MALE SUBSCRIBER 1 BCC $0.00 $223.00 MALE SUBSCRIBER 1 BCC $49.90 $167.00 MALE SUBSCRIBER 1 BCC $34.21 $110.00 MALE SUBSCRIBER 1 BCC $47.16 $181.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE ®' I t ;tSl Im 1/30/2017 1/]/201] 112012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/8/2017 112012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 113012017 1/9/2017 1/17/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E871 HYPO- OSMOLALITY AND PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HYPONATREMIA INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT 15 STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 1/30/2017 1/9/2017 112012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/10/2017 1/13/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D72829 ELEVATED WHITE BLOOD PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH CELL COUNT, INPATIENT /HOSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS: AN UNSPECIFIED EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 113012017 1/10/2017 112012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/11/2017 1/16/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D72829 ELEVATED WHITE BLOOD PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH CELL COUNT, INPATIENT /HDSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS: AN UNSPECIFIED EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR $61.42 $190.00 MALE SUBSCRIBER 1 BCC $6142 $190.00 MALE SUBSCRIBER 1 BCC $27.79 $95.00 MALE SUBSCRIBER 1 BCC $61.42 $190.00 MALE SUBSCRIBER 1 BCC $47.16 $181.00 MALE SUBSCRIBER 1 BCC $61.42 $190.00 MALE SUBSCRIBER 1 BCC $47.16 $181.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE mm ®' WE ®' 1/30/2017 1/11/2017 112012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/12/2017 111812017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D72829 ELEVATED WHITE BLOOD PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH CELL COUNT, INPATIENT /HDSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS: AN UNSPECIFIED EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 113012017 1/12/2017 112012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/13/2017 1/16/2017 72193 COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST R531 WEAKNESS PROFESSIONAL MATERIALS) INPATIENT /HDSPITAL 1/30/2017 1/13/2017 1/18/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D72829 ELEVATED WHITE BLOOD PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH CELL COUNT, INPATIENT /HOSPITAL REQU I R ES AT LEAST 20 F TH ESE 3 KEY COM PO N E MRS AN UNSPECIFIED EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/13/2017 1126/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/16/2017 1/20/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D72829 ELEVATED WHITE BLOOD PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH CELL COUNT, INPATIENT /HOSPITAL REQU I R ES AT LEAST 20 F TH ESE 3 KEY COM PO N E FEES AN UNSPECIFIED EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/30/2017 1/16/2017 1126/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD EFTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1130/2017 1/17/2017 1/19/2017 A0425 GROUND MILEAGE, PER STATUTE MILE M25559 PAIN IN UNSPECIFIED HIP OTHER MEDICAL 1/30/2017 1/17/2017 1/19/2017 A0428 AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON- M25559 PAIN IN UNSPECIFIED HIP OTHER MEDICAL EMERGENCY TRANSPORT, (BLS) $61.42 $190.00 MALE SUBSCRIBER 1 BCC $47.16 $181.00 MALE SUBSCRIBER 1 BCC $61.42 $190.00 MALE SUBSCRIBER 1 BCC $76.63 $235.00 MALE SUBSCRIBER 1 BCC $47.16 $181.00 MALE SUBSCRIBER 1 BCC $61.42 $190.00 MALE SUBSCRIBER 1 BCC $47.16 $181.00 MALE SUBSCRIBER 1 BCC $61.42 $190.00 MALE SUBSCRIBER 1 BCC $343.12 $457.50 MALE SUBSCRIBER 1 BCC $192.37 $296.06 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE ®' Mpg mm k11S] 1/30/2017 1/17/2017 112012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D72829 ELEVATED WHITE BLOOD PROFESSIONAL $250.00 MALE SUBSCRIBER 1 BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH $109.]2 CELL COUNT, INPATIENT /HOSPITAL SUBSCRIBER 1 BCC 3559 REQUIRES AT LEAST 20F THESE 3 KEY COMPONENT&AN $250.00 MALE UNSPECIFIED 1 BCC 3559 $109.72 EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN SUBSCRIBER 1 BCC 3559 $109.72 $250.00 MALE EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL 1 BCC 3559 $109.72 $250.00 MALE SUBSCRIBER DECISION MAKING OF MODERATE COMPLEXITY. 3559 $9.20 $105.50 MALE SUBSCRIBER 1 BCC COUNSELING AND /OR $18.40 $211.00 MALE 1/30/2017 1/17/2017 1/26/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT / HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 113012017 1/21/2017 1/26/2017 - - R300 DYSURIA HOSPITAL OUTPATIENT 1/31/2017 1/2/2017 1/26/2017 1/31/2017 12/1]/2016 1/24/201] 21112017 1/14/201] 1/23/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E875 HYPERKALEMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 2/2/2017 1/30/2017 1/31/2017 99304 INITIAL NURSING FACILITY CARE, PER DAY, FOR THE L89892 PRESSURE ULCER OF OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH OTHER SITE, STAGE REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWAR 2/6/2017 12/17/2016 2/3/2017 2/9/2017 '/"2017 2/7/2017 99308 SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE L98499 NON PRESSURE CHRONIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH ULCER OF SKIN OF OTHER REQUIRESATLEAST 20F THESE 3 KEYCOMPONENTS :AN SITES WITH UNSPECIFIED EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN SEVERITY EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND 2/912011 12/29/2016 2/7/2017 2/13/2017 1/18/2017 1/31/201] +xxxx *x..x xxxxx xx *.. xx.x. 2/13/201] 1/20/201] 1/31/201] 2/13/2017 1/23/2017 1/31/2017 2/13/2017 1/25/2017 1/31/2017 * *xxx *xxx* xxxxx x *... xxx »x 2/13/2017 1/27 /2017 1/31/2017 *x*xx sxswx xxx ** xxsss sxs*w 2/13/2017 1/30/2017 1131/2017 2/13/2017 12/17/2016 2/10/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R531 WEAKNESS PROFE55IONAL LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL 2/13/2017 12/26/2016 2/10/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R531 WEAKNESS PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL $47.16 $181.00 MALE SUBSCRIBER 1 BCC $6142 $190.00 MALE SUBSCRIBER 1 BCC $215.43 $383.00 MALE SUBSCRIBER 1 BCC $71.29 $130.00 MALE SUBSCRIBER 1 BCC 12/17/2016 NNHkk### $168,043.85 $258,529.00 MALE SUBSCRIBER 1 BCC $34.21 $110.00 MALE SUBSCRIBER 1 BCC $3136 $111.46 MALE SUBSCRIBER 1 BCC $615.93 $1,367.00 MALE SUBSCRIBER 1 BCC $35.98 $161.58 MALE SUBSCRIBER 1 BCC C.7.f 3559 III 1 ®' m $148.06 $260.00 MALE SUBSCRIBER 1 BCC 3559 $139.39 $250.00 MALE SUBSCRIBER 1 BCC 3559 $109.]2 $250.00 MALE SUBSCRIBER 1 BCC 3559 $109.72 $250.00 MALE SUBSCRIBER 1 BCC 3559 $109.72 $250.00 MALE SUBSCRIBER 1 BCC 3559 $109.72 $250.00 MALE SUBSCRIBER 1 BCC 3559 $109.72 $250.00 MALE SUBSCRIBER 1 BCC 3559 $9.20 $105.50 MALE SUBSCRIBER 1 BCC 3559 $18.40 $211.00 MALE SUBSCRIBER 1 BCC 3559 2/15/2017 12/22/2016 2/13/2017 99255 INPATIENT CONSULTATION FOR ANEW OR ESTABLISHED M545 LOW BACK PAIN PROFESSIONAL $11.74 $58.00 MALE SUBSCRIBER PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A 3559 INPATIENT /HOSPITAL $689.00 MALE SUBSCRIBER 1 BCC COMPREHENSIVE HISTORY; A COMPREHENSIVE $41.92 $203.00 MALE SUBSCRIBER 1 BCC 3559 EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH $115.00 MALE SUBSCRIBER 1 BCC 3559 $140.92 COMPLEXITY. COUNSELING AND /OR COORDINATION OF SUBSCRIBER 1 BCC 3559 $95.50 $313.00 MALE CARE WITH OTHER PROVIDERS OR AGENCIES ARE 1 BCC 3559 PROVIDED CONSI 2/15/2017 12/30/2016 2/13/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M545 LOW BACK PAIN PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT / HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 2/16/2017 10/27/2016 2/14/2017 93306 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH 110 ESSENTIAL (PRIMARY) PROFESSIONAL IMAGE DOCUMENTATION XM, INCLUDES M -MODE HYPERTENSION OUTPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 211712017 12/30/2016 2/15/2017 2/27/2017 2/14/2017 2/21/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R188 OTHER ASCITES PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 2/27/2017 2/14/2017 2/21/2017 74176 Computed tomography, abdomen and pelvis; without R188 OTHER ASCITES PROFESSIONAL contrast material OUTPATIENT /HOSPITAL 2/27/2017 2/14/2017 2121/2017 76870 ULTRASOUND, SCROTUM AND CONTENTS R188 OTHER ASCITES PROFESSIONAL OUTPATIENT /HOSPITAL 2/27/2017 2/14/2017 2/21/2017 93910 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING R188 OTHER ASCITES PROFESSIONAL RESPONSES TO COMPRESSION AND OTHER MANEUVERS; OUTPATIENT /HOSPITAL COMPLETE BILATERAL STUDY 2/27/2017 2/15/2017 2/20/2017 49083 ABDOMINAL PARACENTE515(DIAGN0STIC OR R188 OTHER ASCITES PR0FE55IONAL THERAPEUTIC); WITH IMAGING GUIDANCE INPATIENT /HOSPITAL 2/27/2017 2120/2017 2/23/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 8601 GENERALIZED EDEMA PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 2/27/2017 2/21/2017 2/24/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 8601 GENERALIZED EDEMA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 3/1/2017 1/812017 2/15/2017 3/1/2017 11101201] 2/15/201] 3/1/2017 1/15/2017 2/15/2017 *"" ** * * * ** *r' * *' * * * ** * * * ** C.7.f $0.00 $425.00 MALE SUBSCRIBER 1 BCC 3559 W N M Q! A 4 $0.00 $120.00 MALE SUBSCRIBER 1 BCC 3559 7 fl } fl CL $65.92 $719.00 MALE SUBSCRIBER 1 BCC 3559 CL Q $97.84 $200.00 MALE SUBSCRIBER 1 BCC 3559 $11.74 $58.00 MALE SUBSCRIBER 1 BCC 3559 $107.81 $689.00 MALE SUBSCRIBER 1 BCC 3559 $41.92 $203.00 MALE SUBSCRIBER 1 BCC 3559 $4531 $115.00 MALE SUBSCRIBER 1 BCC 3559 $140.92 $422.00 MALE SUBSCRIBER 1 BCC 3559 $95.50 $313.00 MALE SUBSCRIBER 1 BCC 3559 $49.90 $167.00 MALE SUBSCRIBER 1 BCC $97.74 $200.00 MALE SU BSCRIRER 1 BCC $9].]4 $200.00 MALE SUBSCRIBER 1 BCC $97.74 $200.00 MALE SUBSCRIBER 1 BCC IM I 3/1/2017 2/15/2017 212112017 99254 INPATIENT CONSULTATION FOR ANEW OR ESTABLISHED N4889 OTHER SPECIFIED PROFESSIONAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DISORDERS OF PENIS INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED C 3/1/2017 2/16/2017 2/21/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N4889 OTHER SPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH DISORDERS OF PENIS INPATIENT / HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 3/6/2017 2/14/2017 3/1/2017 * * *'" "' *' "` *+ ....... " "x 3/6/2017 2/23/2017 3/1/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R601 GENERALIZED EDEMA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PO ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 3/6/2017 2/24/2017 2127/2017 71020 RADIOLDGIC EXAMINATION, CHEST, TWO VIEWS, R509 FEVER, UNSPECIFIED PROFESSIONAL FRONTAL AND LATERAL; INPATIENT /HOSPITAL 3/6/2017 2/24/2017 2/28/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE N4889 OTHER SPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH DISORDERS OF PENIS INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 3/6/2017 2/24/2017 3/2/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R601 GENERALIZED EDEMA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PO ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 3/6/2017 2/26/2017 2/28/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N4889 OTHER SPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH DISORDERS OF PENIS INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 3/6/2017 2/27/2017 3/2/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N4889 OTHER SPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH DISORDERS OF PENIS INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR $114.98 $415.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 $47.16 $181.00 MALE SUBSCRIBER 1 BCC 3559 $136.80 $473.00 MALE SUBSCRIBER 1 BCC 3559 $49.90 $167.00 MALE SUBSCRIBER 1 BCC 3559 $14.60 $45.00 MALE SUBSCRIBER 1 BCC 3559 $47.16 $181.00 MALE SUBSCRIBER 1 BCC 3559 $49.90 $167.00 MALE SUBSCRIBER 1 BCC 3559 $47.16 $181.00 MALE SUBSCRIBER 1 BCC 3559 $47.16 $181.00 MALE SUBSCRIBER 1 BCC 3559 3/8/2017 2/22/2017 2/27/2017 3/8/2017 2/26/2017 3/3/2017 3/8/2017 2/28/2017 3/3/2017 3/10/2017 11/11/2016 3/8/2017 3/13/2017 2/14/2017 2/22/2017 * ** »* 3/13/2017 2/14/2017 2/22/2017 * * * ** 3/13/2017 12/18/2016 3/10/2017 * * * ** 3/13/2017 12/20/2016 3/10/2017 * * * ** 3/13/2017 12/21/2016 3/10/2017 3/13/2017 12/22/2016 3/10/2017 3/13/2017 12/23/2016 3/10/2017 3/13/2017 12/24/2016 3/10/2017 * *... 3/13/2017 12/25/2016 3/10/2017 * * * ** 3/13/2017 12126/2016 3/10/2017 3/13/2017 12/27/2016 3/10/2017 » » »»» 3/13/2017 12/28/2016 3/10/2017 3/13/2017 12/29/2016 3/10/2017 * * * ** 3/13/2017 12/30/2016 3/10/2017 *»* »* 3/13/2017 12/31/2016 3/10/2017 *» » ** 3/14/2017 2/14/2017 3/7/2017 * * * ** 3/14/2017 2/14/2017 3/8/2017 A0425 3/14/2017 2/14/2017 3/8/2017 A0429 3/15/2017 1117/2017 3/4/2017 - 3/16/2017 3/2/2017 3/8/2017 E0260 3/16/2017 12/19/2016 3/14/2017 * * * ** 3/17/2017 2/14/2017 3/8/2017 A0425 3/17/2017 2/14/2017 3/8/2017 A0427 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE R601 GENERALIZED EDEMA PROFESSIONAL $49.90 $167.00 MALE SUBSCRIBER EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R601 GENERALIZED EDEMA PROFESSIONAL $49.90 $167.00 MALE SUBSCRIBER EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R601 GENERALIZED EDEMA PROFESSIONAL $49.90 $167.00 MALE SUBSCRIBER EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 I10 ESSENTIAL (PRIMARY) PROFESSIONAL $8.95 $28.00 MALE SUBSCRIBER LEADS; INTERPRETATION AND REPORT ONLY HYPERTENSION OUTPATIENT /HOSPITAL $11,428.86 $20,781.00 MALE SUBSCRIBER xxxx* *.. *x ..xxs sxxx* $0, $20,781.00 MALE SUBSCRIBER $145.73 $504.00 MALE SUBSCRIBER * * * ** * * » ** * * * ** * * * ** $96.12 $283.00 MALE SUBSCRIBER $96.12 $283.00 MALE SUBSCRIBER * * » ** * * * ** * * * ** * * * ** $96.12 $283.00 MALE SUBSCRIBER * * * ** *' * ** * * + ** * * * ** $96.12 $283.00 MALE SUBSCRIBER $96.12 $283.00 MALE SUBSCRIBER $96.12 $283.00 MALE SUBSCRIBER $96.12 $283.00 MALE SUBSCRIBER MALE SUBSCRIBER $283.00 MALE SUBSCRIBER $96.12 $283.00 MALE SUBSCRIBER $96.12 $283.00 MALE SUBSCRIBER ..... " » » ** ... ** * * * ** $66.72 $195.00 MALE SUBSCRIBER 2/14/2017 # # # # #### $53,006.73 $82,950.00 MALE SUBSCRIBER GROUND MILEAGE, PERSTATUTE MILE 80602 SHORTNESS OF BREATH OTHER MEDICAL $30.00 $39.00 MALE SUBSCRIBER AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY R0602 SHORTNESS OF BREATH OTHER MEDICAL $339.32 $750.00 MALE SUBSCRIBER TRANSPORT (BITS EMERGENCY) - M6282 RHABDOMYOLYSIS HOSPITAL INPATIENT 1/17/2017 # # # # # # ## $0.00 $10,962.57 MALE SUBSCRIBER HOSPITALBED ,SEMI - ELECTRIC (HEAD AND FOOT K7200 ACUTE AND SUBACUTE OTHER MEDICAL $67.77 $67.77 MALE SUBSCRIBER ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITH HEPATIC FAILURE MATTRESS W ITHOUT COMA * * * ** * * * ** * * * ** $96.12 $283.00 MALE SUBSCRIBER GROUND MILEAGE, PER STATUTE MILE N4829 OT HER INFLAMMATORY OTHER MEDICAL $620.00 $806.00 MALE SUBSCRIBER DISORDERS OF PENIS AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, N4829 OT HER INFLAMMATORY OTHER MEDICAL $402.94 $850.00 MALE SUBSCRIBER EMERGENCY TRANSPORT, LEVEL 1(AIS1- EMERGENCY) DISORDERS OF PENIS 0� F�� IId 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 B CC 1 BCC 1 BCC 1 BCC BCC 1 BCC 1 BCC 1 BCC 1 BCE 1 BCC " 'CC 1 BCC 1 BCC 1 BCC m C.7.f 3559 Im WE III= 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 mm 3/17/2017 2/15/2017 3/9/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FORTH EVALUATION 53733XA LACERATION OF PROFESSIONAL $235.00 MALE AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 1 BCC URETHRA, INITIAL INPATIENT /HOSPITAL SUBSCRIBER THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; ENCOUNTER A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 3/17/2017 2/24/2017 3/9/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE S3733XA LACERATION OF PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH URETHRA, INITIAL INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN ENCOUNTER EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 3/17/2017 2/25/2017 3/9/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE S3733XA LACERATION OF PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH URETHRA, INITIAL INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ENCOUNTER DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 3/17/2017 2/26/2017 3/9/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE S3733XA LACERATION OF PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH URETHRA, INITIAL INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ENCOUNTER DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 3/17/2017 2/27/2017 3/3/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R601 GENERALIZED EDEMA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 3/17/2017 2/27/2017 3/9/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 53733XA LACERATION OF PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH URETHRA, INITIAL INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENT&AN ENCOUNTER EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 3/17/2017 2/28/2017 3/3/2017 K0001 STANDARD WHEELCHAIR K7200 ACUTE AND SUBACUTE OTHER MEDICAL HEPATIC FAILURE WITHOUTCOMA 3/17/2017 2/28/2017 3/9/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE S3733XA LACERATION OF PROFESSIONAL THAN 30 MINUTES URETHRA, INITIAL INPATIENT /HOSPITAL ENCOUNTER 3/17/2017 2/28/2017 3/9/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N4889 OTHER SPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH DISORDERS OF PENIS INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 3/21/2017 2/1/2017 3/20/2017 ..... ..... ..... ..... ..... $179.79 $450.00 MALE SUBSCRIBER 1 BCC $6410 $160.00 MALE SUBSCRIBER 1 BCC $92.39 $250.00 MALE SUBSCRIBER 1 BCC $92.39 $250.00 MALE SUBSCRIBER 1 BCC $49.90 $167.00 MALE SUBSCRIBER 1 BCC $64.20 $160.00 MALE SUBSCRIBER 1 BCC $2819 $37.72 MALE SUBSCRIBER 1 BCC $92.38 $235.00 MALE SUBSCRIBER 1 BCC $62.88 $181,00 MALE SUBSCRIBER 1 BCC $146.29 $250.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE mm ®' WE 3559 3559 3559 wo C.7.f 3/21/2017 2/3/2017 3/20/2017 k $250.00 MALE SUBSCRIBER 3/21/2017 2/6/2017 3/20/2017 * ° ** $146.29 312112017 2/8/2017 3/20/2017 * * * "* * * * ** *« * ** 3/21/2017 2/10/2017 3/20/2017 * " * ** * * * ** * " * ** 3/21/2017 2/13/2017 3/20/2017 $146.29 $250.00 MALE 3/23/2017 2/17/2017 3/22/2017 3/23/2017 2/19/2017 3/22/2017 1 BCC 3559 3/24/2017 11/12/2016 3118/2017 $340.00 MALE SUBSCRIBER 3/24/2017 11/12/2016 12/9/2016 $52.95 3/24/2017 11/12/2016 12/9/2016 * * * ** * *' ** * *• *' 3/27/2017 12/20/2016 3123/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE N183 3559 * * * ** * * * ** EVALUATION AND MANAGEMENTOFA PATIENT, WHICH $190.00 MALE SUBSCRIBER 1 BCC 3559 } REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A $0.00 i$270 .D0) MALE SUBSCRIBER DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; 3559 CHRONIC KIDNEY DISEASE, PROFESSIONAL $95.77 MEDICAL DECISION MAKING OF HIGH COMPLEXITY. SUBSCRIBER 1 BCC 3559 STAGE 3 (MODERATE) COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 3/29/2017 3/20/2017 3/28/2017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, R319 W FRONTAL 3/29/2017 3/20/2017 3/28/2017 74176 Computed tomography, abdomen and pelvis; without R319 contrast material fl i® 3/29/2017 3/21/2017 3/28/2017 74176 Computed tomography, abdomen and pelvis; without R319 CL contrast material 3/29/2017 3/23/2017 3/28/2017 74450 URETHROCYSTOGRAPHY , RETROGRADE, RADIOLOGICAL N139 SUPERVISION AND INTERPRETATION 3/29/2017 3/23/2017 3/28/2017 74176 Computed tomography, abdomen and pelvis; without R188 SUBSCRIBER 1 BCC 3559 v ontrast material OUTPATIENT /HOSPITAL 3/30/2017 2/13/2017 3/29/2017 99309 SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE L98499 EVALUATION AND MANAGEMENT OF PATIENT, WHICH Q HEMATURIA, REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A $143.75 $689.00 MALE SUBSCRIBER 1 BCC DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; UNSPECIFIED OUTPATIENT /HOSPITAL MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 3/30/2017 3/20/2017 3/29/2017 99053 SERVICES) PROVIDED BETWEEN 10:00 PM AND 8:00 AM N491 $143.75 $689.00 MALE SUBSCRIBER AT 24 -HOUR FACILITY, IN ADDITION TO BASIC SERVICE 3559 h 3/30/2017 3/20/2017 3/29/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION N481 Z AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A OBSTRUCTIVE AND PROFESSIONAL $30.12 $125.00 MALE DETAILED EXAMINATION; AND MEDICAL DECISION 1 BCC 3559 _ REFLUX UROPATHY, INPATIENT / HDSPITAL MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR 3/30/2017 3/28/2017 3129/2017 K0001 STANDARD WHEELCHAIR K7200 4/3/2017 2/15/2017 3/31/2017 82042 ALBUMIN; URINE OR OTHER SOURCE, QUANTITATIVE, N492 EACH SPECIMEN NON- PRESSURE CHRONIC 4/3/2017 2115/2017 3/31/2017 82945 GLUCOSE, BODY FLUID,OTHERTHAN BLOOD N492 * * * ** * * * ** $146.29 $250.00 MALE SUBSCRIBER 1 BCC 3559 $146.29 $250.00 MALE SUBSCRIBER 1 BCC 3559 * * » »« * * » »* $146.29 $250.00 MALE SUBSCRIBER 1 BCC 3559 {U * * * ** * * * ** $146.29 $250.00 MALE SUBSCRIBER 1 BCC 3559 N $146.29 $250.00 MALE SUBSCRIBER 1 BCC 3559 * * * »« * * * »* $231.75 $340.00 MALE SUBSCRIBER 1 BCC 3559 $52.95 $80.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 * * * ** * * * ** $136.81 $190.00 MALE SUBSCRIBER 1 BCC 3559 } $0.00 i$270 .D0) MALE SUBSCRIBER 1 BCC 3559 CHRONIC KIDNEY DISEASE, PROFESSIONAL $95.77 $240.00 MALE SUBSCRIBER 1 BCC 3559 STAGE 3 (MODERATE) INPATIENT /HOSPITAL ate+ W } fl i® CL CL Q HEMATURIA, PROFESSIONAL $15.65 $58.00 MALE SUBSCRIBER 1 BCC 3559 v UNSPECIFIED OUTPATIENT /HOSPITAL Q HEMATURIA, PROFESSIONAL $143.75 $689.00 MALE SUBSCRIBER 1 BCC 3559 UNSPECIFIED OUTPATIENT /HOSPITAL W HEMATURIA, PROFESSIONAL $143.75 $689.00 MALE SUBSCRIBER 1 BCC 3559 h UNSPECIFIED OUTPATIENT /HOSPITAL Z OBSTRUCTIVE AND PROFESSIONAL $30.12 $125.00 MALE SUBSCRIBER 1 BCC 3559 _ REFLUX UROPATHY, INPATIENT / HDSPITAL UNSPECIFIED OTHER ASCITES PROFESSIONAL $143.75 $689.00 MALE SUBSCRIBER 1 BCC 3559 INPATIENT /HOSPITAL CL NON- PRESSURE CHRONIC OTHER MEDICAL $105.61 $213.90 MALE SUBSCRIBER 1 BCC 3559 ULCER OF SKIN OF OTHER SITES WITH UNSPECIFIED U SEVERITY J ILLJ Ip V BALANITIS PROFESSIONAL $0.00 $30.00 MALE SUBSCRIBER 1 BCC 3559 �q OUTPATIENT /HOSPITAL J BALANITIS PROFESSIONAL $182.40 $443.00 MALE SUBSCRIBER 1 BCC 3559 v OUTPATIENT /HOSPITAL W U Q ACUTE AND SUBACUTE OTHER MEDICAL $37.72 $37.72 MALE SUBSCRIBER 1 BCC 3559 HEPATIC FAI LURE Q WITHOUT COMA C"! INFLAMMATORY PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1 BCC 3559 N DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $11.00 MALE SUBSCRIBER 1 BCC 3559 y DISORDERS OF SCROTUM INPATIENT /HOSPITAL 4/3/2017 2/15/2017 3/31/2017 4/3/2017 2/15/2017 3/31/2017 4/3/2017 2/15/2017 3/31/2017 4/3/2017 2/15/2017 3/31/2017 4/3/2017 2/1S/2017 3/31/2017 4/3/2017 2/15/2017 3/31/2017 4/3/2017 2/15/2017 3/31/2017 4/3/2017 2/15/2017 3/31/2017 41 2/1S/2017 3131/2017 4/3/2017 2/15/2017 3/31/2017 4/3/2017 2/16/2017 3/31/2017 4/3/2017 2/16/2017 3/31/2017 4/3/2017 2/16/2017 3/31/2017 4/3/2017 2/16/2017 3/31/2017 4/3/2017 2/16/2017 3/31/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); N492 INFLAMMATORY PROFESSIONAL $0.00 $9.00 MALE DISORDERS OF SCROTUM INPATIENT /HOSPITAL 84157 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER N492 INFLAMMATORY PROFESSIONAL SOURCE AEG, SYNOVIAL FLUID, CEREBROSPINAL FLUID) $21.00 MALE DISORDERS OF SCROTUM INPATIENT /HOSPITAL 87070 CULTURE, BACTERIAL, ANY OTHER SOURCE EXCEPT URINE, N492 INFLAMMATORY PROFESSIONAL BLOOD DR STOOL, AEROBIC, W ITH ISOLATION AND $19.00 MALE DISORDERS OF SCROTUM INPATIENT/HDSPITAL PRESUMPTIVE IDENTIFICATION OF ISOLATES $8.00 MALE SUBSCRIBER 1 BCC 87075 CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, N492 INFLAMMATORY PROFESSIONAL ANAEROBIC WITH ISOLATION AND PRESUMPTIVE $277.00 MALE DISORDERS OF SCROTUM INPATIENT /HOSPITAL IDENTIFICATION OF ISOLATES 87102 CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH N492 INFLAMMATORY PROFESSIONAL PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER DISORDERS OF SCROTUM INPATIENT /HOSPITAL SOURCE (EXCEPT BLOOD) 87116 CULTURE, TUBERCLE OR OTHER ACID- FAST BACILLI(EG, N492 INFLAMMATORY PROFESSIONAL TB, AFB, MYCOBACTERIA) ANY SOURCE, WITH ISOLATION DISORDERS OF SCROTUM INPATIENT /HOSPITAL AND PRESUMPTIVE IDENTIFICATION OF ISOLATES 87205 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM N492 INFLAMMATORY PROFESSIONAL OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELLTYPES DISORDERS OF SCROTUM INPATIENT /HOSPITAL 87206 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; N492 INFLAMMATORY PROFESSIONAL FLUORESCENT AND /OR ACID FAST STAIN FOR BACTERIA, DISORDERS OF SCROTUM INPATIENT /HOSPITAL FUNGI, PARASITES, VIRUSES OR CELL TYPES 88305 LEVELIV- SURGICAL PATHOLOGY, GROSS AND N492 INFLAMMATORY PROFESSIONAL MICROSCOPIC EXAMINATION ABORTION- DISORDERS OF SCROTUM INPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION 89051 CELL COUNT, MISCELLANEOUS BODY FLUIDS(EG, N492 INFLAMMATORY PROFESSIONAL CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; DISORDERS OF SCROTUM INPATIENT /HOSPITAL WITH DIFFERENTIAL COUNT 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL N492 INFLAMMATORY PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL DISORDERS OF SCROTUM INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (92435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE N492 INFLAMMATORY PROFESSIONAL THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL DISORDERS OF SCROTUM INPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SECT) (84450) 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) N492 INFLAMMATORY PROFESSIONAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE DISORDERS OF SCROTUM INPATIENT /HOSPITAL 84145 Procalci[onin(PCT) N492 INFLAMMATORY PROFESSIONAL DISORDERS OF SCROTUM INPATIENT /HOSPITAL 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, N492 INFLAMMATORY PROFESSIONAL HCT, BBC, WEE AND PLATELET COUNT) AND AUTOMATED DISORDERS OF SCROTUM INPATIENT /HOSPITAL DIFFERENTIAL WEE COUNT $0.00 $21.00 MALE SUBSCRIBER 1 BCC $0.00 $9.00 MALE SUBSCRIBER 1 DEC $0.00 $16.00 MALE SUBSCRIBER 1 BCC $0.00 $21.00 MALE SUBSCRIBER 1 BCC $0.00 $16.00 MALE SUBSCRIBER 1 BCC $0.00 $19.00 MALE SUBSCRIBER 1 BCC $0.00 $8.00 MALE SUBSCRIBER 1 BCC $0.00 $12.00 MALE SUBSCRIBER 1 BCC $0.00 $277.00 MALE SUBSCRIBER 1 BCC $0.00 $26.00 MALE SUBSCRIBER 1 BCC $0.00 $25.00 MALE SUBSCRIBER 1 BCC $0.00 $29.00 MALE SUBSCRIBER 1 BCC $0.00 $12.00 MALE SUBSCRIBER 1 BCC $0.00 $13.00 MALE SUBSCRIBER 1 BCC $0.00 $12.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 w Z 3559 OR m 4) 3559 A :J 3559 m O lu 3559 } fl CL i® 3559 Q, Q 3559 F 3559 3559 3559 ®' 3559 3559 3559 4/3/2017 2/17/2017 3/31/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) N492 INFLAMMATORY PROFESSIONAL $8.00 MALE CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 1 BCC D ISO RDERS OF SCROTUM INPATIENT /HOSPITAL 4/3/2017 2/18/2017 3/31/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL N492 INFLAMMATORY PROFESSIONAL 1 BCC MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL $25.00 MALE D ISO REEFS OF SCROTUM INPATIENT /HOSPITAL $0.00 (82310) CARBON DIOXIDE (82374) CHLOR I DE (82435) SUBSCRIBER 1 BCC $0.00 $26.00 MALE CREATININE(82565) GLUCOSE (82947) POTASS I UM 1 BCC (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 4/3/2017 2/18/2017 3131/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE N492 INFLAMMATORY PROFESSIONAL THE FOLLOWING: ALBUMIN (82040), B ILI RUBIN, TOTAL D ISO DOERS OF SCROTUM INPATIENT /HOSPITAL (82247), BIURUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SOFT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 4/3/2017 2/18/2017 3/31/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) N492 INFLAMMATORY PROFESSIONAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE DISORDERS OF SCROTUM INPATIENT /HOSPITAL 4/3/2017 2/18/2017 3/31/2017 85610 PROTHROMBIN TIME; N492 INFLAMMATORY PROFESSIONAL DISORDERS OF SCROTUM INPATIENT /HOSPITAL 4/3/2017 2/19/2017 3/31/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) N492 INFLAMMATORY PROFESSIONAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE DISORDERS OF SCROTUM INPATIENT /HOSPITAL 4/3/2017 2/19/2017 3/31/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, N492 INFLAMMATORY PROFESSIONAL HCT,RBC,WBC AND PLATELET COUNT) AND AUTOMATED DISORDERS OF SCROTUM INPATIENT /HDSPITAL DIFFERENTIAL W BC COUNT 4/3/2017 2/20/2017 3/31/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL N492 INFLAMMATORY PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL DISORDERS OF SCROTUM INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (92435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 4/3/2017 2/20/2017 3/31/2017 82962 GLUC OSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) N492 INFLAMMATORY PROFESSIONAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE DISORDERS OF SCROTUM INPATIENT /HOSPITAL 4/3/2017 2/21/2017 3/31/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE N492 INFLAMMATORY PROFESSIONAL FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), DISORDERS OF SCROTUM INPATIENT/HOSPITAL CARBON DIOXIDE (BICARBONATE)(82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (82947), PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN (BU 4/3/2017 2/21/2017 3/31/2017 82962 GLUC OSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) N492 INFLAMMATORY PROFESSIONAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE DISORDERS OF SCROTUM INPATIENT /HDSPITAL 4/3/2017 2/21/2017 3/31/2017 83735 MAGNESIUM N492 INFLAMMATORY PROFESSIONAL DISORDERS OF SCROTUM INPATIENT /HOSPITAL 4/3/2017 2/21/2017 3/31/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, N492 INFLAMMATORY PROFESSIONAL HCT,RBC,WBC AND PLATELET COUNT) AND AUTOMATED DISORDERS OF SCROTUM INPATIENT /HDSPITAL DIFFERENTIAL W BC COUNT 4/3/2017 2/22/2017 3/31/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE N492 INFLAMMATORY PROFESSIONAL FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), DISORDERS OF SCROTUM INPATIENT /HOSPITAL CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (82947), PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN (BU $0.00 $24.00 MALE SUBSCRIBER 1 BCC $0.00 $25.00 MALE SUBSCRIBER 1 BCC $0.00 $29.00 MALE SUBSCRIBER 1 BCC $0.00 $12.00 MALE SUBSCRIBER 1 BCC $0.00 $8.00 MALE SUBSCRIBER 1 BCC $0.00 $12.00 MALE SUBSCRIBER 1 BCC $0.00 $12.00 MALE SUBSCRIBER 1 BCC $0.00 $25.00 MALE SUBSCRIBER 1 BCC $0.00 $24.00 MALE SUBSCRIBER 1 BCC $0.00 $26.00 MALE SUBSCRIBER 1 BCC $0.00 $24.00 MALE SUBSCRIBER 1 BCC $0.00 $9.00 MALE SUBSCRIBER 1 BCC $0.00 $12.00 MALE SUBSCRIBER 1 BCC $0.00 $26.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 w �1 3559 N HIM 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 rl 4/3/2017 2/22/2017 3/31/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICES) N492 SUBSCRIBER CLEARED BY THE FDA SPECIFICALLY FOR HOME USE DISORDERS OF SCROTUM INPATIENT /HOSPITAL 4/3/2017 2/22/2017 3/31/2017 83735 MAGNESIUM N492 4/3/2017 2/22/2017 3/31/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HER, N492 $9.00 MALE HUT, RBC, W BC AND PLATELET COUNT) AND AUTOMATED 1 BCC DISORDERS OF SCROTUM INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 3559 4/3/2017 2/23/2017 3/31/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE N492 $0.00 FOLLOWING: ALBUMIN )82040), CALCIUM, TOTAL )82310), SUBSCRIBER 1 BCC CARBON DIOXIDE (BICARBONATE) (92374), CHLORIDE $9.00 MALE SUBSCRIBER )82435), CREATININE (82565), GLUCOSE (82947), 3559 INFLAMMATORY PROFESSIONAL PHOSPHORUS INORGANIC (PHOSPHATE) (84100), $26.00 MALE SUBSCRIBER POTA551UM (84132), SODIUM (84295), UREA NITROGEN DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL (BU $9.00 MALE 4/3/2017 2/23/2017 3/31/2017 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR N492 DISORDERS OF SCROTUM INPATIENT /HOSPITAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, INFLAMMATORY PROFESSIONAL UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; $12.00 MALE SUBSCRIBER AUTOMATED, WITH MICROSCOPY 3559 4/3/2017 2/23/2017 3/31/2017 82570 CREATININE; OTHER SOURCE N492 4/3/2017 2/23/2017 3/31/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) N492 INFLAMMATORY PROFESSIONAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE $15.00 MALE 4/3/2017 2/23/2017 3/31/2017 83735 MAGNESIUM N492 4/3/2017 2/23/2017 3/31/2017 84156 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE N492 4/3/2017 2/23/2017 3/31/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, N492 INFLAMMATORY PROFESSIONAL HCT, RBC, W BC AND PLATELET COUNT) AND AUTOMATED $30.00 MALE SUBSCRIBER DIFFERENTIAL W BE COUNT 3559 4/3/2017 2/23/2017 3/31/2017 87077 CULTURE, BACTERIAL; AEROBIC ISDLATE, ADDITIONAL N492 METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, INFLAMMATORY PROFESSIONAL EACH ISOLATE $27.00 MALE 4/3/2017 2/23/2017 3/31/2017 87088 WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF N492 DISORDERS OF SCROTUM INPATIENT /HOSPITAL EACH ISOLATE, URINE 4/3/2017 2/23/2017 3/31/2017 87186 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; N492 MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION AMICA" OR BREAKPOINT), EACH MULTI - ANTIMICROBIAL, PER PLATE 4/3/2017 2/24/2017 3131/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE N492 FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (92947), PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN (BU 4/3/2017 2/24/2017 3/31/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) N492 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 4/3/2017 2/24/2017 3/31/2017 83735 MAGNESIUM N492 INFLAMMATORY PROFESSIONAL $0.00 $24.00 MALE SUBSCRIBER 1 BCC DISORDERS OF SCROTUM INPATIENT /HOSPITAL DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC DISORDERS OF SCROTUM INPATIENT /HOSPITAL 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HDSPITAL INFLAMMATORY PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC DISORDERS OF SCROTUM INPATIENT /HDSPITAL $9.00 MALE SUBSCRIBER 1 BCC 3559 INFLAMMATORY PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 BCC DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER INFLAMMATORY PROFESSIONAL DISORDERS OF SCROTUM INPATIENT /HOSPITAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 w Z 3559 N tU 3559 A i 3559 fO } fl CL CL 3559 INFLAMMATORY PROFESSIONAL $0.00 $13.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $24.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HDSPITAL INFLAMMATORY PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $15.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $30.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $27.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $24.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL C.7.f 4/3/2017 2/24/2017 3/31/2017 87046 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION N492 INFLAMMATORY PROFESSIONAL $0.00 $24.00 MALE SUBSCRIBER 1BCC 3559 AND PRESUMPTIVE IDENTIFICATION OF ISOLATES DISORDERS OF SCROTUM INPATIENOTOSPITAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) Z N 4/3/2017 2/2S/2017 3/31/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE N492 INFLAMMATORY PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 BCC 3559 FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), DISORDERS OF SCROTUM INPATIENT /HOSPITAL CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435(, CREATININE (82565(, GLUCOSE (82947), PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN "a (BU 4/3/2017 2/25/2017 3/31/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) N492 INFLAMMATORY PROFESSIONAL $0.00 $24.00 MALE SUBSCRIBER I BCC 3559 CLEARED BYTHE FDASPECIFICALLY FOR HOME USE DISORDERS OF SCROTUM INPATIENT /HOSPITAL W } fl 4/3/2017 2/25/2017 3/31/2017 83735 MAGNESIUM N492 INFLAMMATORY PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 N. CL DISORDERS OF SCROTUM INPATIENT /HOSPITAL Q, Q 4/3/2017 2/25/2017 3/31/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, N492 INFLAMMATORY PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 v HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED DISORDERS OF SCROTUM INPATIENT /HOSPITAL DIFFERENTIAL W BE COUNT rf 4/3/2017 2/26/2017 3/31/2017 80069 RENALFUNCTION PANELTHISPANEL MUSTINCLUDETHE N492 INFLAMMATORY PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 BCC 3559 FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), DISORDERS OF SCROTUM INPATIENT /HOSPITAL CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE h ( 82435(, CREATININE(82565), GLUCOSE (92947), PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132(, SODIUM (84295), UREA NITROGEN (BU _ 4/3/2017 2/26/2017 3131/2017 80202 VANCOMYCIN N492 INFLAMMATORY PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL d 4/3/2017 2/26/2017 3/31/2017 83735 MAGNESIUM N492 INFLAMMATORY PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 {j DISORDERS OF SCROTUM INPATIENT /HOSPITAL T� 4/3/2017 2/26/2017 3/31/2017 82962 GLUCOSE, BLOOD BYGLUCOSE MONITORING DEVICE(S) N492 INFLAMMATORY PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BYTHE FDASPECIFICALLY FOR HOME USE DISORDERS OF SCROTUM INPATIENT /HOSPITAL 0 4/3/2017 2/26/2017 3/31/2017 84145 Procalcitonin(PCT( N492 INFLAMMATORY PROFESSIONAL $0.00 $13.00 MALE SUBSCRIBER 1 BCC 3559 LLJ DISORDERS OF SCROTUM INPATIENT /HOSPITAL e 4/3/2017 2/26/2017 3/31/2017 85025 BLOOD COUNT; COMPLETE(CBC(, AUTOMATED(HGB, N492 INFLAMMATORY PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED DISORDERS OF SCROTUM INPATIENT /HOSPITAL DIFFERENTIAL W BE COUNT v 4/3/2017 2/26/2017 3/31/2017 86850 ANTI BODY SCREEN, BBC, EACH SERUMTECHNIQUE N492 INFLAMMATORY PROFESSIONAL $0.00 $25.00 MALE SUBSCRIBER 1BCC 3559 DISORDERS OF SCROTUM INPATIENOTOSPITAL W 4/3/2017 2/26/2017 3/31/2017 86900 BLOOD TYPING, SEROLOGIC; ABO N492 INFLAMMATORY PROFESSIONAL $0.00 $21.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL U 4/3/2017 2/26/2017 3131/2017 86901 BLOOD TYPING, SEROLOGIC; BIT (D) N492 INFLAMMATORY PROFESSIONAL $0.00 $11.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL 4/3/2017 2/26/2017 3/31/2017 86920 COM PATI BILITY TEST EACH UNIT; IMMEDIATESPIN N492 INFLAMMATORY PROFESSIONAL $0.00 $29.00 MALE SUBSCRIBER 1 BCC 3559 CSJ TECHNIQUE DISORDERS OF SCROTUM INPATIENT /HOSPITAL hl 4/3/2017 2/26/2017 3/31/2017 87486 INFECTIOUS AGENT DETECTION BY NUCLEICACID (DNAOR N492 INFLAMMATORY PROFESSIONAL $0.00 $19.00 MALE SUBSCRIBER 1 BCC 3559 = RNA(; CHLAMYDIA PNEUMONIAE, AMPLIFIED PROBE DISORDERS OF SCROTUM INPATIENT /HOSPITAL TECHNIQUE 4/3/2017 2/26/2017 3/31/2017 87581 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR N492 INFLAMMATORY PROFESSIONAL $0.00 $16.00 MALE SUBSCRIBER 1 BCC 3559 .0 RNA(;MYCOPLASMA PNEUMONIAE, AMPLIFIED PROBE TECHNIQUE DISORDERS OF SCROTUM INPATIENT /HOSPITAL �, C.7.f 4/3/2017 2/26/2017 3/31/2017 87633 INFECTIOUS AGENT DETECTION BY NUCLEIC AC I D(DNA OR N492 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL RNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZA INPATIENT /HOSPITAL VIRUS, CORONAVIRUS, METAPNEUMOVIRUS, INFLAMMATORY PROFESSIONAL $0.00 PARAI NFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS, SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM RHINOVIRUS), INCLUDES MULTIPLEX REVERSE N TRANSCRIPTION, WHEN PERFO TOXIC LIVER DISEASE, 4/3/2017 2/26/2017 3/31/2017 87798 INFECTIOUS AGENT DETECTION BY NUCLEICACID(DNAOR N492 3559 Q! RNAI, NOT OTHERWISE SPECIFIED; AMPLIFIED PROBE TECHNIQUE, EACH ORGANISM $0.00 4/3/2017 2/27/2017 3/31/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE N492 ACUTE AND SUBACUTE OTHER MEDICAL $67.77 FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), r 1 BCC 3559 HEPATIC FAILURE CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE INFLAMMATORY PROFESSIONAL $0.00 ( 82435), CREATININE(82565), GLUCOSE (82947), SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL PHOSPHORUS INORGANIC (PHOSPHATE) (84100), OTHER SPECIFIED PROFESSIONAL POTASSIUM (64132), SODIUM (84295), UREA NITROGEN $141.00 MALE SUBSCRIBER 1 BCC 3559 (BU INPATIENT /HOSPITAL 4/3/2017 2/2]/201] 3/31/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(5) N492 SYSTEM CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 4/3/2017 2/27/2017 3/31/2017 83735 MAGNESIUM N492 4/3/2017 2/27/2017 3/31/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, N492 * * * ** $113.25 CL HCF, BBC, W BC AND PLATELET COUNT) AND AUTOMATED 1 BCC 3559 DIFFERENTIAL W BC COUNT INFLAMMATORY PROFESSIONAL 4/3/2017 2/28/2017 3/31/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE N492 DISORDERS OF SCROTUM INPATIENT /HOSPITAL $124.58 MALE SUBSCRIBER FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), 3559 OTHER GENERAL OTHER MEDICAL $0.00 CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE SUBSCRIBER 1 BCC 3559 INFLAMMATORY PROFESSIONAL (82435), CREATININE (82565), GLUCOSE (92947), $9.00 MALE SUBSCRIBER 1 BCC 3559 PHOSPHORUS INORGANIC (PHOSPHATE) (84100), OTHER GENERAL OTHER MEDICAL $6.66 $41.25 MALE POTASSIUM (84132), SODIUM (84295), UREA NITROGEN 1 BCC 3559 SYMPTOMS AND SIGNS (BU W 4/3/2017 2/28/2017 3/31/2017 83735 MAGNESIUM N492 4/3/2017 2/28/2017 3/31/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED INGE, N492 SYMPTOMS AND SIGNS INFLAMMATORY PROFESSIONAL HCF, BBC, W BC AND PLATELET COUNT) AND AUTOMATED $26.00 MALE SUBSCRIBER 1 BCC 3559 _ DIFFERENTIAL WEE COUNT 4/3/2017 3/28/2017 3/31/2017 E0163 COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED K719 ARMS 4/5/2017 21112017 3/18/2017 - - N16292 4/5/2017 4/2/2017 4/4/2017 E0260 HOSPITAL BED, SEMI-ELECTRIC (HEAD AND FOOT K7200 ADJUSTMENT), WITH ANY TYPE SIDE RAILS, WITH MATTRESS 4/6/2017 3/27/2017 4/4/2017 7685] ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH N398 IMAGE DOCUMENTATION; LIMITED OR FOLLOW -UP (ES, FOR FOLLICLES) 4/7/2017 3/22/2017 4/5/2017 4/12/2017 3/3/2017 4/11/2017 *' "* * * * ** * * * ** 4/12/2017 3/13/2017 4111/2017 4112/2017 3/30/2017 4/11/2017 4/14/2017 2/8/2017 4/13/2017 36415 COLLECTION DF VENOUS BLOOD BY VENIPUNCTURE R6889 4/14/2017 21812017 4/13/2017 83036 HEMOGLOBIN; GLYCOSYLATED(A1C) R6889 4/14/2017 2/8/2017 4/13/2017 84134 PREALBUMIN 86889 INFLAMMATORY PROFESSIONAL $0.00 $19.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 Z SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL N TOXIC LIVER DISEASE, m $50.48 $50.48 MALE SUBSCRIBER 1 BCC 3559 Q! INFLAMMATORY PROFESSIONAL $0.00 $25.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT / HDSPITAL ACUTE AND SUBACUTE OTHER MEDICAL $67.77 $67.77 MALE r 1 BCC 3559 HEPATIC FAILURE INFLAMMATORY PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL OTHER SPECIFIED PROFESSIONAL $34.30 $141.00 MALE SUBSCRIBER 1 BCC 3559 fl INPATIENT /HOSPITAL } SYSTEM fl * * * ** * * * ** 3/22/2017 # # # # # ### $10,194.66 $76,872.02 MALE CL 1 BCC 3559 * * * ** * * * ** $113.25 CL SUBSCRIBER 1 BCC 3559 Q INFLAMMATORY PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 v DISORDERS OF SCROTUM INPATIENT /HOSPITAL $124.58 MALE SUBSCRIBER 1 BCC 3559 OTHER GENERAL OTHER MEDICAL $0.00 $10.00 MALE SUBSCRIBER 1 BCC 3559 INFLAMMATORY PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL OTHER GENERAL OTHER MEDICAL $6.66 $41.25 MALE F 1 BCC 3559 SYMPTOMS AND SIGNS W INFLAMMATORY PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL SUBSCRIBER 1 BCC 3559 SYMPTOMS AND SIGNS INFLAMMATORY PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 BCC 3559 _ DISORDERS OF SCROTUM INPATIENT /HOSPITAL L INFLAMMATORY PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL INFLAMMATORY PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL TOXIC LIVER DISEASE, OTHER MEDICAL $50.48 $50.48 MALE SUBSCRIBER 1 BCC 3559 UNSPECIFIED RHABDOMYOLYSIS HOSPITAL INPATIENT 1/17/2017 # # # # # # ## $0.00 $9,304.65 MALE SUBSCRIBER 1 BCC 3559 ACUTE AND SUBACUTE OTHER MEDICAL $67.77 $67.77 MALE SUBSCRIBER 1 BCC 3559 HEPATIC FAILURE WITHOUTCOMA OTHER SPECIFIED PROFESSIONAL $34.30 $141.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF URINARY INPATIENT /HOSPITAL SYSTEM * * * ** * * * ** 3/22/2017 # # # # # ### $10,194.66 $76,872.02 MALE SUBSCRIBER 1 BCC 3559 * * * ** * * * ** $113.25 $113.26 MALE SUBSCRIBER 1 BCC 3559 $3]3.74 $3]3.]4 MALE SUBSCRIBER 1 BCC 3559 * * * ** * * * ** $124.58 $124.58 MALE SUBSCRIBER 1 BCC 3559 OTHER GENERAL OTHER MEDICAL $0.00 $10.00 MALE SUBSCRIBER 1 BCC 3559 SYMPTOMS AND SIGNS OTHER GENERAL OTHER MEDICAL $6.66 $41.25 MALE SUBSCRIBER 1 BCC 3559 SYMPTOMS AND SIGNS OTHER GENERAL OTHER MEDICAL $10.01 $61.95 MALE SUBSCRIBER 1 BCC 3559 SYMPTOMS AND SIGNS C.7.f 4/14/2017 2/8/2017 4/13/2017 P9603 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH R6889 OTHER GENERAL OTHER MEDICAL $34.61 $57.68 MALE SUBSCRIBER 1 BCC 3559 MEDICALLY NECESSARY LABORATORY SPECIMEN SYMPTOMS AND SIGNS COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED. 4/17/2017 1/1/2017 4/13/2017 * * " ** * *' ** * * * ** * * *" * *' ** $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/2/2017 4/13/2017 " * ** * * * ** * " ** * * * ** * * * ** $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/3/2017 4/13/2017 * * * ** * * » ** *««.. » »x »: .x » »» $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/4/2017 4/13/201] * * » ** * *' ** *a * ** " * * ** * *' ** $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/5/2017 4/13/2017 * * * ** * *' ** * " ** * * *" * * *'* $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/6/2017 4/13/2017 * *' ** * * * ** *' * ** * * * ** * * * »* $9fi.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/7 /2017 4/13/201] xxxxx w.. w.* xxxsx a *.*« w...w $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/8/2017 4/13/2017 + » » *» * *' ** + * * *+ : * * *' * * * «* $96.12 $286.00 MALE SUBSCRIBER 1 SCC 3559 4/17/2017 1/9/2017 4/13/2017 * * "* * * * ** *' * ** * * * "» * * * ** $9fi.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/10/2017 4/13/2017 ' " * *` * * * ** * * *`* * * * ** * * * ** $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/11/201] 4/13/2017 * * " ** ** « «. + »x ++ * * *x» ** « «« $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/12/2017 4/13/2017 ' » » ** * * * ** * » *`. » *'.a * * * »* $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/13/201] 4/13/2017 * * * ** " *» ** » »» ** . * * ** +. » ** $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/14/2017 4/13/2017 * * ° *' * * * ** + »x ++ * *+xx *.. »» $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/15/2017 4/13/2017 * * * "* * * * ** * * * ** * * * ** * * * ** $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/16/201] 4/13/2017 *x» »x x.» +* +«« +* : * + »» +.. »+ $96.12 $286.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 1/17/2017 4/13/2017 x »a »* * * * *» » » * ** * * * ** * * * ** $96.01 $292.00 MALE SUBSCRIBER 1 BCC 3559 4/17/2017 3/28/2017 4/14/2017 A0425 GROUND MILEAGE, PER STATUTE MILE Z7401 BED CONFINEMENT OTHER MEDICAL $100.00 $130.00 MALE SUBSCRIBER 1 BCC 3559 STATUS 4/17/2017 3/28/2017 4/14/2017 A0428 AMBULANCE SERVICE, BASIC LIFE SUPPORT, NOW Z7401 BED CONFINEMENT OTHER MEDICAL $256.50 $750.00 MALE SUBSCRIBER 1BCC 3559 EMERGE N CY TRANSPORT, (BLS) STATUS 4/20/2017 2/16/2017 4/18/2017 83605 LACTATE (LACTIC ACID) N492 INFLAMMATORY PROFESSIONAL $0.00 $13.00 MALE SUBSCRIBER 1 BCC 3559 DI SORDERS OF SCROTUM INPATIENT /HOSPITAL 4/26/2017 3/23/2017 4124/2017 99255 INPATIENT CONSULTATION FOR ANEW OR ESTABLISHED R339 RETENTION OF URINE, PROFESSIONAL $242.72 $808.50 MALE SUBSCRIBER 1BCD 3559 PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS:A UNSPECIFIED INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY, COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSI 4126/2017 3/27/2017 4/24/2017 52000 CYSTOURETHROSCOPY(SEPARATE PROCEDURE) R339 RETENTION OF URINE, PROFESSIONAL $160.95 $866.25 MALE SUBSCRIBER 1 BCC 3559 UNSPECIFIED INPATIENT /HOSPITAL 4/26/2017 3/2]/201] 4/24/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE 8339 RETENTION OF URINE, PROFESSIONAL $81.88 $420.00 MALE SUBSCRIBER 1 BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 4/26/2017 4/17/2017 4/24/2017 - - K7460 UNSPECIFIED CIRRHOSIS HOSPITAL OUTPATIENT $943.50 $1,258.00 MALE SUBSCRIBER 1 BCC 3559 OF LIVER 4/27/2017 2/14/2017 4/25/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R0602 SHORTNESS OF BREATH PROFESSIONAL $8.95 $28.00 MALE SUBSCRIBER 1 BCC 3559 LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL 5/11/2017 3/27/2017 5/10/2017 910 ANESTHESIA ED R TRA N S U R ETH RA L P ROCEDU R ES N359 U R ETH RAE STIR I CTU R E, PROFESSIONAL $383.63 $660.00 MALE SUBSCRIBER 1 BCC 3559 (INCLUDING URETHROCYSTOSCOPY ); NOTOTHERWISE UNSPECIFIED INPATIENT /HOSPITAL SPECIFIED 5/23/2017 2/15/2017 5/16/2017 82042 ALBUMIN; URINE OR OTHER SOURCE, QUANTITATIVE, N492 INFLAMMATORY PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1 BCC 3559 EACHSPECIMEN DISORDERS OF SCROTUM INPATIENT /HOSPITAL 5/23/2017 2115/2017 5/16/2017 82945 GLUCOSE, BODY FLUID, OTHER THAN BLOOD N492 INFLAMMATORY PROFESSIONAL $0.00 $11.00 MALE SUBSCRIBER 1 BCC 3559 DISORDERS OF SCROTUM INPATIENT /HOSPITAL 5/23/2017 2/15/2017 5/16/2017 5/23/2017 2/15/2017 5/16 /2017 5/23/2017 2/15/2017 5/16/2017 5/23/2017 2/15/2017 5/16/2017 5/23/2017 2/1S/2017 5/16/2017 5/23/2017 2/15/2017 5/16/2017 5/23/2017 2/15/2017 5/16/2017 5/23/2017 2/15/2017 5/16/2017 5/23/2017 2/1S/2017 5/16/2017 5/23/2017 2/15/2017 5/16/2017 5/25/2017 5/18/2017 5/23/2017 6/26/2017 3/22/2017 6/23/2017 6/26/2017 3/23/2017 6/23/2017 83615 LACTATE DEHYDROGENASE(ED), BUSH); N492 INFLAMMATORY PROFESSIONAL 1 BCC $0.00 DISORDERS OF SCROTUM INPATIENT /HOSPITAL 84157 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER N492 INFLAMMATORY PROFESSIONAL SOURCE EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID) SUBSCRIBER DISORDERS OF SCROTUM INPATIENT /HOSPITAL 87302 CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH N492 INFLAMMATORY PROFESSIONAL PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER $0.00 DISORDERS OF SCROTUM INPATIENT/HDSPITAL SOURCE (EXCEPT BLOOD) 1 BCC $0.00 89051 CELL COUNT, MISCELLANEOUS BODY FLUIDS(EG, N492 INFLAMMATORY PROFESSIONAL CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; $19.00 MALE DISORDERS OF SCROTUM INPATIENT /HOSPITAL WITH DIFFERENTIAL COUNT $0.00 $8.00 MALE 87070 CULTURE, BACTERIAL, ANY OTHER SOURCE EXCEPT URINE, N492 INFLAMMATORY PROFESSIONAL BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND SUBSCRIBER DISORDERS OF SCROTUM INPATIENT /HOSPITAL PRESUMPTIVE IDENTIFICATION OF ISOLATES $277.00 MALE SUBSCRIBER 87075 CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, N492 INFLAMMATORY PROFESSIONAL ANAEROBIC WITH ISOLATION AND PRESUMPTIVE DISORDERS OF SCROTUM INPATIENT /HOSPITAL IDENTIFICATION OF ISOLATES 87116 CULTURE, TUBERCLE OR OTHER ACID- FAST BACILLI(EG, N492 INFLAMMATORY PROFESSIONAL TB, AFB, MYCOBACTERIA) ANY SOURCE, WITH ISOLATION DISORDERS OF SCROTUM INPATIENT/HOSPITAL AND PRESUMPTIVE IDENTIFICATION OF ISOLATES 87205 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM N492 INFLAMMATORY PROFESSIONAL OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELLTYPES DISORDERS OF SCROTUM INPATIENT /HOSPITAL 87206 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; N492 INFLAMMATORY PROFESSIONAL FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, DISORDERS OF SCROTUM INPATIENT /HOSPITAL FUNGI, PARASITES, VIRUSES OR CELL TYPES 88305 LEVEL IV- SURGICAL PATHOLOGY, GROSS AND N492 INFLAMMATORY PROFESSIONAL MICROSCOPIC EXAMINATION ABORTION- DISORDERS OF SCROTUM INPATIENT / HDSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R531 WEAKNESS PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION A419 SEPSIS, UNSPECIFIED PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES ORGANISM INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; ACOMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGED 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A419 SEPSIS, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH ORGANISM INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $0.00 $21.00 MALE SUBSCRIBER 1 BCC $0.00 $9.00 MALE SUBSCRIBER 1 DEC $0.00 $16.00 MALE SUBSCRIBER 1 BCC $0.00 $26.00 MALE SUBSCRIBER 1 BCC $0.00 $16.00 MALE SUBSCRIBER 1 BCC $0.00 $21.00 MALE SUBSCRIBER 1 BCC $0.00 $19.00 MALE SUBSCRIBER 1 BCC $0.00 $8.00 MALE SUBSCRIBER 1 BCC $0.00 $12.00 MALE SUBSCRIBER 1 BCC $51.64 $277.00 MALE SUBSCRIBER 1 BCC $8.95 $28.00 MALE SUBSCRIBER 1 BCC $245.63 $425.00 MALE SUBSCRIBER 1 BCC $125.90 $220.00 MALE SUBSCRIBER 1 BCC 6/26/2017 3/24/2017 6/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A419 SEPSIS, UNSPECIFIED PROFESSIONAL $37.72 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH SUBSCRIBER ORGANISM INPATIENT /HOSPITAL $37.72 REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A SUBSCRIBER 1 BCC 3559 $0.00 DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; SUBSCRIBER 1 BCC 3559 $0.00 MEDICAL DECISION MAKING OF HIGH COMPLEXITY. SUBSCRIBER 1 BCC 3559 $0.00 COUNSELING AND /OR COORDINATION OF CARE WITH SUBSCRIBER 1 BCC 3559 $0.00 OTHER PROVI SUBSCRIBER 1 BCC 3559 6/26/2017 3/25/2017 6/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A419 SEPSIS, UNSPECIFIED PROFESSIONAL $0.00 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH SUBSCRIBER ORGANISM INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 6/26/2017 3/26/2017 6/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A419 SEPSIS, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH ORGANISM INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/26/2017 3/27/2017 6/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A419 SEPSIS, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH ORGANISM INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/26/2017 3/28/2017 6/23/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE A419 SEPSIS, UNSPECIFIED PROFESSIONAL THAN 30 MINUTES ORGANISM INPATIENT /HOSPITAL 6/26/2017 4/28/2017 6123/2017 K0001 STANDARD W HEELCHAIR K7200 ACUTE AND SUBACUTE OTHER MEDICAL HEPATIC FAILURE WITHOUTCOMA 6/26/2017 5/28/2017 6/23/2017 K0001 STANDARD WHEELCHAIR K7200 ACUTE AND SUBACUTE OTHER MEDICAL HEPATIC FAILURE WITHOUTCOMA 8/7/2017 1/1/2017 8/3/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL HCT, RBC, WED AND PLATELET COUNT) CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 81712017 1/1/2017 8/3/2017 85610 PROTHROMBIN TIME; E46 UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 11112017 8/3/2017 87045 CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION E46 UNSPECIFIED PROTEIN- PROFE55IONAL AND PRELIMINARY EXAMINATION LEG, KIA, LIA), CALORIE MALNUTRITION OUTPATIENT /HOSPITAL SALMONELA AND SHIGELIA SPECIES 8/7/2017 1/1/2017 8/3/2017 87046 CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL E46 UNSPECIFIED PROTEIN- PROFESSIONAL PATHOGENS, ISDATIDN AND PRESUMPTIVE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL IDENTIFICATION OF ISOLATES, EACH PLATE 8/7/2017 1/112017 8/3/2017 874931nfectious agent detection by nucleic acid (DNA o, RNA); E46 UNSPECIFIED PROTEIN- PROFE55IONAL Clostridium dlfficile, toxin gene(,), amplified probe CALORIE MALNUTRITION OUTPATIENT /HOSPITAL technique 8/7/2017 1/1/2017 8/3/2017 87899 INFECTIOUS AGENT ANTIGEN DETECTION BY E46 UNSPECIFIED PROTEIN- PROFESSIONAL IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; CALORIE MALNUTRITION OUTPATIENT /HOSPITAL NOT OTHERWISE SPECIFIED $125.90 $220.00 MALE SUBSCRIBER 1 BCC $12530 $220.00 MALE SUBSCRIBER 1 BCC $125.90 $220.00 MALE SUBSCRIBER 1 BCC $125.90 $220.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE mm $128.50 $325.00 MALE SUBSCRIBER 1 BCC 3559 $37.72 $37.72 MALE SUBSCRIBER 1 BCC 3559 $37.72 $37.72 MALE SUBSCRIBER 1 BCC 3559 $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $14.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $28.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $54.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $30.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $24.00 MALE SUBSCRIBER 1 BCC 3559 81712017 1/1/2017 81312017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 $72.00 MALE MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL 1 BCC (82310) CARBON DIOXIDE (82374) CHLOR I RE (82435) CALORIE MALNUTRITION OVTPATIENT /HOSPITAL CREATININE(82565) GLUCOSE (82947) POTASS I UM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 11112017 8/3/2017 82140 AMMONIA E46 8/7/2017 1/1/2017 8/3/2017 82550 CREATINE KINASE(CK),(CPK); TOTAL E46 8/7/2017 1/1/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 1 BCC CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 8/7/2017 1/1/2017 8/3/2017 87449 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME E46 IMMUNOASSAY TECHNIQUE QUALITATIVE OR SE M I QUANTITATIVE; MULTIPLE STEP METHOD, NOT $0.00 OTHERWISE SPECIFIED, EACH ORGANISM 81712017 1/1/2017 8/3/2017 87899 INFECTIOUS AGENT ANTIGEN DETECTION BY E46 3559 IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; CALORIE MALNUTRITION OUTPATIENT /HOSPITAL NOT OTHERWISE SPECIFIED 8/7 /2017 11212017 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL UNSPECIFIED PROTEIN- PROFESSIONAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) $29.00 MALE CREATININE (92565) GLUCOSE (82947) POTASSIUM 1 BCC (64132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 1/2/2017 8/3/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE E46 THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, $0.00 ALKALINE (84075), PROTEIN, TOTAL (84155), SUBSCRIBER TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), 3559 TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 8/7/2017 1/2/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 81712017 1/2/2017 8/3/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (TIES, E46 UNSPECIFIED PROTEIN- PROFESSIONAL HCT, BBC, VVBC AND PLATELET COUNT) 8/7/2017 1/2/2017 8/3/2017 85610 PROTHROMBIN TIME; E46 8/7/2017 1/2/2017 8/3/2017 86850 ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE E46 8/7/2017 1/2/2017 8/3/2017 86900 BLOOD TYPING, SEROLOGIC; ABO E46 8/7/2017 1/2/2017 8/3/2017 86901 BLOOD TYPING, SEROLOGIC; RH(D) E46 8/7/2017 1/2/2017 8/3/2017 86923 COMPATIBILITY TEST EACH UNIT; ELECTRONIC E46 6/7/2017 1/3/2017 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 $28.00 MALE MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL 1 BCC (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CALORIE MALNUTRITION OUTPATIENT /HOSPITAL CREATININE(92565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL C.7.f $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL N UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL tU $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 A CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $29.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL i $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 "a CALORIE MALNUTRITION OUTPATIENT/HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $11.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $28.00 MALE SUBSCRIBER 1 BCC W CALORIE MALNUTRITION OUTPATIENT /HOSPITAL } UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC fl $0.00 $24.00 MALE SUBSCRIBER 1 BCC 3559 N. CL CL Q $0.00 $24.00 MALE SUBSCRIBER 1 BCC 3559 4 $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 W h D Z $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 y ® UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $14.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $29.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $29.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT/HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $11.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $28.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL C.7.f 81712017 1/3/2017 81312017 80076 HEPATIC FUNCTION PAN ELTH IS PANEL MUST INCLUDE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 THE FOLLOWING: ALBUMIN (82040), BILIRUBINT0TAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (94075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 8/7/2017 1/3/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/3/2017 8/3/2017 83735 MAGNESIUM E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/3/2017 8/3/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 81712017 113/2017 8/3/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 HCT, RBC, WBCAND PLATELETCOUNT) CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/3/2017 8/3/2017 85610 PROTHROMBIN TIME; E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $14.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 81712017 1/4/2017 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 1/412017 8/3/2017 82140 AMMONIA E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/4/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OVTPATIENT /HOSPITAL 8/7/2017 1/4/2017 8/3/2017 85027 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 HCF, RBC, WBCAND PLATELETCOUNT) CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/4/2017 8/3/2017 85610 PROTHROMBIN TIME; E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $14.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 81712017 1/5/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7 /2017 1/5/2017 8/3/2017 87015 CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/5/2017 81 87070 CULTURE, BACTERIAL, ANY OTHER SOURCE EXCEPT URINE, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $23.00 MALE SUBSCRIBER 1 BCC 3559 BLOOD DR STOOL, AEROBIC, WITH ISOIATIONAND CALORIE MALNUTRITION OUTPATIENT /HOSPITAL PRESUMPTIVE IDENTIFICATION OF ISOLATES 8/7/2017 1/5/2017 8/3/2017 87116 CULTURE, TUBERCLE OR OTHER ACID- FAST BACILLI(EG, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 TB, AFB, MYCOBACTERIA) ANY SOURCE, WITH ISOLATION CALORIE MALNUTRITION OUTPATIENT /HOSPITAL AND PRESUMPTIVE IDENTIFICATION OF ISOLATES 8/7/2017 1/5/2017 8/3/2017 87302 CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $17.00 MALE SUBSCRIBER 1BCC 3559 PRESUMPTIVE IDENTIFICATION OF ISOLATES; OTHER CALORIE MALNUTRITION OUTPATIENT /HOSPITAL SOURCE (EXCEPT BLOOD) 8/7/2017 1/5/2017 8/3/2017 87205 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $7.00 MALE SUBSCRIBER 1 BCC 3559 ORGIEMSASTAIN FORBACTERIA, FUNGI, OR CELL TYPES CALORIE MALNUTRITION OUTPATIENT /HOSPITAL C.7.f 81712017 1/5/2017 81312017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $27.00 MALE SUBSCRIBER 1 BCC 3559 FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), CALORIE MALNUTRITION OUTPATIENT /HOSPITAL CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (82947), PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN (BU 8/7/2017 1/5/2017 8/3/2017 82042 ALBUMIN; URINE OR OTHER SOURCE, QUANTITATIVE, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1 BCC 3559 EACHSPECIMEN CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/5/2017 8/3/2017 82150 AMYLASE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $16.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/5/2017 8/3/2017 82247 BILIRUBIN; TOTAL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $7.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 115/2017 8/3/2017 82570 CREATININE; OTHER SOURCE E45 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $13.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/5/2017 8/3/2017 82945 GLUCOSE, BODY FLUID, OTHER THAN BLOOD E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $11.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 81712017 1/5/2017 8/3/2017 83540 IRON E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $28.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/S/2017 8/3/2017 83550 IR0N BINDING CAPACITY E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $11.00 MALE SUBSCRIBER 1BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL 8/7/2017 1/5/2017 8/3/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $21.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/5/2017 8/3/2017 83986 PH; BODY FLUID, NOT OTHERWISE SPECIFIED E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/5/2017 8/3/2017 84133 POTASSIUM; URINE E46 UNSPECIFIED PROTEIN. PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 115/2017 8/3/2017 84157 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER E45 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 SOURCE (EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID) CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/5/2017 8/3/2017 84478 TRIGLYCERIDES E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $11.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 81712017 1/5/2017 8/3/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 HCT, RBC,WBCAND PLATELETCOUNT) CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/S/2017 8/3/2017 87075 CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $21.00 MALE SUBSCRIBER 1 BCC 3559 ANAEROBIC WITH ISOLATION AND PRESUMPTIVE CALORIE MALNUTRITION OVTPATIENT /HOSPITAL IDENTIFICATION OF ISOLATES 8/7/2017 1/5/2017 8/3/2017 87206 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 FLUORESCENT AND /DR ACID FASTSTAIN FOR BACTERIA, CALORIE MALNUTRITION OUTPATIENT /HOSPITAL FUNGI, PARASITES, VIRUSES OR CELL TYPES 8/7/2017 1/S/2017 8/3/2017 89051 CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $27.00 MALE SUBSCRIBER 1 BCC 3559 CEREBROSPINAL FLUID, JOINT FLUID), EXCEPTBLOOD; CALORIE MALNUTRITION OUTPATIENT /HOSPITAL WITH DIFFERENTIAL COUNT 8/7/2017 1/5/2017 8/3/2017 88108 CYTOPATHOLOGY, CONCENTRATION TECHNIQUE, SMEARS E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $152.00 MALE SUBSCRIBER 1 BCC 3559 AND INTERPRETATION (EG, SACCOMANNO TECHNIQUE) CALORIE MALNUTRITION OUTPATIENT /HOSPITAL C.7.f 81712017 1/5/2017 81312017 88305 LEVEL IV- SURD ICA L PATH OLOGY, GROSS AND E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $278.00 MALE SUBSCRIBER 1 BCC 3559 MICROSCOPIC EXAMINATION ABORTION- CALORIE MALNUTRITION OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE Z MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, N OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION 8/7/2017 1/6/2017 8/3/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $27.00 MALE SUBSCRIBER 1 BCC 3559 7 FOLLOWING: ALBUMIN (92040), CALCIUM, TOTAL (82310), CALORIE MALNUTRITION OUTPATIENT /HOSPITAL CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (82947), PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN } (BU CL s® 81]1201] 1/6/2017 81312017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 Q, THE FOLLOWING: ALBUMIN (82040), BILIRUBIN,TOTAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, v ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460(, TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) �+ F 8/7/2017 1/6/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 LIJ CLEARED BETTE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL D 8/7/2017 1/6/2017 8/3/2017 83735 MAGNESIUM E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL _ 8/7/2017 1/6/2017 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED CALORIE MALNUTRITION OVTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT Q 8/7/2017 1/6/2017 8/3/2017 85610 PROTHROMBIN TIME; E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $14.00 MALE SUBSCRIBER 1 BCC 3559 {i CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/7/2017 8/3/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $27.00 MALE SUBSCRIBER 1 BCC 3559 FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), CALORIE MALNUTRITION OVTPATIENT /HOSPITAL CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (82947), een PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN (BU J 8/7/2017 1/7/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 v CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OVTPATIENT /HOSPITAL f' 8/7/2017 11712017 81 83605 LACTATE ILACTIC ACID) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $13.00 MALE SUBSCRIBER 1 BCE 3559 LLJ CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 1/7/2017 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 (' HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED CALORIE MALNUTRITION OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 8/7/2017 1/7/2017 8/3/2017 87070 CULTURE, BACTERIAL, ANY OTHER SOURCE EXCEPT URINE, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $23.00 MALE SUBSCRIBER 1 BCC 3559 BLOOD DR STOOL, AEROBIC, W ITH ISOLATIONAND CALORIE MALNUTRITION OUTPATIENT /HOSPITAL N PRESUMPTIVE IDENTIFICATION OF ISOLATES N 8/7/2017 11712017 8/3/2017 87075 CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $21.00 MALE SUBSCRIBER 1 BCC 3559 = ANAEROBIC WITH 150LATION AND PRESUMPTIVE CALORIE MALNUTRITION OUTPATIENT/HOSPITAL y IDENTIFICATION OF ISOLATES 8/7/2017 1/7/2017 8/3/2017 87205 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $7.00 MALE SUBSCRIBER 1 BCC 3559 .0 ORGIEMSA STAIN FOR BACTERIA, FUNGI, OR CELLTYPES CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 0 81712017 1/8/2017 81312017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL( THIS PANEL E46 SUBSCRIBER MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL $0.00 (82310) CARBON DIOXIDE (82374) CHLOR I RE (82435) SUBSCRIBER CREATININE(82565) GLUCOSE (82947) POTASS I UM $0.00 (84132) SODIUM (84295) UREA NITROGEN (BUN( (84520) 8/7/2017 11812017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICES) E46 $0.00 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 8/7/2017 1/8/2017 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 $0.00 HCT, RBC, WED AND PLATELET COUNT) AND AUTOMATED SUBSCRIBER DIFFERENTIAL W BC COUNT 8/7/2017 1/8/2017 8/3/2017 87077 CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL E46 SUBSCRIBER METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, $0.00 EACH ISOLATE 8/7/2017 1/8/2017 8/3/2017 87186 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; E46 $0.00 MICRODILUTION OR AGAR DILUTION (MINIMUM SUBSCRIBER INHIBITORY CONCENTRATION AMICA OR BREAKPOI NT), EACH MULTI - ANTIMICROBIAL, PER PLATE 8/7/2017 1/9/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE 81712017 1/9/2017 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 1 BCC HCT, BBC, W BC AND PLATELET COUNT) AND AUTOMATED CALORIE MALNUTRITION OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 8/7/2017 1/9/2017 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (92565) GLUCOSE (92947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 1/10/2017 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 81712017 1/10/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 8/7/2017 1/10/2017 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 HCT, BBC, W BC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL W BE COUNT 8/7/2017 1/11/2017 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 1/11/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 8/7/2017 1/11/2017 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 HCF, BBC, W BC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL W BC COUNT 8/7/2017 1/12/2017 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (82374) CHLORIDE (92435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OVTPATIENT/HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OVTPATIENT /HOSPITAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC $0.00 $72.00 MALE SUBSCRIBER 1 BCC $0.00 $18.00 MALE SUBSCRIBER 1 BCC $0.00 $48.00 MALE SUBSCRIBER 1 BCC $0.00 $112.00 MALE SUBSCRIBER 1 BCC $0.00 $72.00 MALE SUBSCRIBER 1 BCC $0.00 $18.00 MALE SUBSCRIBER 1 BCC $0.00 $35.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL C.7.f 81]1201] 1/12/2017 81312017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICES) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL Z 8/]/201] 1/12/2017 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 N HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED CALORIE MALNUTRITION OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 8/7/2017 1/13/2017 81 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 A MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) i CREATI NINE (82565) GLUCOSE (82947) POTASSIUM "a (84132) SODIUM (84295) UREA NITROGEN (BUM) (84520) m 0 8/7/2017 1/13/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $54.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL } fl 8/7/2017 1/13/2017 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (LED, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 A. CL HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED CALORIE MALNUTRITION OVTPATIENT /HOSPITAL Q, DIFFERENTIAL W BC COUNT Q 81]1201] 1/14/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/]/201] 1/15/2017 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) uj CREATININE(82565) GLUCOSE (82947) POTASSIUM F (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 1/15/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $54.00 MALE SUBSCRIBER 1 BCC 3559 _ CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OVTPATIENT /HOSPITAL 8/7/2017 1/15/2017 8/3/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED CALORIE MALNUTRITION OUTPATIENT /HOSPITAL Q DIFFERENTIAL W BC COUNT uj 8/7/2017 1/16/2017 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL U`J (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) Q {JJ 8/7/2017 1/16/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OVTPATIENT /HOSPITAL � J 81]1201] 1/16/2017 8/3/2017 85025 BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 HCT,RBC, WBCAND PLATELET COUNT) AND AUTOMATED CALORIE MALNUTRITION OUTPATIENT /HOSPITAL v DIFFERENTIAL W BC COUNT 8/7/2017 1/17/2017 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCDSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OVTPATIENT /HOSPITAL LLJ 8/7/2017 1/1]/201] 8/3/201] 85610 PROTHROMBIN TIME; E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $14.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (' 8/]/201] 6/28/2017 8/5/2017 K0001 STANDARD WHEELCHAIR K7200 ACUTE AND SUBACUTE OTHER MEDICAL $37.72 $3].]2 MALE SUBSCRIBER 1 BCC 3559 HEPATIC FAILURE Q WITHOUT COMA CN! 8/7/2017 7/28/2017 8/5/2017 K0001 STANDARD WHEELCHAIR K7200 ACUTE AND SUBACUTE OTHER MEDICAL $37.72 $37.72 MALE SUBSCRIBER 1 BCC 3559 N HEPATIC FAILURE WITHOUTCOMA 8/]/201] 12/17/2016 8/3/2017 80051 ELECTROLYTE PANEL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $41.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL C.7.f 81712017 12/17/2016 81312017 82550 CREATIVE KINASE KEY (CPK); TOTAL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/17/2016 8/3/2017 82565 CREATININE; BLOOD E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 N CALORIE MALNUTRITION OUTPATIENT /HOSPITAL OR Q! 8/7/2017 12/17/2016 8/3/2017 82607 CYANOCOBALAMIN(VITAMIN B -12); E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $19.00 MALE SUBSCRIBER 1 BCC 3559 A CALORIE MALNUTRITION OUTPATIENT /HOSPITAL i 8/7/2017 12/17/2016 8/3/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $14.00 MALE SUBSCRIBER 1 BCC 3559 "a STRIP) CALORIE MALNUTRITION OUTPATIENT/HOSPITAL m O 8/7/2017 12/17/2016 8/3/2017 83605 LACTATE (LACTIC ACID) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $13.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL } fl 8/7/2017 12/17/2016 81312017 84443 THYROID STIMULATING HORMONE(TSH) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $33.00 MALE SUBSCRIBER 1 BCC 3559 N. CL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL Q, Q 8/7/2017 12/17/2016 8/3/2017 84484 TRDPDNIN, QUANTITATIVE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 v CALORIE MALNUTRITION OVTPATIENT/HOSPITAL 81712017 12/17/2016 8/3/2017 84520 UREA NITROGEN; QUANTITATIVE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $14.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL LL! 8/7/2017 12/17/2016 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/17/2016 8/3/2017 DIFFERENTIAL W BC COUNT 86850 ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $29.00 MALE SUBSCRIBER 1BCC 3559 _ CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/17/2016 8/3/2017 86900 BLOOD TYPING, SEROLOGIC; ABO E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.0D $29.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT/HOSPITAL 0. W 8/7/2017 12/17/2016 8/3/2017 86901 BLOOD TYPING, SEROLOGIC; BIT (M E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $11.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UJ 8/7/2017 12/18/2016 81312017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN,TOTAL E46 UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 LLJ (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SEPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) 81712017 12/18/2016 8/3/2017 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 V BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, CALORIE MALNUTRITION OUTPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; LLJ AUTOMATED, WITH MICROSCOPY 8/7/2017 12/18/2016 8/3/2017 82140 AMMONIA E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL U 8/7/2017 12/18/2016 8/3/2017 82376 CARBOHYHEMOGLDBIN; QUALITATIVE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL 8/7/2017 12/18/2016 8/3/2017 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0GD $22.00 MALE SUBSCRIBER 1 BCC 3559 Cy CO2, HCO3 (INCLUDING CALCULATED D2 SATURATION); CALORIE MALNUTRITION OUTPATIENT /HOSPITAL WITH 02 SATURATION, BY DIRECT MEASUREMENT, _ EXCEPT PULSE OXIMETRY y 8/7/2017 12/18/2016 8/3/2017 83045 HEMOGLOBIN; METHEMOGLOBIN, QUALITATIVE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $14.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL .0 C.7.f 81712017 12/18/2016 81312017 85018 BLOOD COUNT; HEMOGLOBIN (HGB) E46 8/7/2017 12/19/2016 8/3/2017 82330 CALCIUM; IONIZED E46 8/7/2017 12/19/2016 81 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, POE, E46 COE, HCO3 (INCLUDING CALCULATED D2 SATURATION); 8/7/2017 12/19/2016 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 SUBSCRIBER 1 BCC CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE 8/7/2017 12/19/2016 8/3/2017 83516 IMMUNOASSAY FDRANALYTE OTHER THAN INFECTIOUS E46 AGENT ANTI BODY OR INFECTIOUS AGENT ANTIGEN, UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 QUALITATIVE OR SEMIQUANTITATIVE; MULTIPLE STEP SUBSCRIBER 1 BCC METHOD 81712017 12/19/2016 8/3/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 HOT, BBC, W BC AND PLATELET COUNT) 8/772017 12/19/2016 8/3/2017 85610 PROTHROMBIN TIME; E46 81712017 12/19/2016 8/3/2017 86160 COMPLEMENT; ANTIGEN, EACH COMPONENT E46 8/7/2017 12/19/2016 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) SUBSCRIBER 1 BCC CREATININE (92565) GLUCOSE (82947) POTASSIUM CALORIE MALNUTRITION OVTPAUENT/HOSPITAL (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 12/19/2016 8/3/2017 82550 CREATINE KINASE(CK),(CPK); TOTAL E46 8/7 /2017 12/20/2016 8/3/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE E46 SUBSCRIBER 1 BCC FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), CALORIE MALNUTRITION OUTPATIENT /HOSPITAL CARBON DIOXIDE (BICARB0NATE)(82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (82947), UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 PHOSPHORUS INORGANIC (PH0SPHATE)(84100), SUBSCRIBER 1 BCC POTASSIUM (84132), SODIUM (84295), UREA NITROGEN CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (BU 81712017 12/20/2016 8/3/2017 80320 ALCOHOLS E46 8/7/2017 12/20/2016 8/3/2017 82550 CREATINE KINASE ICE), (CPK); TOTAL E46 8/7 /2017 12/20/2016 8/3/2017 82570 CREATININE; OTHER SOURCE E46 8/7/2017 12/20/2016 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 8/7/2017 12/20/2016 8/3/2017 84156 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE E46 8/7/2017 12/20/2016 8/3/2017 85652 SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $14.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $CAD $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $19.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPAUENT/HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $15.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $14.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $46.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $C.00 $27.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $13.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $90.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT/HOSPITAL 81712017 12/20/2016 81312017 86140 &REACTIVE PROTEIN; E46 8/7/2017 12/21/2016 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 1 BCC MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL CALORIE MALNUTRITION OVTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 12/21/2016 8/3/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE E46 $22.00 MALE FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), 1 BCC CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE CALORIE MALNUTRITION OVTPATIENT /HOSPITAL (82435), CREATININE (92565), GLUCOSE (82947), PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN UNSPECIFIED PROTEIN- PROFESSIONAL (BU 8/7/2017 12/21/2016 8/3/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE E46 1 BCC THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (94075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), UNSPECIFIED PROTEIN- PROFESSIONAL TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 8/7/2017 12/21/2016 8/3/2017 82550 CREATINE KINASE(CK), CPK); TOTAL E46 81712017 12/21/2016 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 8/7/2017 12/21/2016 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 HCT, RBC, W BC AND PLATELET COUNT) AND AUTOMATED UNSPECIFIED PROTEIN- PROFESSIONAL DIFFERENTIAL W BC COUNT 8/7/2017 12/22/2016 8/3/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE E46 1 BCC FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), CALORIE MALNUTRITION OUTPATIENT /HOSPITAL CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE ( 82435), CREATININE (82565), GLUCOSE (82947), PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN (BU 8/7/2017 12/22/2016 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 8/7/2017 12/22/2016 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 HCT, BBC, W BC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL W BC COUNT 8/7/2017 12/23/2016 8/3/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE E46 FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (82947), PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN (BU 8/7/2017 12/23/2016 8/3/2017 82550 CREATINE KINASE(CK),(CPK); TOTAL E46 81712017 12/23/2016 9/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL CALORIE MALNUTRITION OVTPATIENT /HOSPITAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC $0.00 $35.00 MALE SUBSCRIBER 1 BCC $0.00 $27.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 w Z 3559 N om UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $27.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $27.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL rl C.7.f 81712017 12/23/2016 81312017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 HCT, BBC, WBCAND PLATELET COUNT) AND AUTOMATED CALORIE MALNUTRITION OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 8/7/2017 12/24/2016 8/3/2017 82140 AMMONIA E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/24/2016 8/3/2017 82550 CREATINE KINASE(CK),(CPK); TOTAL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/24/2016 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0GD $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OUTPATIENT/HOSPITAL 8/7/2017 12/24/2016 8/3/2017 83615 LACTATE DEHYDROGENASE(ED),(LDHU E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $21.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/24/2016 81312017 83874 MYOGLOBIN E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $17.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/25/2016 8/3/2017 82550 CREATINE KINASE(CK),(CPK); TOTAL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL 81712017 12/25/2016 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/25/2016 8/3/2017 86703 ANTIBODY; HIV -1 AND HIV -2, SINGLE RESULT E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $30.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/25/2016 8/3/2017 86706 HEPATITIS B SURFACE ANTIBODY(HBSAB) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/25/2016 8/3/2017 86803 HEPATITIS C ANTIBODY; E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0GD $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/26/2016 8/3/2017 82140 AMMONIA E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/26/2016 81312017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/26/2016 8/3/2017 83036 HEMOGLOBIN; GLYCOSYL4TED(AlC) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $16.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL 81712017 12/26/2016 8/3/2017 84484 TROPONIN, QUANTITATIVE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $70.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/26/2016 8/3/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 HCT, RBC, WBCAND PLATELETCOUNT) CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/26/2016 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 12/26/2016 8/3/2017 82550 CRE41FINE KINASE(CK),(CPK); TOTAL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 81712017 12/27/2016 81312017 80076 HEPATIC FUNCTION PAN ELTH IS PANEL MUST INCLUDE E46 $16.00 MALE THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL 1 BCC (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, CALORIE MALNUTRITION OUTPATIENT /HOSPITAL ALKALINE (94075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SEPT) (84460(, TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 8/7/2017 12/27/2016 8/3/2017 82150 AMYLASE E46 8/7/2017 12/27/2016 8/3/2017 82550 CREATINE KINASE ICE),(CPK); TOTAL E46 8/7/2017 12/27/2016 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 81712017 12/27/2016 8/3/2017 83690 LIPASE E46 8/7/2017 12/27/2016 8/3/2017 84132 POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD E46 81712017 12/28/2016 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 $54.00 MALE MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL 1 BCC (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CALORIE MALNUTRITION OUTPATIENT /HOSPITAL CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 12/28/2016 8/3/2017 82550 CREATINE KINASE ICE),(CPK); TOTAL E46 8/7/2017 12/28/2016 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 $17.00 MALE CLEARED BY THE FDA SPECIFICALLY FOR HOME USE 8/7/2017 12/28/2016 8/3/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, E46 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL HCF, BBC, W BC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL W BC COUNT 8/7/2017 12/29/2016 8/3/2017 83735 MAGNESIUM E46 81712017 12/29/2016 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 $6.00 MALE HCF, BBC, W BC AND PLATELET COUNT) AND AUTOMATED 1 BCC DIFFERENTIAL W BC COUNT 8/7 /2017 12/29/2016 8/3/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION E46 AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) 8/7/2017 12/29/2016 81 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE E46 $35.00 MALE FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), 1 BCC CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (82435), CREATININE (82565), GLUCOSE (92947), PHOSPHORUS INORGANIC (PH0SPHATE)(84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN UNSPECIFIED PROTEIN- PROFESSIONAL (BU 8/7/2017 12/29/2016 8/3/2017 SOWS HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE E46 1 BCC THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL CALORIE MALNUTRITION OUTPATIENT/HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SEPT) (84450), UNSPECIFIED PROTEIN- PROFESSIONAL TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC CALORIE MALNUTRITION OUTPATIENT /HOSPITAL C.7.f 3559 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $16.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $54.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $17.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT/HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $46.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT/HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $27.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL C.7.f 81712017 12/29/2016 81312017 81001 URINALYSIS, BY D I P STICK OR TABLET REAGENT FOR E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 BCC 3559 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, CALORIE MALNUTRITION OUTPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 8/7/2017 12/29/2016 8/3/2017 82140 AMMONIA E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/29/2016 8/3/2017 82550 CREATINE KINASE(CK),(CPK); TOTAL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL 8/7/2017 12/29/2016 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 81712017 12/29/2016 8/3/2017 83935 OSMOLALITY; URINE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL 8/7/2017 12/29/2016 8/3/2017 84145 PFOCZICIt- mH`CT) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $13.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/29/2016 8/3/2017 84300 SODIUM; URINE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/29/2016 8/3/2017 84550 URIC ACID; BLOOD E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL 8/7/2017 12/30/2016 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (92374) CHLORIDE (92435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 12/30/2016 8/3/2017 82140 AMMONIA E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/30/2016 8/3/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/7/2017 12/30/2016 8/3/2017 83735 MAGNESIUM E45 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT/HOSPITAL 8/7/2017 12/30/2016 8/3/2017 83930 OSMOLALITY; BLOOD E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OVTPATIENT /HOSPITAL 81712017 12/30/2016 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 HCT,RBC, WBCAND PLATELET COUNT) AND AUTOMATED CALORIE MALNUTRITION OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 8/7/2017 12/31/2016 8/3/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL CALORIE MALNUTRITION OVTPATIENT/HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE(92565) GLUCOSE R32947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/7/2017 12/31/2016 8/3/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE E46 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 THE FOLLOWING: ALBUMIN (82040), BILIRUBINTOTAL CALORIE MALNUTRITION OUTPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) C.7.f 61712017 12/31/2016 8/3/2017 82140 AMMONIA E46 8/7/2017 12/31/2016 8/3/2017 82550 CREATINE KINASE ICE),(CPK); TOTAL E46 8/7/2017 12/31/2016 81 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) E46 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE UNSPECIFIED PROTEIN- PROFESSIONAL 8/7/2017 12/31/2016 8/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E46 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL HCT, BBC, W BC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WEE COUNT 8/7/2017 12/31/2016 8/3/2017 87088 WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF E46 SUBSCRIBER 1 BCC 3559 A EACH ISOLATE, URINE 8/9/2017 8/1 /2017 9/7/2017 - - K7290 8/21/2017 8/9/2017 8/18/2017 * * * ** * * * ** * * * ** 812112017 819/2017 811812017 43239 ESOPHAGOGASTRODUODENOSCOPY ,FLEXIBLE, 18500 3559 "a CALORIE MALNUTRITION OUTPATIENT /HOSPITAL TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE 8/21/2017 8/9/2017 8/18/2017 43244 ESOPHAGOGASTRODUDDENOSCOPY, FLEXIBLE, 18500 O TRANSORAL; WITH BAND LIGATION OF $0.00 $35.00 MALE SUBSCRIBER 1 BCC ESOPHAGEAL /GASTRIC VARICES CALORIE MALNUTRITION OUTPATIENT /HOSPITAL 8/21/2017 81 811812017 45380 COLON0SC OPY , FLEXIBLE; WITH BIOPSY, SINGLE OR 18500 MULTIPLE 8/21/2017 8/9/2017 8/18/2017 45381 COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL 18500 1 BCC 3559 N. UNSPECIFIED WITHOUT INJECTION(S), ANY SUBSTANCE 8/21/2017 8/9/2017 81 45385 COLON0SCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), 18500 POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE F # ** * * * ** 9/21/2017 8/9/2017 8/18/2017 88305 LEVELIV- SURGICAL PATHOLOGY, GROSS AND D125 ESOPHAGEAL VARICES PROFESSIONAL $272.25 $613.00 MALE MICROSCOPIC EXAMINATION ABORTION - 1 BCC 3559 WITHOUT BLEEDING OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE MARROW, BIOPSY, BONE EXOSTO515, BRAIN /MENINGES, OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, $239.36 $1,07fi.00 MALE SUBSCRIBER 1 BCC NOT REQUIRING MICROSCOPIC EVALUATION OF WITHOUT BLEEDING OUTPATIENT /HOSPITAL SURGICAL MARGINS, BREAST, REDUCTION F 812112017 8/10 /2017 8/18/2017 * * * ** 812112017 11/12/2016 8/18/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) N179 ESOPHAGEAL VARICES PROFESSIONAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE $1,064.00 MALE 8/21/2017 11/12/2016 8/18/2017 87040 CU ETU RE, BACTERIAL; B LOOD, A FRO B I C, W ITH ISDLATI ON N179 AND PRESUMPTIVE IDENTIFICATION OF ISOLATES ESOPHAGEAL VARICES PROFESSIONAL $43.22 $1,007.00 MALE SUBSCRIBER (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) 3559 8/23/2017 8/9/2017 8/22/2017 - - Z1211 8/23/2017 8/10/2017 8/22/2017 * * * ** * * * ** * * * ** 8/23/2017 8/10/2017 8/22/2017 * * * *s $491.54 $1,263.00 MALE 8/31/2017 1/3/2017 8/25/2017 * * * ** * * * ** * * * ** 8/31/2017 1/5/2017 81 NJ 912812017 8/28/2017 912712017 0001 STANDARD WHEELCHAIR K7200 UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $9.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL Z UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER 1 BCC 3559 N CALORIE MALNUTRITION OUTPATIENT /HOSPITAL Q! UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $72.00 MALE SUBSCRIBER 1 BCC 3559 A CALORIE MALNUTRITION OUTPATIENT /HOSPITAL i UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 "a CALORIE MALNUTRITION OUTPATIENT /HOSPITAL m O UNSPECIFIED PROTEIN- PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 CALORIE MALNUTRITION OUTPATIENT /HOSPITAL } fl HEPATIC FAILURE, HOSPITA L OUTPATIENT $1,351.25 $1,815.00 MALE SUBSCRIBER 1 BCC 3559 N. UNSPECIFIED WITHOUT Q, COMA F # ** * * * ** $681.45 $1,155.00 MALE SUBSCRIBER 1 BCC 3559 ESOPHAGEAL VARICES PROFESSIONAL $272.25 $613.00 MALE SUBSCRIBER 1 BCC 3559 WITHOUT BLEEDING OUTPATIENT /HOSPITAL ESOPHAGEAL VARICES PROFESSIONAL $239.36 $1,07fi.00 MALE SUBSCRIBER 1 BCC 3559 WITHOUT BLEEDING OUTPATIENT /HOSPITAL F ESOPHAGEAL VARICES PROFESSIONAL $6926 $1,064.00 MALE SUBSCRIBER 1 BCC 3559 WITHOUT BLEEDING OUTPATIENT /HOSPITAL ESOPHAGEAL VARICES PROFESSIONAL $43.22 $1,007.00 MALE SUBSCRIBER 1 BCC 3559 WITHOUT BLEEDING OUTPATIENT /HOSPITAL O ESOPHAGEAL VARICES PROFESSIONAL $491.54 $1,263.00 MALE SUBSCRIBER 1 BCC 3559 IL WITHOUT BLEEDING OUTPATIENT /HOSPITAL NJ BENIGN NEOPLASM OF PROFESSIONAL $23418 $560.00 MALE SUBSCRIBER 1 BCC 3559 UJ SIGMOID COLON OUTPATIENT /HOSPITAL J LLJ 4 J " * * *" * * * ** $108.44 $299.00 MALE SUBSCRIBER 1 BCC 3559 ACUTE KIDNEY FAILURE, PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 V UNSPECIFIED INPATIENT /HOSPITAL r ACUTE KIDNEY FAILURE, PROFESSIONAL $0.00 $23.00 MALE SUBSCRIBER 1 BCC 3559 LLJ UNSPECIFIED INPATIENT /HOSPITAL U ENCOUNTERFOR HOSPITAL OUTPATIENT $11,471.85 $31,005.00 MALE SUBSCRIBER 1 BCC 3559 SCREENING FOR MALIGNANT NEOPLASM OFCOLON N $539.00 $539.00 MALE SUBSCRIBER 1 BCC 3559 hl $0.00 $539.00 MALE SUBSCRIBER 1 BCC 3559 * * * ** * * * ** $97.74 $200.00 MALE SUBSCRIBER 1 BCC 3559 = * * * ** * * * ** $97.74 $200.00 MALE SUBSCRIBER 1 BCC 3559 y ACUTE AND SUBACUTE OTHER MEDICAL $0.00 $37.72 MALE SUBSCRIBER 1 BCC 3559 HEPATIC FAILURE WITHOUTCOMA 2 C.7.f 10/4/2017 9/28/2017 101 K0001 STANDARD WHEELCHAIR K7200 101 4/4/2017 101 87507 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR 8197 RNA; GASTROINTESTINAL PATHOGEN )EG ,CLOSTRIDIUM DIFFICILE, E. COLI, SALMONELLA, SHIGELLA, NOROVIRUS, GIARDIA), INCLUDES MULTIPLEX REVERSE DIARRHEA, UNSPECIFIED TRANSCRIPTION, $0.00 10/11/2017 5/25/2017 101 * * * ** * * * ** * * * ** 11/1/2017 10/23/2017 10/30/201] 11/1/2017 10/23/201] 10/31/201] 74150 COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT R188 * * * »* $158.49 CONTRAST MATERIAL SUBSCRIBER 11/1/2017 10/24/2017 10/30/2017 - - R188 11/1/2017 10/24/2017 1013012017 - - 8188 11/1/2017 10/24/2017 10/30/2017 - - R198 11/1/2017 10/28/2017 10/31/2017 K0001 STANDARD WHEELCHAIR K7200 111212017 10/24/2017 10/31/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R0602 FRONTAL OTHER ASCITES 11/3/2017 10/24/2017 11/2/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R188 1 BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES HOSPITA L OUTPATIENT $3,412.50 $4,550.00 MALE THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS 1 BCC 3559 OTHER ASCITES IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL $0.00 $4,550.00 MALE SUBSCRIBER CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE 3559 ACUTE AND SUBACUTE OTHER MEDICAL HISTORY; A COMPREHENSIVE EXAMINATION; AND $39.98 MALE SUBSCRIBER 1 BCC M E DICAL DECIS HEPATIC FAILURE 11/6/2017 11/2/2017 11/3/2017 * * * ** * * * ** * * * ** 11/6/2017 11/2/2077 1113/201] WITHOUTCOMA 11/7/2017 11/2/2017 11/6/2017 11/8/2017 10124/2017 11/3/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION D696 $58.00 MALE SUBSCRIBER AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 3559 OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL OTHER ASCITES PROFESSIONAL $269.58 CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE SUBSCRIBER 1 BCC 3559 HISTORY; A COMPREHENSIVE EXAMINATION; AND OUTPATIENT /HOSPITAL MEDICAL DECIS 11/8/2017 10/24/2017 11/7/2017 A0425 GROUND MILEAGE, PER STATUTE MILE K7290 11/8/2017 10/24/2017 11/7/2017 A0427 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, K7290 EMERGENCY TRANSPORT, LEVEL 1 )AL51- EMERGENCY) $66.20 MALE 11/13/2017 11/212017 11/10/201] 88108 CYTOPATHOLOGY, CONCENTRATION TECHNIQUE, SMEARS R188 * * * ** $120.11 AND INTERPRETATION (EG, SACCOMANNO TECHNIQUE) SUBSCRIBER 11/17/2017 10/24/2017 11/15/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R188 $268.82 $665.00 MALE THERAPEUTIC); WITH IMAGING GUIDANCE 1 BCC 11/27/2011 11/8/2017 11/23/2017 OUTPATIENT /HOSPITAL 11/27/2017 11/8/2017 11/23/2017 11/29/2017 11/17/2017 11/27/2017 * » » ** $620.00 $806.00 MALE 1113012017 11/28/2017 11/29/2017 K0001 STANDARD WHEELCHAIR K7200 ACUTE AND SUBACUTE OTHER MEDICAL $39.98 $39.98 MALE SUBSCRIBER 1 BCC 3559 HEPATIC FAILURE WITHOUTCOMA DIARRHEA, UNSPECIFIED PROFESSIONAL $0.00 $300.00 MALE SUBSCRIBER 1 BCC 3559 OUTPATIENT /HOSPITAL * * * ** * * * »* $158.49 $1,878.11 MALE SUBSCRIBER 1 BCC 3559 * * * ** * * * ** $3,966.75 $5,289.00 MALE SUBSCRIBER 1 BCC 3559 OTHER ASCITES PROFESSIONAL $103.31 $356.00 MALE SUBSCRIBER 1 BCC 3559 OUTPATIENT /HOSPITAL OTHER ASCITES HOSPITAL OUTPATIENT $4,060.20 $6,76].00 MALE SUBSCRIBER 1 BCC 3559 OTHER ASCITES HOSPITA L OUTPATIENT $3,412.50 $4,550.00 MALE SUBSCRIBER 1 BCC 3559 OTHER ASCITES HOSPITAL OUTPATIENT $0.00 $4,550.00 MALE SUBSCRIBER 1 BCC 3559 ACUTE AND SUBACUTE OTHER MEDICAL $39.98 $39.98 MALE SUBSCRIBER 1 BCC 3559 HEPATIC FAILURE WITHOUTCOMA SHORTNESS OF BREATH PROFESSIONAL $15.65 $58.00 MALE SUBSCRIBER 1 BCC 3559 OUTPATIENT /HOSPITAL OTHER ASCITES PROFESSIONAL $269.58 $665.00 MALE SUBSCRIBER 1 BCC 3559 OUTPATIENT /HOSPITAL $0.00 $68.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $66.20 MALE SUBSCRIBER 1 BCC 3559 * * * ** * * * ** $120.11 $299.07 MALE SUBSCRIBER 1 BCC 3559 THROMBOCYTOPENIA, PROFESSIONAL $268.82 $665.00 MALE SUBSCRIBER 1 BCC 3559 UNSPECIFIED OUTPATIENT /HOSPITAL HEPATIC FAILURE, OTHER MEDICAL $620.00 $806.00 MALE SUBSCRIBER 1 BCC 3559 UNSPECIFIED WITHOUT COMA HEPATIC FAILURE, OTHER MEDICAL $402.94 $850.00 MALE SUBSCRIBER 1 BCC 3559 UNSPECIFIED WITHOUT COMA OTHER ASCITES PROFESSIONAL $30.52 $86.00 MALE SUBSCRIBER 1 BCC 3559 OUTPATIENT /HOSPITAL OTHER ASCITES PROFESSIONAL $200.15 $422.00 MALE SUBSCRIBER 1 BCC 3559 OUTPATIENT /HOSPITAL ** * * * ** $234.54 $560.00 MALE SUBSCRIBER 1 BCC 3559 $203.52 $507.00 MALE SUBSCRIBER 1 BCC 3559 $5,602.80 $9,338.00 MALE SUBSCRIBER 1 BCC 3559 ACUTE AND SUBACUTE OTHER MEDICAL $39.98 $39.98 MALE SUBSCRIBER 1 BCC 3559 HEPATIC FAILURE WITHOUTCOMA 12/8/2017 11/1]/2017 12/6/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL SUBSCRIBER 1 BCC $0.00 THERAPEUTIC); WITH IMAGING GUIDANCE SUBSCRIBER 1 BCC OUTPATIENT /HOSPITAL 12/20/2017 11/2/2017 1211912017 + + +«. $154.42 $437.00 MALE SUBSCRIBER 1 BCC 12/21/2017 11/17/2017 12/19/201] 1 BCC $310,937.48 $653,134.67 12/21/2017 12112/2017 12/19/2017 DEPENDENT 1050 12/27/2017 11/2/2017 1212112017 * * * ** * * * ** *« * ** * * * ** * * * ** 12/2]/201] 12/12/2017 12/23/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL Sub Total 1.625E +10 1/4/2017 12/29/2016 1/3/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1069 ACUTE UPPER PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED RESPIRATORY INFECTION, PATIENT,WHI CH REQUIRESAT LEAST2 OF THESE 3 KEY UNSPECIFIED COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 1/19/2017 12/6/2016 1/17/2017- - Q379 UNSPECIFIED CLEFT HOSPITAL OUTPATIENT PALATE WITH UNILATERAL CLEFT LIP 1/30/2017 1/13/2017 1118/2017 90471 IMMUNIZATION ADMINISTRATION (INCLUDES Z23 ENCOUNTER FOR PROFESSIONAL OFFICE PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR IMMUNIZATION INTRAMUSCULAR INIECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE /TOXOID) 1/30/2017 1/13/2017 1/18/2017 90685 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLITVIRUS, Z23 ENCOUNTERFOR PROFESSIONAL OFFICE PRESERVATIVE FREE, WHEN ADMINISTERED TO CHILDREN IMMUNIZATION 6 -35 MONTHS OF AGE, FOR INTRAMUSCULAR USE 1/30/2017 1/23/2017 1/25/2017 99213 OFFICE DR OTHER OUTPATIENT VISIT FOR THE N4889 OTHER SPECIFIED PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISORDERS OF PENIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 2/1/2017 1/26/2017 1/30/2017 99243 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED H65493 OTHER CHRONIC PROFESSIONAL OFFICE PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS:A NONSUPPURATIVE OTITIS DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDIA, BILATERAL MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE 2/10/2017 1/31/2017 2/2/2017 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 Q211 ATRIALSEPTAL DEFECT PROFESSIONAL OFFICE LEADS; WITH INTERPRETATION AND REPORT 2/10/2017 1/31/2017 2/2/2017 93303 TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE CARDIAC ANOMALIES; COMPLETE 2/10/2017 1/31/2017 2/2/2017 93320 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND /OR Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING(; COMPLETE 2/10/2017 1/31/2017 2/2/2017 93325 DOPPLER ECHOCARDIOGRAPHV COLOR FLOW VELOCITY Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE MAPPING( IST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHY) $200.15 $422.00 MALE SUBSCRIBER 1 BCC $5,586.36 $17,238.00 MALE SUBSCRIBER 1 BCC $0.00 $312.00 MALE SUBSCRIBER 1 BCC $3,171.60 $5,286.00 MALE SUBSCRIBER 1 BCC $154.42 $437.00 MALE SUBSCRIBER 1 BCC $200.15 $422.00 MALE SUBSCRIBER 1 BCC $310,937.48 $653,134.67 $87.66 $175.00 MALE DEPENDENT 1050 $383.98 $526.00 MALE DEPENDENT 1050 $28.33 $57.00 MALE DEPENDENT 1050 $26.00 $100.00 MALE DEPENDENT 1050 $62.32 $175.00 MALE DEPENDENT 1050 $128.80 $315.00 MALE DEPENDENT 1050 $33.32 $122.00 MALE DEPENDENT 1050 $8517 $1,487.00 MALE DEPENDENT 1050 $127.31 $467.00 MALE DEPENDENT 1050 $76.07 $569.00 MALE DEPENDENT 1050 2/10/2017 1/31/2017 2/2/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE $143.98 $353.00 MALE DEPENDENT 1050 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 2/27/2017 2/3/2017 2/20/2017 99241 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED T819XXA UNSPECIFIED PROFESSIONAL OFFICE $8939 $135.00 MALE DEPENDENT 1050 PATIENT,WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPLICATION OF PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED PROCEDURE, INITIAL EXAMINATION; ANDSTRAIGHTFORWARD MEDICAL ENCOUNTER DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSIST 2/27/2017 2/10/2017 212212017 69436 TYMPANOST0MY (REQUIRING INSERTION OF H65493 OTHER CHRONIC PROFESSIONAL $215.88 $700.00 MALE DEPENDENT 1050 VENTILATING TUBE, GENERAL ANESTHESIA N0N5UPPURATIVE OTITIS OUTPATIENT /HOSPITAL MEDIA, BILATERAL 3/13/2017 2/10/2017 2/24/2017- - Q379 UNSPECIFIED CLEFT HOSPITAL INPATIENT 2/10/2017 $22,532.50 $39,483.84 MALE DEPENDENT 1050 PALATE WITH UNILATERAL CLEFT LIP 3/17/2017 3/13/2017 3/15/2017 90744 HEPATITIS B VACCINE, PEDIATRIC /ADOLESCENT DOSAGE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $20.00 $55.00 MALE DEPENDENT 1050 (3 DOSE SCHEDULE(, FOR INTRAMUSCULAR USE ROUTINE CHILD HEALTH EXAMINATION WITHOUT ABNORMAL FINDINGS 3/17/2017 3/13/2017 3/15/2017 99391 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $11737 $242.00 MALE DEPENDENT 1050 REEVALUATION AND MANAGEMENTOF AN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGEAND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; INFANT (AGE YOUNGER THAN 1YEAR) 3120/2017 2/17/2017 3/17/2017 * * * "* 11 - *i ° ** ffi #k- $121.27 $348.00 MALE DEPENDENT 1 050 3/27/2017 2110/2017 3/24/2017 102 ANESTHESIA F0RPR0 CEDURESON PLASTICREPAIROF Q379 UNSPECIFIED CLEFT PR0FE55IONAL $1,415.62 $2,480.00 MALE DEPENDENT 1050 CLEFT LIP PALATE WITH UNILATERAL INPATIENT /HOSPITAL CLEFT LIP 4/10/2017 3/30/2017 4/7/2017- - H6530 CHRONIC MUCOID OTITIS HOSPITAL OUTPATIENT $162.06 $222.00 MALE DEPENDENT 1050 MEDIA, UNSPECIFIED EAR 4/26/2017 4/17/2017 4/24/2017 93000 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 0211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE $44.43 $122.00 MALE DEPENDENT 1050 LEADS; WITH INTERPRETATION AND REPORT 4/26/2017 4/17/2017 4/24/2017 93303 TRANSTHORACIC ECHOCARDIDGRAPHY FOR CONGENITAL Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE $513.69 $1,487.00 MALE DEPENDENT 1 050 CARDIAC ANOMALIES; COMPLETE 4/26/2017 4/17/2017 4/24/2017 93320 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND /OR Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE $169.75 $467.00 MALE DEPENDENT 1050 CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING(; COMPLETE 4/26/2017 4/17/2017 4/24/2017 93325 DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE $101.43 $569.00 MALE DEPENDENT 1050 MAPPING (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHV) C.7.f 3559 Im WE 3559 3559 Em 3559 3559 3559 3559 3559 3559 mm 4/26/2017 4/17/2017 4/24/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE DEPENDENT 1050 EVALUATION AND MANAGEMENT OF AN ESTABLISHED $227.00 MALE DEPENDENT 1050 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 5/12/2017 5/9/2017 5/11/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H66001 ACUTE SUPPURATIVE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OTITIS MEDIA WITHOUT PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SPONTANEOUS RUPTURE COMPONENTS: AN EXPANDED PROBLEM FOCUSED OF EAR DRUM, RIGHT EAR HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 5/22/2017 5/4/2017 5/19/2017 99244 OFFICE CONSULTATION FORA NEW OR ESTABLISHED K219 GASTRO- ESOPHAGEAL PROFESSIONAL OFFICE PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A REFLUX DISEASE COMPREHENSIVE HISTORY; A COMPREHENSIVE WITHOUT ESOPHAGITIS EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE CDMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONS 5/26/2017 5/23/2017 5/25/2017 * « * ** 6/14/2011 6/6/2017 6/13/2017 6/15/2017 5/1/201] 6/14/2017 99244 OFFICE CONSULTATION FORA NEW OR ESTABLISHED K219 CASTRO- ESOPHAGEAL PROFESSIONAL OFFICE PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A REFLUX DISEASE COMPREHENSIVE HISTORY; A COMPREHENSIVE WITHOUT ESOPHAGITIS EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONS 6/15/2017 6/]/201] 6/14/2017 69210 REMOVAL IMPACTED CERUMEN REQUIRING H6993 UNSPECIFIED PROFESSIONAL OFFICE INSTRUMENTATION, UNILATERAL EUSTACHIAN TUBE DISORDER, BILATERAL 6115/2017 6/7/2017 6/14/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE H6993 UNSPECIFIED PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED EUSTACHIAN TUBE PATIENT,WHI CH REQUIRES AT LEAST 2 OF THESE 3 KEY DISORDER, BILATERAL COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/20/2017 6/6/2017 6/17/2017- - Q379 UNSPECIFIED CLEFT HOSPITAL OUTPATIENT PALATE WITH UNILATERAL CLEFT LIP 6/20/2017 6/6/2017 6/17/2017 - - K219 CASTRO- ESOPHAGEAL HOSPITAL OUTPATIENT REFLUX DISEASE WITHOUT ESOPHAGITIS 6/23/2017 6/18/2017 6122/2017 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L509 URTICARIA, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF A NEW PATIENT, OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE P $168.98 $353.00 MALE DEPENDENT 1050 $8732 $175.00 MALE DEPENDENT 1050 $257.66 $410.00 MALE DEPENDENT 1050 $87.32 $175.00 MALE DEPENDENT 1050 $51.00 $55.00 MALE DEPENDENT 1050 $0.00 $410.00 MALE DEPENDENT 1050 $5733 $135.00 MALE DEPENDENT 1050 $118.46 $225.00 MALE DEPENDENT 1050 $472.00 $1,075.00 MALE DEPENDENT 1050 $0.00 $685.00 MALE DEPENDENT 1050 $0.00 $227.00 MALE DEPENDENT 1050 C.7.f 3559 ®' WE 3559 3559 3559 3559 3559 6/23/2017 6/20/2017 6/22/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, 201818 ENCOUNTER FOR OTHER PROFESSIONAL OFFICE $28,576.59 MALE HCF,RBC,WBC AND PLATELET COUNT) AND AUTOMATED 1050 PREPROCEDURAL $211.00 MALE DEPENDENT DIFFERENTIAL W BC COUNT $2.72 EXAMINATION DEPENDENT 6/23/2017 6/20/2017 6/22/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z01818 ENCOUNTER FOR OTHER PROFESSIONAL OFFICE $9138 EVALUATION AND MANAGEMENT OF AN ESTABLISHED DEPENDENT PREPROCEDURAL $30.70 $64.00 MALE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY 1050 EXAMINATION COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 7/5/2017 6/18/2017 7/3/2017- - LS09 URTICARIA, UNSPECIFIED HOSPITAL OUTPATIENT 8/7/2017 712812017 8/3/2017- - Q379 UNSPECIFIED CLEFT HOSPITAL OUTPATIENT PALATE WITH UNILATERAL CLEFT LIP 8118/2017 8/15/2017 8/17/2017 54450 FORESKIN MANIPUVITION INCLUDING LYSIS OF Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE PREPUTIAL ADHESIONS AND STRETCHING ROUTINE CHILD HEALTH EXAMINATION WITH ABNORMAL FINDINGS 8/18/2017 8/15/2017 8/17/2017 81000 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, ROUTINE CHILD HEALTH LEUIKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, EXAMINATION WITH UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; ABNORMAL FINDINGS NON AUTOMATED, WITH MICROSCOPY 8/18/2017 8/15/2017 8/17/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE HCF,REG,REG AND PLATELET COUNT) AND AUTOMATED ROUTINE CHILD HEALTH DIFFERENTIAL W BC COUNT EXAMINATION WITH ABNORMAL FINDINGS 8/18/2017 8/15/2017 8/17/2017 90460 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH EXAMINATION WITH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF ABNORMAL FINDINGS EACH VACCINE OR TOXOID ADMINISTERED 8/18/2017 8/15/2017 8/17/2017 90461 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH EXAMINATION WITH CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR ABNORMAL FINDINGS TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 8/18/2017 8/15/2017 8/17/2017 90633 HEPATITIS A VACCINE ,PEDIATRIC /ADOLESCENT DOSAGE -2 Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE DOSE SCHEDULE, FOR INTRAMUSCULAR USE ROUTINE CHILD HEALTH EXAMINATION WITH ABNORMAL FINDINGS 8/18/2017 8/15/2017 8117/2017 90707 MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE LIVE, FOR SUBCUTANEOUS USE ROUTINE CHILD HEALTH EXAMINATION WITH ABNORMAL FINDINGS 8/18/2017 8/15/2017 8/17/2017 90716 VARICELLA VIRUS VACCINE, LIVE, FOR SUBCUTANEOUS Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE USE ROUTINE CHILD HEALTH EXAMINATION WITH ABNORMAL FINDINGS $6.40 $25.00 MALE DEPENDENT 1050 $128.29 $250.00 MALE DEPENDENT 1050 $460.00 $460.00 MALE DEPENDENT 1050 $19,162.00 $28,576.59 MALE DEPENDENT 1050 $100.03 $211.00 MALE DEPENDENT 1050 $2.72 $19.00 MALE DEPENDENT 1050 $6.68 $25.00 MALE DEPENDENT 1050 $9138 $189.00 MALE DEPENDENT 1050 $30.70 $64.00 MALE DEPENDENT 1050 $33.00 $75.00 MALE DEPENDENT 1050 $74.00 $115.00 MALE DEPENDENT 1050 $126.00 $204,00 MALE DEPENDENT 1050 811812017 8/15/2017 8/17/2017 99392 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE $37.00 MALE REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL 1050 ROUTINE CHILD HEALTH $19.00 MALE DEPENDENT INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, $1,255.80 EXAMINATION WITH DEPENDENT 1050 EXAMINATION ,COUNSELING /ANTICIPATORY $250.00 MALE ABNORMAL FINDINGS 1050 $218.49 GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, DEPENDENT 1050 ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; EARLY CHILDHOOD (AGE 1 TH ROUGH 4 YEARS) 8/21/2017 7/27/2017 8118/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, Q379 UNSPECIFIED CLEFT PROFESSIONAL HCT, RBC, WBC AND PLATELET COUNT( PALATE WITH UNILATERAL OUTPATIENT /HOSPITAL CLEFT LIP 8/21/2017 7/27/2017 8/18/2017 86850 ANTIBODY SCREEN, BBC, EACH SERUM TECHNIQUE Q379 UNSPECIFIED CLEFT PROFESSIONAL PALATE WITH UNILATERAL OUTPATIENT /HOSPITAL CLEFT LIP 8/21/2017 7127/2017 8/18/2017 86901 BLOOD TYPING, SEROLOGIC; RH(D) Q379 UNSPECIFIED CLEFT PROFESSIONAL PALATE WITH UNILATERAL OUTPATIENT /HOSPITAL CLEFT LIP 9/7/2017 7/27/2017 9/5/2017 172 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING Q379 UNSPECIFIED CLEFT PROFESSIONAL BIOPSY; REPAIR OF CLEFT PALATE PALATE WITH UNILATERAL OUTPATIENT /HOSPITAL CLEFT LIP 9/11/2017 9/1/2017 9/7/2017 95004 PERCUTANEOUS TESTS (SCRATCH, PUNCNRE, PRICK) L509 URTICARIA, UNSPECIFIED PROFESSIONAL OFFICE WITH ALLERGENIC EXTRACTS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT BY A PHYSICIAN, SPECIFY NUMBER OF TESTS 9/11/2017 9/1/2017 9/7/2017 99245 OFFICE CONSULTATION FORA NEW DR ESTABLISHED L509 URTICARIA, UNSPECIFIED PROFESSIONAL OFFICE PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY, COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTE 10/2/2017 9/27/2017 9/29/2017 90471 IMMUNIZATION ADMINISTRATION (INCLUDES Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR ROUTINE CHILD HEALTH INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR EXAMINATION WITH COMBINATION VACCINE /TOXOID) ABNORMAL FINDINGS 10/2/2017 9/27/2017 9/29/2017 90472 IMMUNIZATION ADMINISTRATION (INCLUDES Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR ROUTINE CHILD HEALTH INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL EXAMINATION WITH VACCINE (SINGLE OR COMBINATION VACCINE /TOXOID( ABNORMAL FINDINGS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 10/2/2017 9/27/2017 9/29/2017 90648 HEMOPHILUS INFLUENZA B VACCINE(HIB), PRP -T Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE CONJUGATE 14 DOSE SCHEDULE), FOR INTRAMUSCULAR ROUTINE CHILD HEALTH USE EXAMINATION WITH ABNORMAL FINDINGS 10/2/2017 9/27/2017 9/29/2017 90670 PNEUCOCOCCAL CONJUGATE VACCINE, 13 VALENT, FOR Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE INTRAMUSCULAR USE ROUTINE CHILD HEALTH EXAMINATION WITH ABNORMAL FINDINGS 10/2/2017 9/27/2017 9/29/2017 90685 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLITVIRUS, Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE PRESERVATIVE FREE, WHEN ADMINISTERED TO CHILDREN ROUTINE CHILD HEALTH 6 -35 MONTHS OF AGE, FOR INTRAMUSCULAR USE EXAMINATION WITH ABNORMAL FINDINGS $114.06 $242.00 MALE DEPENDENT 1050 $0.00 $11.00 MALE DEPENDENT 1050 $0DD $37.00 MALE DEPENDENT 1050 $0.00 $19.00 MALE DEPENDENT 1050 $1,255.80 $2,000.00 MALE DEPENDENT 1050 $145.25 $250.00 MALE DEPENDENT 1050 $218.49 $325.00 MALE DEPENDENT 1050 $2833 $57.00 MALE DEPENDENT 1050 $29.28 $60.00 MALE DEPENDENT 1050 $15.00 $65.00 MALE DEPENDENT 1050 $186.00 $310.00 MALE DEPENDENT 1050 $20.00 $100.00 MALE DEPENDENT 1050 C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 C.7.f 10/2/2017 9/27/2017 9/29/2017 99188 APPLICATION OF TOPICAL FLUORIDE VARNISH BYA Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE $21.00 $75.00 MALE DEPENDENT 1050 3559 PHYSICIAN OR OTHER QUALIFIED HEALTH CARE ROUTINE CHILD HEALTH PROFESSIONAL EXAMINATION WITH ABNORMAL FINDINGS N 10/2/2017 9/27/2017 912912017 99392 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE $114.06 $242.00 MALE DEPENDENT 1050 3559 REEVALUATION AND MANAGEMENTOF AN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGEAND GENDER APPROPRIATE HISTORY, EXAMINATION WITH EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS } GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, "a ANDTHE ORDERING OF LABDRATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; EARLY CHILDHOOD (AGE 1 TH ROUGH 4 YEARS) W 10/6/2017 7/18/2017 10/5/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R633 FEEDING DIFFICULTIES PROFESSIONAL OFFICE $135.08 $200.00 MALE DEPENDENT 1050 } 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED CL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY Q, COMPONENTS: A DETAILED HISTORY; A DETAILED v EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 10/11/2017 7/18/2017 10/10/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R633 FEEOIN6 DIFFICULTIES PROFESSIONAL OFFICE $0.00 $200.00 MALE DEPENDENT 1050 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED uj PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR _ COORDINATION OF CARE WITH OTHER 10/12/2017 10/9/2017 10/11/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H6993 UNSPECIFIED PROFESSIONAL OFFICE $118.46 $245.00 MALE DEPENDENT 1050 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED EUSTACHIAN TUBE IL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY DISORDER, BILATERAL NJ COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF UJ MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 10/20/2017 10/12/2017 10/18/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L509 URTICARIA, UNSPECIFIED PROFESSIONAL OFFICE $93.52 $175.00 MALE DEPENDENT 1050 3559 e LLJ EVALUATION AND MANAGEMENTOFAN ESTABLISHED °✓ PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED J EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR v COORDINATION OF CARE WITH OTHER 10/24/2017 10/5/2017 10/21/2017- - H6530 CHRONIC MUCOIDOTITIS HOSPITAL OUTPATIENT $290.00 $290.00 MALE DEPENDENT 1050 3559 LLJ MEDIA, UNSPECIFIED EAR 11/8/2017 11/3/2017 11/7/2017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE L739 FOLLICULAR DISORDER, PROFESSIONAL OFFICE $87.66 $175.00 MALE DEPENDENT 1050 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED UNSPECIFIED Q PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY F COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED N EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD Cy 11/17/2017 9/26/2017 11/16/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R633 FEEDING DIFFICULTIES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 11/28/2017 11/21/2017 11/27/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Q355 CLEFT HARD PALATE WITH PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED CLEFT SOFT PALATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 12/22/2017 12/19/2017 1212112017 90460 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH COUNSELING BY PHY5ICIAN OR OTHER QUALIFIED HEALTH EXAMINATION WITHOUT CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF ABNORMAL FINDINGS EACH VACCINE DR TOXOID ADMINISTERED 1212212017 12/19/2017 1212112017 90461 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH COUNSELING BY PHYSICIAN DR OTHER QUALIFIED HEALTH EXAMINATION WITHOUT CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR ABNORMAL FINDINGS TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 12/22/2017 12/19/2017 12/21/2017 90700 DIPHTHERIA, TETANUSTOXOIDS, AND ACELLULAR Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE PERTUSSIS VACCINE(DTAP), WHEN ADMINISTERED TO ROUTINE CHILD HEALTH INDIVIDUALS YOUNGER THAN 7 YEARS, FOR EXAMINATION WITHOUT INTRAMUSCULAR USE ABNORMAL FINDINGS 1212212017 12/19/2017 1212112017 96110 DEVELOPMENTAL SCREENING )EG ,DEVELOPMENTAL Z00129 ENCOUNTER FOR PROFE55IONAL OFFICE MILESTONE SURVEY, SPEECH AND LANGUAGE DELAY ROUTINE CHILD HEALTH SCREEN), WITH SCORING AND DOCUMENTATION, PER EXAMINATION WITHOUT STANDARDIZED INSTRUMENT ABNORMAL FINDINGS 12/22/2017 12/19/2017 12/21/2017 99392 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION, COUNSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLI5HED PATIENT; EARLY CHILDHOOD )AGE 1 TH ROUGH 4 YEARS) 12/27/2017 12/21/2017 12/26/2017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE L509 URTICARIA, UNSPECIFIED PROFESSIONAL OFFICE EVALUATION AND MANAGEMENTOFAN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 5ub T—I 1.875E +10 1/23/2017 12/16/2016 112012017 92014 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H524 PRESBYOPIA OTHER MEDICAL AND EVALUATION, WITH INITIATION OR CONTINUATION OF DIAGNOSTIC AND TREATMENT PROGRAM; COMPREHENSIVE, ESTABLISHED PATIENT, ONE OR MORE VISITS $135.08 $200.00 MALE DEPENDENT 1050 $8518 $89.00 MALE DEPENDENT 1050 $30.23 $63.00 MALE DEPENDENT 1050 $30.42 $64.00 MALE DEPENDENT 1050 $31.00 $56.00 MALE DEPENDENT 1050 $11.58 $60.00 MALE DEPENDENT 1050 $125.90 $242.00 MALE DEPENDENT 1 OSO $87.32 $175.00 MALE DEPENDENT 1050 $51,617.30 $90,822A3 $0.00 $134.84 MALE SUBSCRIBER 1 BCC C.7.f 1/23/2017 12/16/2016 112012017 92015 DETERMINATION OF REFRACTIVE STATE H524 PRESBYOPIA OTHER MEDICAL $0.00 $32.41 MALE SUBSCRIBER 1 BCC 3559 1/23/2017 12/16/2016 1/20/2017 - - H524 PRESBYOPIA HOSPITAL OUTPATIENT $233.67 $399.43 MALE SUBSCRIBER 1 BCC 3559 C! 1/26/2017 11/23/2016 1/25/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E119 TYPE 20IABETES OTHER MEDICAL $43.91 $157.67 MALE SUBSCRIBER 1BCC 3559 N EVALUATION AND MANAGEMENTOFAN ESTABLISHED MELLITUS WITHOUT PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPLICATIONS COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW 7 COMPLEXITY. COUNSELING AND COORD "a 1/26/2017 11/23/2016 1/25/2017 - - E119 TYPE DIABETES HOSPITAL OUTPATIENT $190.78 $326.11 MALE SUBSCRIBER 1 BCC 3559 MELLITUS WITHOUT COMPLICATIONS 1/27/2017 10/17/2016 1/26/2017 - - C44612 BASALCELL CARCINOMA HOSPITAL OUTPATIENT $445.91 $762.24 MALE SUBSCRIBER 1 BCC 3559 OF SKIN OF RIGHT UPPER E. CL LIMB, INCLUDING CL SHOULDER Q 2/6/2017 10/17/2016 1/26/2017 17261 DESTRUCTION, MALIGNANT LESION(EG, LASER SURGERY, C44612 BASALCELL CARCINOMA PROFESSIONAL $82.57 $453.73 MALE SUBSCRIBER 1 BCC 3559 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, OF SKIN OF RIGHT UPPER OUTPATIENT /HOSPITAL SURGICAL CURETTEMENTD, TRUNK, ARMS OR LEGS; LIMB, INCLUDING rf LESION DIAMETER 0.6 TO 1.0 CM SHOULDER F 2/6/2017 10/17/2016 1/26/2017 99212 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C44612 BASALCELL CARCINOMA PROFESSIONAL $21.88 $78.26 MALE SUBSCRIBER 1BCC 3559 uj EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF SKIN OF RIGHT UPPER OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LIMB, INCLUDING COMPONENTS: A PROBLEM FOCUSED HISTORY; A SHOULDER PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD _ MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT O 2/8/2017 1/27/2017 2/6/2017 990535ERVICE(S) PROVIDED BETWEEN 10:00 PM AND 8:00 AM R1030 LOWER ABDOMINAL PAIN, PROFESSIONAL $0.00 $30.00 MALE SUBSCRIBER 1BCC 3559 AT24 -HOUR FACILITY, INADDITIONTO BASICSERVICE UNSPECIFIED OUTPATIENT /HOSPITAL uj 2/8/2017 1/27/2017 2/6/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R1030 LOWER ABDOMINAL PAIN, PROFESSIONAL $26747 $665.00 MALE SUBSCRIBER 18CC 3559 U`J AND MANAGEMENTOFA PATIENT, WHICH REQUIRES UNSPECIFIED OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS 0 IMPOSED BY THE URGENCY OF TH E PATIENT'S CLINICAL CONDITION AND /DR MENTALSTATUS: ACOMPREHENSIVE e LLJ HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS Q J 2/13/2017 1/23/2017 2/6/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L821 OTHER SEBORRHEIC OTHER MEDICAL $44.07 $157.67 MALE SUBSCRIBER 16CC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED KERATOSIS v PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED llJ EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED U 2/13/2017 1/27/2017 1/31/2017 74176 Computed t ... graphV, abd—, and pelvis; without N320 BLADDER -NECK PROFESSIONAL $0.00 $689.00 MALE SUBSCRIBER 1 BCC 3559 contrast m at"I'l OBSTRUCTION OUTPATIENT /HOSPITAL 2/27/2017 2/6/2017 2/22/2017 51702 INSERTION OF TEMPORARY INDWELLING BLADDER N401 BENIGN PROSTATIC OTHER MEDICAL $20.11 $157.18 MALE SUBSCRIBER 1 BCC 3559 CATHETER; SIMPLE HG, FOLEY) HYPERPLASIA WITH LOWER URINARYTRACT N SYMPTOMS n 2/27/2017 2/6/2017 212212017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N401 BENIGN PROSTATIC OTHER MEDICAL 1 BCC $1,436.29 $3,124.32 MALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC HYPERPLASIA WITH $10,935.00 MALE SUBSCRIBER 1 BCC $0.00 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SUBSCRIBER LOWER URINARY TRACT $0.00 $3,12432 MALE SUBSCRIBER 1 BCC COMPONENTS: A PROBLEM FOCUSED HISTORY; A $449.55 MALE SYMPTOMS 1 BCC $1,237.60 $2,597.61 MALE SUBSCRIBER PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD $225.00 $2,670.17 MALE SUBSCRIBER 1 BCC $71.68 $443.18 MALE MEDICAL DECISION MAKING. COUNSELING AND /OR 1 BCC COORDINATION OF CARE WIT 3/9/2017 2/11/2017 2/28/2017 99283 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION N390 URINARYTRACT PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INFECTION, SITE NOT OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM SPECIFIED FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 3/13/2017 1/23/2017 2/7/2017 - - L821 OTHER SEBORRHEIC HOSPITAL OUTPATIENT KERATOSIS 3/13/2017 2/6/2017 2/22/2017 - - N401 BENIGN PROSTATIC HOSPITAL OUTPATIENT HYPERPLASIA WITH LOWER URINARYTRACT SYMPTOMS 3/13/2017 2/11/2017 212812017 - - N390 URINARYTRACT HOSPITAL OUTPATIENT INFECTION, SITE NOT SPECIFIED 3/21/2017 1/27/2017 2/1/2017 - - N401 BENIGN PROSTATIC HOSPITAL OUTPATIENT HYPERPLASIA WITH LOWER URINARYTRACT SYMPTOMS 3/22/2017 1/27/2017 2/1/2017 - - N401 BENIGN PROSTATIC HOSPITAL OUTPATIENT HYPERPLASIA WITH LOWER URINARYTRACT SYMPTOMS 4/4/2017 2/11/2017 4/3/2017 - - N390 URINARYTRACT HOSPITAL OUTPATIENT INFECTION, SITE NOT SPECIFIED 4/12/2017 3/8/2017 4/11/2017 - - 8339 RETENTION OF URINE, HOSPITAL OUTPATIENT UNSPECIFIED 4/12/2017 3/20/2017 4/11/2017- - Z01818 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT PREPROCEOURAL EXAMINATION 5/1/2017 4/3/2017 4/28/2017 914 ANESTHESIA FO R TRAM S U R ETH RAE P ROCEDU R ES N401 BENIGN PROSTATIC PROFESSIONAL (INCLUDING URETHROCYSTOSCOPY(; TRANSURETHRAL HYPERPLASIA WITH OUTPATIENT /HOSPITAL RESECTION OF PROSTATE LOWER URINARYTRACT SYMPTOMS 5/1/2017 4/3/2017 4/28/2017 88307 LEVELV - SURGICAL PATHOLOGY, GROSS AND N401 BENIGN PROSTATIC PROFESSIONAL MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE HYPERPLASIA WITH OUTPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENTS( , PATHOLOGIC LOWER URINARYTRACT FRACTURE BRAIN, BIOPSY BRAIN/MENINGES, TUMOR SYMPTOMS RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT 5/1/2017 4/3/2017 4/28/2017 52601 TRANSURETHRAL ELE CTROSURGICAL RESECTION OF N401 BENIGN PROSTATIC OTHER MEDICAL PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE HYPERPLASIA WITH BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, LOWER URINARY TRACT CYSTOURETHROSCOPY , URETHRAL CALIBRATION AND /OR SYMPTOMS DIIATION, AND INTERNAL URETHROTOMY ARE INCLUDED( $18.91 $82.87 MALE SUBSCRIBER 1 BCC $54.89 $558.21 MALE SUBSCRIBER 1 BCC $190.78 $326.11 MALE SUBSCRIBER 1 BCC $773.30 $1,321.88 MALE SUBSCRIBER 1 BCC $1,436.29 $3,124.32 MALE SUBSCRIBER 1 BCC $5,625.92 $10,935.00 MALE SUBSCRIBER 1 BCC $0.00 $10,935.00 MALE SUBSCRIBER 1 BCC $0.00 $3,12432 MALE SUBSCRIBER 1 BCC $262.98 $449.55 MALE SUBSCRIBER 1 BCC $1,237.60 $2,597.61 MALE SUBSCRIBER 1 BCC $225.00 $2,670.17 MALE SUBSCRIBER 1 BCC $71.68 $443.18 MALE SUBSCRIBER 1 BCC $769.99 $4,877.48 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' 3559 3559 3559 3559 WbSI 3559 3559 3559 3559 3559 5/1/2017 4/3/2017 412812017 914 ANESTHESIA FORTRAN SUR ETHRAL PROCEDURES N401 BENIGN PROSTATIC OTHER MEDICAL $225.00 $2,670.17 MALE SUBSCRIBER 1 BCC (INCLUDING URETHROCYSTOSCDPY); TRANSURETHRAL HYPERPLASIA WITH RESECTION OF PROSTATE LOWER URINARY TRACT SYMPTOMS 5/11/2017 4/25/2017 5/9/2017 99282 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION N451 EPIDIDYMITIS PROFESSIONAL $36.70 $441.98 MALE SUBSCRIBER 1 BCC AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESES KEYCOMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5/11/2017 4/25/2017 5/9/2017 76870 ULTRASOUND, SCROTUM AND CONTENTS N50812 LEFT TESTICULAR PAIN PROFESSIONAL $27.94 $253.69 MALE SUBSCRIBER I BCC OUTPATIENT /HOSPITAL 5/12/2017 4/26/2017 5/10/2017 99219 INITIAL OBSERVATION CARE, PERDAY, FORTHE N451 EPIDIDYMITIS PROFESSIONAL $156.31 $682.24 MALE SUBSCRIBER 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH OUTPATIENT /HOSPITAL REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DEC15IDN MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS 5/12/2017 4/27/2017 5/10/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N453 EPIDIDYMO- ORCHITIS PROFESSIONAL $90.14 $274.28 MALE SUBSCRIBER 1BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED OUTPATIENT /HOSPITAL PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5/18/2017 4/27/2017 5/10/2017 - - N451 EPIDIDYMITIS HOSPITAL INPATIENT 4/27/2017 5/1/2017 $37,954.56 $51,527.29 MALE SUBSCRIBER 1 BCC 5/18/2017 4/28/2017 5/16/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE N453 EPIDIDYMO- ORCHITIS PROFESSIONAL $82.71 $363.59 MALE SUBSCRIBER 1BCC EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 5/18/2017 4/28/2017 5/16/2017 99253 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED N451 EPIDIDYMITIS PROFESSIONAL $130.56 $443.75 MALE SUBSCRIBER 1BCC PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT /HOSPITAL DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH 5/22/2017 4/29/2017 5/19/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N453 EPIDIDYMO- ORCHITIS PROFESSIONAL $45.62 $196.75 MALE SUBSCRIBER 1BCC EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PO ENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 5/22/2017 4/30/2017 5/19/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N453 EPIDIDYMO- ORCHITIS PROFESSIONAL $4162 $196.75 MALE SUBSCRIBER IBCC EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PO ENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ C.7.f 3559 w MR N 3559 3559 3559 mg III I= R 5/22/2017 5/1/2017 5/19/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE N453 EPIDIDYMO- ORCHITIS PROFESSIONAL 1 BCC $20,713.66 $26,683.88 MALE THAN 3D MINUTES 1 BCC $90.14 INPATIENT /HOSPITAL 5/22/2017 5/5/2017 5/19/2017 - - E119 TYPE DIABETES HOSPITAL OUTPATIENT $1,38658 MALE SUBSCRIBER 1 BCC $210.86 $499.67 MALE MELLITUS WITHOUT 1 BCC COMPLICATIONS 5/24/2017 4/3/2017 5/23/2017 - - N401 BENIGN PROSTATIC HOSPITAL OUTPATIENT HYPERPLASIA WITH LOWER URINARYTRACT SYMPTOMS 5/30/2017 5/8/2017 5/26/2017 99214 OFFICE OR OTHER DUTPATIENTVISIT FOR THE N451 EPIDIDYMITIS PROFESSIONAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING .AND /OR COORDINATION OF CARE WITH OTHER 5130/2017 5/8/2017 5/29/2017 - - N451 EPIDIDYMITIS HOSPITAL OUTPATIENT 5/30/2017 5/11/2017 5/29/2017 - - E1165 TYPE DIABETES HOSPITAL OUTPATIENT MELLITUS WITH HYPERGLYCEMIA 5/30/2017 5/12/2017 5/29/2017 - - E1165 TYPE DIABETES HOSPITAL OUTPATIENT MELLITUS WITH HYPERGLYCEMIA 6/8/2017 4/25/2017 6/6/2017 99213 OFFICE OR OTHER DUTPATIENTVISIT FOR THE N451 EPIDIDYMITIS PROFESSIONAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY, COUNSELING AND COORD 6/8/2017 4/25/2017 6/7/2017- - N451 EPIDIDYMITIS HOSPITAL OUTPATIENT 6/8/2017 5/19/2017 6/6/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE B372 CANDIDIASIS OF SKIN AND PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED NAIL OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 6/8/2017 5/19/2017 6/7/2017- - B372 CANDIDIASIS OF SKIN AND HOSPITAL OUTPATIENT NAIL 6/8/2017 5/22/2017 6/7/2017- - Z48816 ENCOU MITER FOR HOSPITAL OUTPATIENT SURGICAL AFTERCARE FOLLOWING SURGERY ON THE GENITOURINARY SYSTEM 6/14/2017 5/15/2017 6/13/2017 - - R9720 ELEVATED PROSTATE HOSPITAL OUTPATIENT SPECIFIC ANTIGEN [PSA] 6/27/2017 4/25/2017 6/7/2017 - - N451 EPIDIDYMITIS HOSPITAL OUTPATIENT 6/27/2017 4/25/2017 6/7/2017 - - N451 EPIDIDYMITIS HOSPITAL OUTPATIENT 71512017 6/20/2017 7/3/2017 - - E119 TYPE DIABETES HOSPITAL OUTPATIENT MELLITUS WITHOUT COMPLICATIONS 7/21/2017 7/7 /2017 7/19/2017- - R310 GROSS HEMATURIA HOSPITAL OUTPATIENT $122.66 $544.50 MALE SUBSCRIBER 1 BCC $299.05 $708.65 MALE SUBSCRIBER 1 BCC $20,713.66 $26,683.88 MALE SUBSCRIBER 1 BCC $90.14 $274.28 MALE SUBSCRIBER 1 BCC $210.86 $499.67 MALE SUBSCRIBER 1 BCC $299.05 $708.65 MALE SUBSCRIBER 1 BCC $53.98 $127.91 MALE SUBSCRIBER 1 BCC $58.76 $178.10 MALE SUBSCRIBER 1 BCC $298.13 $382.22 MALE SUBSCRIBER 1 BCC $58.76 $178.10 MALE SUBSCRIBER 1 BCC $422.75 $1,001.76 MALE SUBSCRIBER 1 BCC $195.31 $462.82 MALE SUBSCRIBER 1 BCC $165.81 $392.91 MALE SUBSCRIBER 1 BCC $0.00 $382.22 MALE SUBSCRIBER 1 BCC $0.00 $0.00 MALE SUBSCRIBER 1 BCC $585.14 $1,38658 MALE SUBSCRIBER 1 BCC $210.86 $499.67 MALE SUBSCRIBER 1 BCC C.7.f 3559 w 3559 N 3559 i 3559 "a fl } O B. CL CL 3559 3559 Q 3559 W 3559 O d W 3559 3559 J W 4 J 3559 v 3559 3559 3559 3559 3559 3559 712112017 71712017 7/19/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R310 GROSS HEMATURIA PROFESSIONAL 1 BCC ($298.131 $382.22 MALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC $11536 OUTPATIENT /HOSPITAL SUBSCRIBER 1 BCC $37.25 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SUBSCRIBER 1 BCC $2,084.30 $4,939.11 MALE SUBSCRIBER 1 BCC COMPONENTS: A DETAILED HISTORY; A DETAILED $239.11 MALE SUBSCRIBER 1 BCC ($2,084.30j {$4,939.117 MALE SUBSCRIBER EXAMINATION; MEDICAL DECISION MAKING OF $2,332.05 $5,526.20 MALE SUBSCRIBER 1 BCC $0.00 $5,526.20 MALE MODERATE COMPLEXITY. COUNSELING AND /OR 1 BCC $90.14 $261.01 MALE SUBSCRIBER 1 BCC COORDINATION OF CARE WITH OTHER 7/26/2017 5/2/2017 7/3/2017 - - N453 EPIDIDYMO- ORCHITIS HOSPITAL OUTPATIENT 8/9/2017 7/26/2017 8/8/2017 - - E1165 TYPE DIABETES HOSPITAL OUTPATIENT MELLITUS WITH HYPERGLYCEMIA 8/15/2017 4/25/2017 6/7/2017 - - N451 EPIDIDYMITIS HOSPITAL OUTPATIENT 8/16/2017 8/2/2017 8/15/2017 74178 COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; R319 HEMATURIA, PROFESSIONAL WITHOUT CONTRAST MATERIAL IN I OR BOTH BODY UNSPECIFIED OUTPATIENT /HOSPITAL REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN 1 OR BOTH BODY REGIONS 8/16/2017 8/2/2017 8/15/2017 76870 ULTRASOUND, SCROTUM AND CONTENTS N433 HYDROCELE, UNSPECIFIED PROFESSIONAL OUTPATIENT /HOSPITAL 8/16/2017 8/2/2017 8/15/2017 - - R319 HEMATURIA, HOSPITAL OUTPATIENT UNSPECIFIED 8/22/2017 8/7/2017 812112017 - - N5082 SCROTAL PAIN HOSPITAL OUTPATIENT 8/23/2017 8/2/2017 8/15/2017- - R319 HEMATURIA, HOSPITAL OUTPATIENT UNSPECIFIED 8/23/2017 8/2/2017 8/22/2017- - N433 HYDROCELE, UNSPECIFIED HOSPITAL OUTPATIENT 8/23/2017 8/2/2017 8/22/2017- - N433 HYDROCELE, UNSPECIFIED HOSPITAL OUTPATIENT 121412017 7/28/2017 12/1/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE R319 HEMATURIA, OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/4/2017 712812017 121112017- - R319 HEMATURIA, HOSPITAL OUTPATIENT UNSPECIFIED Sub Total 1.875E +10 1/5/2017 12/27/2016 1/3/2017- - Z7901 LONG TERM (CURRENT) HOSPITAL OUTPATIENT USE OF ANTICOAGULANTS 4/25/2017 12/5/2016 4/11/2017 93306 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH 1482 CHRONIC ATRIAL PROFESSIONAL IMAGE DOCUMENTATION (2D), INCLUDES M -MODE FIBRILLATION OUTPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 4/28/2017 4/6/2017 4/27/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E1065 TYPE 1 DIABETES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MELLITUS WITH PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY HYPERGLYCEMIA COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER $90.14 $274.28 MALE SUBSCRIBER 1 BCC $0.00 $332.48 MALE SUBSCRIBER 1 BCC $49.32 $116.87 MALE SUBSCRIBER 1 BCC ($298.131 $382.22 MALE SUBSCRIBER 1 BCC $11536 $805.00 MALE SUBSCRIBER 1 BCC $37.25 $253.69 MALE SUBSCRIBER 1 BCC $2,084.30 $4,939.11 MALE SUBSCRIBER 1 BCC $100.90 $239.11 MALE SUBSCRIBER 1 BCC ($2,084.30j {$4,939.117 MALE SUBSCRIBER 1 BCC $2,332.05 $5,526.20 MALE SUBSCRIBER 1 BCC $0.00 $5,526.20 MALE SUBSCRIBER 1 BCC $90.14 $261.01 MALE SUBSCRIBER 1 BCC $199.07 $471.72 MALE SUBSCRIBER 1 BCC $77,313.89 $151,140.43 $111.75 $149.00 MALE SUBSCRIBER 1 BCC $65.92 $719.00 MALE SUBSCRIBER 1 BCC $85.14 $185.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 im 5/1/2017 4/20/2017 412812017 - - Z0000 ENCOUNTER FOR HOSPITAL OUTPATIENT 1 BCC $0.00 $58.00 MALE SUBSCRIBER 1 BCC GENERAL ADULT MEDICAL $350.00 MALE SUBSCRIBER 1 BCC $0.00 $106.00 MALE SUBSCRIBER EXAMINATION WITHOUT $0.00 $115.00 MALE SUBSCRIBER 1 BCC $6,345.95 $11,82100 MALE ABNORMAL FINDINGS 1 BCC 5/19/2017 5/11/2017 5/17/2017- - 1480 PAROXYSMAL ATRIAL HOSPITAL OUTPATIENT 1 BCC FIBRILLATION 5/25/2017 5/19/2017 5/23/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, M79672 PAIN IN LEFT FOOT PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 5/25/2017 5/19/2017 5/23/2017 73701 COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH M79672 PAIN IN LEFT FOOT PROFE55IONAL CONTRAST MATERIALS) OUTPATIENT /HOSPITAL 5/25/2017 5/19/2017 5/23/2017 93925 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR M79672 PAIN IN LEFT FOOT PROFESSIONAL ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY OUTPATIENT /HOSPITAL 5/25/2017 5/19/2017 5/23/2017 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING M79672 PAIN IN LEFT FOOT PROFESSIONAL RESPONSES TO COMPRESSION AND OTHER MANEUVERS; OUTPATIENT/HOSPITAL COMPLETE BILATERAL STUDY 5/30/2017 5/19/2017 5/26/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT LOWER LIMB 5/31/2017 5/19/2017 5/30/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 L03116 CELLULITIS OF LEFT PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY LOWER LIMB OUTPATIENT /HOSPITAL 5/31/2017 5/19/2017 5/30/2017 99285 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION L03116 CELLULITIS OF LEFT PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LOWER LIMB OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF TH E PATIENT'S CLINICAL CONDITION AND /DR MENTALSTATUS: ACOMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 6/7/2017 5/25/2017 6/5/2017 11043 DEBRIDEMENT, MUSCLE AND /OR FASCIA (INCLUDES L97411 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF ULCER OF RIGHT HEEL PERFORMED); FIRST 20 SQ CM OR LESS AND MIDFOOT LIMITED TO BREAKDOWN OF SKIN 6/7/2017 5/25/2017 6/5/2017 29580 STRAPPING; UNNA BOOT L97411 NON- PRESSURE CHRONIC PROFESSIONAL OFFICE ULCER OF RIGHT HEEL AND MIDFOOT LIMITED TO BREAKDOWN OF SKIN 6/7/2017 5/25/2017 6/5/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L97411 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED ULCER OF RIGHT HEEL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY AND MIDFOOT LIMITED COMPONENTS: AN EXPANDED PROBLEM FOCUSED TO BREAKDOWN OF SKIN HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY, COUNSELING AND COORD 6/7/2017 5/30/2017 6/5/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R0602 SHORTNESS OF BREATH PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 6/12/2017 S/30/2017 6/8/2017 93030 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 L03115 CELLULITIS OF RIGHT PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY LOWER LIMB OUTPATIENT /HOSPITAL $111.75 $149.00 MALE SUBSCRIBER 1 BCC $0.00 $149.00 MALE SUBSCRIBER 1 BCC $0.00 $58.00 MALE SUBSCRIBER 1 BCC $0.00 $350.00 MALE SUBSCRIBER 1 BCC $0.00 $106.00 MALE SUBSCRIBER 1 BCC $0.00 $115.00 MALE SUBSCRIBER 1 BCC $6,345.95 $11,82100 MALE SUBSCRIBER 1 BCC $0.00 $35.00 MALE SUBSCRIBER 1 BCC $205.79 $665.00 MALE SUBSCRIBER 1 BCC $350.82 $1,690.00 MALE SUBSCRIBER 1 BCC $21.22 $380.00 MALE SUBSCRIBER 1 BCC $51.53 $195.00 MALE SUBSCRIBER 1 BCC $1134 $58.00 MALE SUBSCRIBER 1 BCC $0.00 $35.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 C.7.f 6/12/2017 5/30/2017 6/8/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION L03115 CELLULITIS OF RIGHT PROFESSIONAL $0.00 $665.00 MALE SUBSCRIBER 1 BCC 3559 AND MANAGEMENTOFA PATIENT, WHICH REQUIRES LOWER LIMB OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF TH E PATIENT'S CLINICAL N CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 6/14/2017 5/11 /2017 6/12/2017 - - E1165 TYPE DIABETES HOSPITAL OUTPATIENT $91.12 $162.00 MALE SUBSCRIBER 1 BCC 3559 7 MELLITUS WITH HYPERGLYCEMIA PIS 6/15/2017 5/19/2017 6/14/2017 11042 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES L03115 CELLULITIS OF RIGHT PROFESSIONAL OFFICE $119.57 $1,260.00 MALE SUBSCRIBER 1 BCC 3559 EPIDERMISAND DERMIS, IFPERFORMED); FIRST20SQCM LOWER LIMB OR LESS 6/15/2017 5/19/2017 6/14/2017 11045 Debridement, subcutaneous tissue (Includes epidermis L03115 CELLULITIS OF RIGHT PROFESSIONAL OFFICE $56.54 $300.00 MALE SUBSCRIBER 1 BCC 3559 and dermis, If performed); each additional 20 sq cm, or LOWER LIMB L CL pare thereof IList separately in addition to code for primary Q, pracedure) 6/15/2017 5/19/2017 6/14/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL OFFICE $89.30 $245.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED LOWER LIMB rf PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LIJ MODERATE COMPLEXITY. COUNSELING AND /OR F D COORDINATION OF CARE WITH OTHER 7/3/2017 6/23/2017 6/30/2017 99254 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED 1872 VENOUS INSUFFICIENCY PROFESSIONAL $14630 $415.00 MALE SUBSCRIBER 1BCC 3559 PATIENT,WHICH REQUIRESTHESE3 KEYCOMPONENTS: A (CHRONIC) (PERIPHERAL) INPATIENT /HDSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR IL COORDINATION OF CARE WITH OTHER PROVIDERS OR Uj AGENCIES ARE PROVIDED C 7/3/2017 6/26/2017 6/30/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1872 VENOUS INSUFFICIENCY PROFESSIONAL $62.88 $181.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH (CHRONIC) (PERIPHERAL) INPATIENT /HOSPITAL 0 REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN IL ILLJ EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. � COUNSELING AND /OR w• J 7/5/2017 5/30/2017 612812017 - - L03115 CELLULITIS OF RIGHT HOSPITAL INPATIENT 5/30/2017 # # # # # # ## $46,006.56 $66,328.00 MALE SUBSCRIBER 1 BCC 3559 v LOWER LIMB 7/5/2017 6/22/2017 7/3/2017- - L03116 CELLULITIS OF LEFT HOSPITAL INPATIENT 6/22/2017 # # # # # # ## $8,112.00 $28,649.00 MALE SUBSCRIBER 1 BCC 3559 LOWER LIMB W 7/5/2017 6/22/2017 7/3/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT $7,222.50 $9,693.00 MALE SUBSCRIBER 16CC 3559 LOWER LIMB 71512017 6/22/2017 7 /3/2017- - L03116 CELLU LITIS OF LEFT HOSPITAL OUTPATIENT $0.00 $9,693.00 MALE SUBSCRIBER 1BCC 3559 LOWER LIMB Q 71512017 6/22/2017 7/3/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT $91115 $1,215.00 MALE SUBSCRIBER 1BCC 3559 F LOWER LIMB „p 7/5/2017 6/22/2017 7/3/2017 99285 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION L03115 CELLULITIS OF RIGHT OTHER MEDICAL $269.58 $665.00 MALE SUBSCRIBER 1 BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LOWER LIMB N THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS N IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL = CONDITION AND /OR MENTALSTATUS: ACOMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 7/6/2017 6/26/2017 7/4/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, L0390 CELLULITIS, UNSPECIFIED PROFESSIONAL $16.29 $41.00 MALE SUBSCRIBER 1 BCC 3559 FRONTAL INPATIENT/HOSPITAL ]1]12017 5/31/2017 7/6/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FORTH E EVALUATION L03115 CELLULITIS OF RIGHT PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LOWER LIMB INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 7/7/2017 6/1/2017 7/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RI6HT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 71712017 6/2/2017 71612017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 71712017 6/3/2017 7/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 7/7/2017 6/4/2017 7/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RI6HT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEV COMPON ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 71712017 6/5/2017 7/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 71712017 6/6/2017 7/6/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEV COMPON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR $245.63 $425.00 MALE SUBSCRIBER 1 BCC $12530 $220.00 MALE SUBSCRIBER 1 BCC $125.90 $220.00 MALE SUBSCRIBER 1 BCC $125.90 $220.00 MALE SUBSCRIBER 1 BCC $12530 $220.00 MALE SUBSCRIBER 1 BCC $125.90 $220.00 MALE SUBSCRIBER 1 BCC $86.65 $180.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE mm ®' WE WE 71712017 6/7/2017 7/6/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 7/13/2017 7/5/2017 7/11/2017 7/14/2017 5/12/2017 7/13/2017 7/14/2017 5/12/2017 7/13/2017 7/14/2017 5/12/2017 7/13/2017 7/14/2017 5/12/2017 7/13/2017 7/14/2017 5/12/2017 7/13/2017 7/14/2017 5/12/2017 7/13/2017 7/14/2017 5/12/2017 7/13/2017 7/17/2017 6/15/2017 7/14/2017 7/17/2017 6/19/2017 7/14/2017 7/19/2017 6/22/2017 7/5/2017 7/20/2017 7/14/2017 7/18/2017 - E119 TYPE 2 DIABETES HOSPITAL OUTPATIENT $4.58 $38.00 MALE MELLITUS WITHOUT 1 BCC $5.91 $113.88 MALE COMPLICATIONS 1 BCC 87015 CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS 1872 VENOUS INSUFFICIENCY OTHER MEDICAL $5.29 $103.00 MALE (CHRONIC) (PERIPHERAL) 1 BCC 87070 CULTURE, BACTERIAL, ANY OTHER SOURCE EXCEPT URINE, 1872 VENOUS INSUFFICIENCY OTHER MEDICAL BLOOD OR STOOL, AEROBIC, W ITH ISOUlTION AND $49.00 MALE (CHRONIC) (PERIPHERAL) 1 BCC PRESUMPTIVE IDENTIFICATION OF ISOLATES $52.79 MALE SUBSCRIBER 1 BCC 87075 CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, 1872 VENOUS INSUFFICIENCY OTHER MEDICAL ANAEROBIC WITH ISOLATION AND PRESUMPTIVE $5,826.00 MALE (CHRONIC) (PERIPHERAL) 1 BCC IDENTIFICATION OF ISOLATES $665.00 MALE SUBSCRIBER 1 BCC 87101 CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH 1872 VENOUS INSUFFICIENCY OTHER MEDICAL PRESUMPTIVE IDENTIFICATION OF ISOLATES; SKIN, HAIR, (CHRONIC) (PERIPHERAL) OR NAIL 87116 CULTURE, TUBERCLE OR OTHER ACID- FAST BACILLI(EG, 1872 VENOUS INSUFFICIENCY OTHER MEDICAL TB, AFB, MYCOBACTERIA) ANY SOURCE, WITH ISOLATION (CHRONIC) (PERIPHERAL) AND PRESUMPTIVE IDENTIFICATION OF ISOLATES 87205 SMEAR, PRIMARYSOURCE WITH INTERPRETATION; GRAM 1872 VENOUS INSUFFICIENCY OTHER MEDICAL OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELLTYPES (CHRONIC) (PERIPHERAL) 87206 SMEAR, PRIMARYSOURCE WITH INTERPRETATION; 1872 VENOUS INSUFFICIENCY OTHER MEDICAL FLUORESCENT AND /OR ACID FAST STAIN FOR BACTERIA, (CHRONIC) (PERIPHERAL) FUNGI, PARASITES, VIRUSES OR CELL TYPES - 1872 VENOUS INSUFFICIENCY HOSPITAL OUTPATIENT (CHRONIC) (PERIPHERAL) - 1872 VENOUS INSUFFICIENCY HOSPITAL OUTPATIENT (CHRONIC) (PERIPHERAL) 99285 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION L03115 CELLULITIS OF RIGHT PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LOWER LIMB OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF TH E PATIENTS CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 99254 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED L03116 CELLULITIS OF LEFT PROFESSIONAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A LOWER LIMB INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED C $86.65 $180.00 MALE SUBSCRIBER 1 BCC $1,245.00 $1,660.00 MALE SUBSCRIBER 1 BCC $4.58 $38.00 MALE SUBSCRIBER 1 BCC $5.91 $113.88 MALE SUBSCRIBER 1 BCC $6.50 $125.12 MALE SUBSCRIBER 1 BCC $5.29 $103.00 MALE SUBSCRIBER 1 BCC $7.41 $106.21 MALE SUBSCRIBER 1 BCC $2.93 $49.00 MALE SUBSCRIBER 1 BCC $3.70 $52.79 MALE SUBSCRIBER 1 BCC $2,718.75 $3,625.00 MALE SUBSCRIBER 1 BCC $4,369.50 $5,826.00 MALE SUBSCRIBER 1 BCC $268.82 $665.00 MALE SUBSCRIBER 1 BCC $153.31 $415.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 ME C.7.f 7/24/2017 7/13/2017 7/20/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT $407.25 $543.00 MALE SUBSCRIBER 1BCC 3559 LOWER LIMB W 7/24/2017 7/15/2017 7/21/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE L03116 CELLULITIS OF LEFT PROFESSIONAL $62.88 $181.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL N REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD IN ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 7 7/25/2017 7/15/2017 7124/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION L03032 CELLULITIS OF LEFT TOE PROFESSIONAL $92.35 $200.00 MALE SUBSCRIBER 1 BCC 3559 AND MANAGEMENTOFA PATIENT, WHICH REQUIRES INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; ACOMPREHENSIVE EXAMINATION; AND MEDICAL } DECISION MAKING OF MODERATE COMPLEXIN. COUNSELING AND /OR COORDINATION OF CARE WITH CL OTHER PROVIDERS OR Q, Q 7/25/2017 7/16/2017 7/24/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03032 CELLULITIS OF LEFT TOE PROFESSIONAL $48.26 $85.00 MALE SUBSCRIBER 1BCC 3559 v EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD IN ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. Ljj h COUNSELING AND /OR D 7/25/2017 7/17/2017 7/24/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03032 CELLULITIS OF LEFT TOE PROFESSIONAL $48.26 $85.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD IN ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. Q COUNSELING AND /OR ui 7/25/2017 7/17/2017 7124/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03116 CELLULITIS OF LEFT PROFESSIONAL $62.88 $181.00 MALE SUBSCRIBER IBCC 3559 U`J EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL ILLJ DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 4 J 7/25/2017 7/18/2017 7/24/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03032 CELLULITIS OF LEFT TOE PROFESSIONAL $48.26 $85.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL U REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD IN ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL LLJ DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR U 7/25/2017 7/18/2017 7124/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03116 CELLULITIS OF LEFT PROFESSIONAL $62.88 $181.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL {V DECISION MAKING OF MODERATE COMPLEXITY. N COUNSELING AND /OR n C.7.f 7/25/2017 7/19/2017 7/24/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03032 CELLULITIS OF LEFT TOE PROFESSIONAL $48.26 $85.00 MALE SUBSCRIBER 1BOO 3559 EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 712712017 6/23/2017 7/26/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION L03115 CELLULITIS OF R16HT PROFESSIONAL $135.17 $896.00 MALE SUBSCRIBER 1 BCC 3559 AND MANAGEMENTOFA PATIENT, WHICH REQUIRES LOWER LIMB INPATIENT /HDSPITAL THESE 3 KEYCOMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGES 712712017 6/27/2017 7/26/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL $48.26 $316.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 7/28/2017 6/22/2017 7/27/2017 A0425 GROUND MILEAGE, PER STATUTE MILE A419 SEPSIS, UNSPECIFIED OTHER MEDICAL $680.00 $884.00 MALE SUBSCRIBER 1 BCC 3559 ORGANISM 7/28/2017 6/22/2017 7/27/2017 A0427 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, A419 SEPSIS, UNSPECIFIED OTHER MEDICAL $402.94 $850.00 MALE SUBSCRIBER 1BCC 3559 EM ERG ENCY TRANSPORT, LEVELI)ALSl- EMERGENCY) ORGANISM 7/28/2017 7 /13/2017 7/26/2017- - L03116 CELLULITIS OF LEFT HOSPITAL INPATIENT 7/13/2017 # # # # # # ## $9,464.00 $31,761.00 MALE SUBSCRIBER 1 BCC 3559 LOWER LIMB 7/28/2017 7/19/2017 7/26/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03116 CELLULITIS OF LEFT PROFESSIONAL $62.88 $181.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 7/28/2017 7/20/2017 7/26/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03116 CELLULITIS OF LEFT PROFESSIONAL $62.88 $181.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY, COUNSELING AND /OR 7/31/2017 6/28/2017 7/28/201710692 INJECTION, CEFEPIME HYDROCHLORIDE, 500 M6 L03119 CELLULITIS OF OTHER MEDICAL $84.48 $84.48 MALE SUBSCRIBER 1 BCC 3559 UNSPECIFIED PART OF LIMB 7/31/2017 6/28/2017 7/28/201759501 HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR L03119 CELLULITIS OF OTHER MEDICAL $72.67 $363.35 MALE SUBSCRIBER 1BCC 3559 ANTI FUNGAL THERAPY; ONCE EVERY 12 HOURS; UNSPECIFIED PARTOF ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY LIMB SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT )DRUGS AND NURSING VISITS CODED SEPARATELY), PE 7/31/2017 6/29/2017 7/28/201759501 HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR L03119 CELLULITIS OF OTHER MEDICAL SUBSCRIBER 1 BCC ANTI FUNGAL THERAPY; ONCE EVERY 12 HOURS; $543.00 MALE UNSPECIFIED PART OF 1 BCC $2,403.00 $3,204.00 MALE ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY 1 BCC LIMB $185.00 MALE SUBSCRIBER 1 BCC SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PE 7/31/2017 6/30/2017 7/28/201759501 HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR L03119 CELLULITISOF OTHER MEDICAL ANTI FUNGAL THERAPY; ONCE EVERY 12 HOURS; UNSPECIFIED PART OF ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY LIMB SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PE 7/31/2017 7/1/2017 7/28/201759501 HOME INFUSION THERAPY, ANTIBIOTIC, ANTIVIRAL, OR L03119 CELLULITIS OF OTHER MEDICAL ANTI FUNGAL THERAPY; ONCE EVERY 12 HOURS; UNSPECIFIED PARTOF ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY LIMB SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PE 7/31/2017 7/16/2017 7/28/2017 73718 MAGNETIC RESONANCE(EG, PROTON) IMAGING, LOWER M7989 OTHER SPECIFIED SOFT PROFESSIONAL EXTREMITY OTHERTHAN JOINT; WITHOUTCONTRAST TISSUE DISORDERS INPATIENT /HOSPITAL MATERIALS) 8/3/2017 7 11012017 7 /31/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT LOWER LIMB 8/3/2017 7/25/2017 8/1/2017 - - 1872 VENOUS INSUFFICIENCY HOSPITAL OUTPATIENT (CHRONIC( (PERIPHERAL( 8/4/2017 7/13/2017 8/1/2017 - - 1739 PERIPHERAL VASCULAR HOSPITAL OUTPATIENT DISEASE, UNSPECIFIED 8/7/2017 7/27/2017 8/412017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 1872 VENOUS INSUFFICIENCY PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED (CHRONIC) (PERIPHERAL) PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 81712017 712812017 8/3/2017- - 591302D UNSPECIFIED OPEN HOSPITAL OUTPATIENT WOUND, LEFT FOOT, SUBSEQUENT ENCOUNTER 8/8/2017 7/13/2017 8/4/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 1739 PERIPHERAL VASCULAR PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES DISEASE, UNSPECIFIED OUTPATIENT /HOSPITAL THESE 3 KEYCOMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AG ENCIES ARE PR 8/9/2017 8/1/2017 8/7/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT LOWER LIMB 8/11/2017 5/11/2017 8/10/2017 11043 DEBRIDEMENT, MUSCLEAND /OR FASCIA (INCLUDES L97411 NON - PRESSURE CHRONIC PROFE55IONAL OFFICE EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF ULCER OF RIGHT HEEL PERFORMED); FIRST 20 SO, CM OR LESS AND MIDFOOT LIMITED TO BREAKDOWN OF SKIN $72.67 $72.67 MALE SUBSCRIBER 1 BCC $72.67 $72.67 MALE SUBSCRIBER 1 BCC $72.67 $72.67 MALE SUBSCRIBER 1 BCC $121.15 $273.00 MALE SUBSCRIBER 1 BCC $470.25 $627.00 MALE SUBSCRIBER 1 BCC $407.25 $543.00 MALE SUBSCRIBER 1 BCC $2,403.00 $3,204.00 MALE SUBSCRIBER 1 BCC $110.14 $185.00 MALE SUBSCRIBER 1 BCC $407.25 $543.00 MALE SUBSCRIBER 1 BCC $183.33 $443.00 MALE SUBSCRIBER 1 BCC $407.25 $543.00 MALE SUBSCRIBER 1 BCC $311.54 $845.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 mm Em 3559 3559 3559 3559 3559 3559 3559 C.7.f 811112017 5/11/2017 811012017 11046 Debridement, muscle and /or fascia (includes epidermis, L97411 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE $65.21 $350.00 MALE SUBSCRIBER 1 BCC 3559 dermis, and subcutaneous tissue, If performed); each ULCER OF RIGHT HEEL additional 205q cm, or part thereof (List separately in AND MIDFOOT LIMITED 41) addition to code for primary procedure) TO BREAKDOWN OF SKIN N 811112017 5/11/2017 811012017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L97411 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE $225.69 $495.00 MALE SUBSCRIBER 1BCC 3559 EVALUATIONAND MANAGEMENTOFA NEW PATIENT, ULCEROF RIGHTHEEL WHICH REQUIRESTHESE 3 KEYCDMPDNENTS:A AND MIDFOOT LIMITED COMPREHENSIVE HISTORY; A COMPREHENSIVE TO BREAKDOWN OF SKIN } EXAMINATION; MEDICAL DECISION MAKING OF HIGH "a COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE 8/14/2017 6/30/2017 8/11/2017- - L0311, CELLULITIS OF LEFT HOSPITAL OUTPATIENT $40715 $543.00 MALE SUBSCRIBER 1BCC 3SS9 lu } > LOWER LIMB 8/14/2017 8/4/2017 8/10/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT $407.25 $543.00 MALE SUBSCRIBER 1BCC 3559 iL CL LOWER LIMB Q, 8116/2017 8/7/2017 8/14/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT $407.25 $543.00 MALE SUBSCRIBER 1BICE 3559 LOWER LIMB v 8/17/2017 7/13/2017 8/15/2017 99285 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION L03116 CELLULITIS OF LEFT PROFESSIONAL $630.95 $1,450.00 MALE SUBSCRIBER 1 BCC 3559 AND MANAGEMENTOFA P.ATIENT,WHICH REQUIRES LOWER LIMB OUTPATIENT/HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE h HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 8/17/2017 8/11/2017 8/15/2017 72100 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO M545 LOW BACK PAIN PROFESSIONAL $20.57 $73.00 MALE SUBSCRIBER 1BCC 3559 OR THREE VIEWS OUTPATIENT /HOSPITAL 8/22/2017 7/5/2017 8/17/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT $1,221.75 $1,629.00 MALE SUBSCRIBER 1BCC 3559 LOWER LIMB IL 8/23/2017 6/8/2017 8122/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, HOSTILE L0311S CELLULITIS OF RIGHT PROFESSIONAL $125.90 $220.00 MALE SUBSCRIBER 1BCC 3559 {i EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A Uy DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. 0 COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI LLJ V 8/23/2017 6/9/2017 8/22/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL $125.90 $220.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PO ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; v MEDICAL DECISION MAKING OF HIGH COMPLEXITY, COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM LLJ 8/23/2017 6/10/2017 8/22/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE L03115 CELLULITIS OF RIGHT PROFESSIONAL $128.50 $325.00 MALE SUBSCRIBER 1 BCC 3559 THAN 30 MINUTES LOWER LIMB INPATIENT /HOSPITAL 0 8/23/2017 8/11/2017 8/21/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT $407.25 $543.00 MALE SUBSCRIBER 1BCC 3559 LOWER LIMB 8/23/2017 8/14/2017 8/21/2017 - - 591302D UNSPECIFIED OPEN HOSPITAL OUTPATIENT $40715 $543.00 MALE SUBSCRIBER 1 BCC 3559 „p < WOUND, LEFT FOOT, SUBSEQUENT ENCOUNTER {V fV 8/28/2017 8/18/2017 8/24/2017 - - 1872 VENOUS INSUFFICIENCY HOSPITAL OUTPATIENT $407.25 $543.00 MALE SUBSCRIBER 1 BCC 3559 = (CHRONIC) (PERIPHERAL) y E L 91 8/28/2017 91 72072 RADIOLOGIC EXAMINATION, SPINE; THORACIC, THREE N1546 PAIN IN THORACICSPINE PROFESSIONAL $19.23 $73.00 MALE SUBSCRIBER 1 BCC 3559 VIEWS OUTPATIENT /HOSPITAL 9/8/2017 6/22/2017 9/6/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FORTH EVALUATION L03116 CELLULITIS OF LEFT PROFESSIONAL $666.00 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES SUBSCRIBER LOWER LIMB INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; DISC DISORDERS, A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING THORACIC REGION AND /OR COORDINATION OF CARE WITH OTHER 9/18/2017 PROVIDERS OR AGEN 9/14/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT 9/8/2017 6/23/2017 9/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03116 CELLULITIS OF LEFT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A 9/25/2017 DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; 9/21/2017 - - 591302D UNSPECIFIED OPEN HOSPITAL OUTPATIENT $40715 MEDICAL DECISION MAKING OF HIGH COMPLEXITY. SUBSCRIBER 1 BCC 3559 COUNSELING AND /OR COORDINATION OF CARE WITH WOUND, LEFT FOOT, OTHER PROM 9/8/2017 6/24/2017 9/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03116 CELLULITIS OF LEFT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL 9/25/2017 REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A 9/21/2017 - - 1872 VENOUS INSUFFICIENCY HOSPITAL OUTPATIENT $407.25 DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; SUBSCRIBER 1 BCC 3559 MEDICAL DECISION MAKING OF HIGH COMPLEXITY. (CHRONIC) (PERIPHERAL) COUNSELING AND /OR COORDINATION OF CARE WITH 9/25/2017 OTHER PROVI 9/21/2017 - - 581802A UNSPECIFIED OPEN HOSPITAL OUTPATIENT 9/8/2017 6/25/2017 9/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03116 CELLULITIS OF LEFT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; LEG, INITIAL ENCOUNTER MEDICAL DECISION MAKING OF HIGH COMPLEXITY. 10/9/2017 COUNSELING AND /OR COORDINATION OF CARE WITH 10/5/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 L03115 CELLULITIS OF RIGHT PROFESSIONAL $0.00 OTHER PROVI SUBSCRIBER 1 BCC 3559 9/8/2017 6/26/2017 9/6/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE L03116 CELLULITIS OF LEFT PROFESSIONAL THAN 30 MINUTES LOWER LIMB INPATIENT /HOSPITAL 9/8/2017 6/27/2017 9/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE L03116 CELLULITIS OF LEFT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $188.01 $558.00 MALE SUBSCRIBER 1 BCC $96.12 $286.00 MALE SUBSCRIBER 1 BCC $96.12 $286.00 MALE SUBSCRIBER 1 BCC $96.12 $286.00 MALE SUBSCRIBER 1 BCC $96.01 $292.00 MALE SUBSCRIBER 1 BCC $96.12 $286.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE mm 9/8/2017 8/28/2017 9/6/2017 - - M5184 OTHERINTERVERTEBRAL HOSPITAL OUTPATIENT $666.00 $888.00 MALE SUBSCRIBER 1 BCC 3559 DISC DISORDERS, THORACIC REGION 9/18/2017 9/1/2017 9/14/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT $1,500.00 $2,000.00 MALE SUBSCRIBER 1BCC 3559 LOWER LIMB 9/25/2017 8/21/2017 9/21/2017 - - 591302D UNSPECIFIED OPEN HOSPITAL OUTPATIENT $40715 $543.00 MALE SUBSCRIBER 1 BCC 3559 WOUND, LEFT FOOT, SUBSEQUENT ENCOUNTER 9/25/2017 8/25/2017 9/21/2017 - - 1872 VENOUS INSUFFICIENCY HOSPITAL OUTPATIENT $407.25 $543.00 MALE SUBSCRIBER 1 BCC 3559 (CHRONIC) (PERIPHERAL) 9/25/2017 8/28/2017 9/21/2017 - - 581802A UNSPECIFIED OPEN HOSPITAL OUTPATIENT $519.00 $692.00 MALE SUBSCRIBER 1 BCC 3559 WOUND, LEFT LOWER LEG, INITIAL ENCOUNTER 10/9/2017 5/30/2017 10/5/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 L03115 CELLULITIS OF RIGHT PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 LEADS; INTERPRETATION AND REPORT ONLY LOWER LIMB OUTPATIENT /HOSPITAL 10/9/2017 5/30/2017 10/5/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION L03115 CELLULITIS OF RIGHT PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LOWER LIMB OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF TH E PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 10/9/2017 7/13/2017 10/5/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION L0390 CELLULITIS, UNSPECIFIED PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HDSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 10/9/2017 711412017 10/5/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L0390 CELLULITIS, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 10/9/2017 7/15/2017 10/5/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L0390 CELLULITIS, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 101 7/16/2017 10/5/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L0390 CELLULITIS, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 10/9/2017 711712017 10/5/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L0390 CELLULITIS, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 10/9/2017 7/18/2017 10/5/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L0390 CELLULITIS, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR $268.82 $665.00 MALE SUBSCRIBER 1 BCC $188.01 $558.00 MALE SUBSCRIBER 1 BCC $96.12 $286.00 MALE SUBSCRIBER 1 BCC $96.12 $286.00 MALE SUBSCRIBER 1 BCC $6632 $197.00 MALE SUBSCRIBER 1 BCC $66.72 $197.00 MALE SUBSCRIBER 1 BCC $6632 $197.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE mm ®' WE ®' 10/9/2017 7/19/2017 10/5/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L0390 CELLULITIS, UNSPECIFIED PROFESSIONAL $1,123.00 MALE SUBSCRIBER EVALUATION AND MANAGEMENTOFA PATIENT, WHICH $0.00 INPATIENT /HOSPITAL SUBSCRIBER 1 BCC REQUI RES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A $1,299.00 MALE SUBSCRIBER 1 BCC $0.00 DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; SUBSCRIBER 1 BCC $0.00 $859.00 MALE MEDICAL DECISION MAKING OF HIGH COMPLEXITY. 1 BCC $0.00 $3,687.00 MALE SUBSCRIBER COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 10/9/2017 7/20/2017 10/5/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE L0390 CELLULITIS, UNSPECIFIED PROFESSIONAL THAN 30 MINUTES INPATIENT / HDSPITAL 10/12/2017 8/9/2017 10111/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M545 LOW BACK PAIN PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 10/12/2017 8/17/2017 10/11/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5136 OTHERINTERVERTEBRAL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISC DEGENERATION, PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LUMBAR REGION COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 10/18/2017 9/4/2017 10/16/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT LOWER LIMB 10/18/2017 10/12/2017 10/17/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L03116 CELLU LITIS OF LEFT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LOWER LIMB PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 10/19/2017 9129/2017 10/17/2017- - 581802D UNSPECIFIED OPEN HOSPITAL OUTPATIENT WOUND, LEFT LOWER LEG, SUBSEQUENT ENCaUNTER 10/19/2017 10/10/2017 10/17/2017 - - 1872 VENOUS INSUFFICIENCY HOSPITAL OUTPATIENT (CHRONIC) (PERIPHERAL) 10/20/2017 9/26/2017 10/18/2017- - L97829 NON - PRESSURE CHRONIC HOSPITAL OUTPATIENT ULCER OF OTHER PART OF LEFT LOWER LEG WITH UNSPECIFIED SEVERITY 10/25/2017 10/16/2017 10123/2017- - L03115 CELLULITIS OF RIGHT HOSPITAL OUTPATIENT LOWER LIMB 10/30/2017 10/20/2017 10/28/2017- - L03116 CELLU LITIS OF LEFT HOSPITAL OUTPATIENT LOWER LIMB 11/6/2017 10/3/2017 11/2/2017- - 183025 VARICOSE VEINS OF LEFT HOSPITAL OUTPATIENT LOWER EXTREMITY WITH ULCER OTHER PART OF FOOT 11/6/2017 10/13/2017 111212017- - 581802D UNSPECIFIED OPEN HOSPITAL OUTPATIENT WOUND, LEFT LOWER LEG, SUBSEQUENT ENCOUNTER $96.12 $286.00 MALE SUBSCRIBER 1 BCC $96.01 $292.00 MALE SUBSCRIBER 1 BCC $110.14 $250.00 MALE SUBSCRIBER 1 BCC $110.14 $250.00 MALE SUBSCRIBER 1 BCC $0.00 $543.00 MALE SUBSCRIBER 1 BCC $0.00 $250.00 MALE SUBSCRIBER 1 BCC $0.00 $1,36100 MALE SUBSCRIBER 1 BCC $0.00 $1,123.00 MALE SUBSCRIBER 1 BCC $0.00 $859.00 MALE SUBSCRIBER 1 BCC $0.00 $1,299.00 MALE SUBSCRIBER 1 BCC $0.00 $1,387.00 MALE SUBSCRIBER 1 BCC $0.00 $859.00 MALE SUBSCRIBER 1 BCC $0.00 $3,687.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 w Z N Q! A 4 3559 7 3559 W } fl i® CL CL Q 3559 v 3559 3559 3559 1 III. 111812017 10/6/2017 11/2/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT SUBSCRIBER 1 BCC $0.00 $895.00 MALE LOWER LIMB 1 BCC 11/8/2017 10/27/2017 11/6/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT SUBSCRIBER 1 BCC INTERVERTEBRAL DISC PROFESSIONAL LOWER LIMB $288.00 MALE SUBSCRIBER 1 BCC 3559 11/20/2017 10/24/2017 11/17/2017- - L03116 CELLULITIS OF LEFT HOSPITAL OUTPATIENT $73.13 $93.76 MALE SUBSCRIBER 1 BCC LOWER LIMB MATERIAL Sub Total F 1.875E +10 1/26/2017 11/2/2016 1/25/2017 99202 OFFICE OR OTHER OUTPATIENTVISIT FOR THE M7712 LATERAL EPICONDYLITIS, OTHER MEDICAL 1 BCC 3559 IE D EVALUATION AND MANAGEMENT OF A NEW PATIENT, 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5416 LEFT ELBOW PROFESSIONAL OFFICE $99.69 $99.69 WHICH REQUIRES THESE 3 KEY COMPONENTS: AN SUBSCRIBER 1 BCC 3559 LUMBAR REGION EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COMPONENTS: A DETAILED HISTORY; A DETAILED COORDINATION OF CARE WITH 0 EXAMINATION; MEDICAL DECISION MAKING OF 1/26/2017 11/2/2016 1/25/2017- - M7712 LATERAL EPICONDYLITIS, HOSPITAL OUTPATIENT MODERATE COMPLEXITY. COUNSELING AND /OR LEFT ELBOW 1/26/2017 11/10/2016 1/25/2017- - M7712 LATERAL EPICONDYLITIS, HOSPITAL OUTPATIENT LEFT ELBOW 1/26/2017 11/15/2016 1/25/2017- - M7712 LATERAL EPICONDYLITIS, HOSPITAL OUTPATIENT LEFT ELBOW 1/26/2017 11/18/2016 1/25/2017- - M7712 LATERAL EPICONDYLITIS, HOSPITAL OUTPATIENT LEFT ELBOW 1/30/2017 1/3/2017 1/24/2017 99214 DFFICE DR OTHER OUTPATIENT VISIT FOR THE M5416 RADICULOPATHY, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LUMBAR REGION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 1/30/2017 1/3/2017 1/24/2017 L0637 LUMBAR- SACRALORTHOSIS, SAGITTAL- CORONAL M5416 RADICULOPATHY, PROFESSIONAL OFFICE CONTROL, WITH RIGID ANTERIOR AND POSTERIOR LUMBAR REGION FRAME /PANELS, POSTERIOR EXTENDS FROM SACROCOCCYGEAL JUNCTION TO T -9 VERTEBRA, LITERAL STRENGTH PROVIDED BY RIGID LATERAL FRAME /PANELS, PRODUCES INTR.ACAVITARY PRESSURE TO REDUCE LOAD ON INTERVERTEBRAL DISC $0.00 $1,035.00 MALE SUBSCRIBER 1 BCC $0.00 $1,299.00 MALE SUBSCRIBER 1 BCC $0.00 $895.00 MALE SUBSCRIBER 1 BCC $107,676.50 $228,456.84 Q $259.96 $49.61 $154.28 MALE SUBSCRIBER 1 BCC C.7.f 3559 w 3559 N 3559 Q! Fll 3559 $203.64 $261.08 MALE SUBSCRIBER 1 BCC 3559 CL HOSPITAL OUTPATIENT $2,474.25 $5,957.11 MALE SUBSCRIBER 1 BCC 3559 CL LUMBAR REGION Q $259.96 $333.28 MALE SUBSCRIBER 1 BCC 3559 v INTERVERTEBRAL DISC PROFESSIONAL $92.25 $288.00 MALE SUBSCRIBER 1 BCC 3559 CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST DISORDERS WITH OUTPATIENT/HOSPITAL $73.13 $93.76 MALE SUBSCRIBER 1 BCC 3559 MATERIAL RADICULOPATHY, F W $117.24 $150.31 MALE SUBSCRIBER 1 BCC 3559 IE D 1/24/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5416 RADICULOPATHY, PROFESSIONAL OFFICE $99.69 $99.69 $464.00 MALE SUBSCRIBER 1 BCC 3559 $557.71 $5,240.40 MALE SUBSCRIBER 1 BCC Im 1/30/2017 1/16/2017 1120/2017 - - M5416 RADICULOPATHY, HOSPITAL OUTPATIENT $2,474.25 $5,957.11 MALE SUBSCRIBER 1 BCC 3559 LUMBAR REGION 1/30/2017 1/16/2017 1/25/2017 72148 MAGNETIC RESONANCE (EG, PROTONS IMAGING, SPINAL M5116 INTERVERTEBRAL DISC PROFESSIONAL $92.25 $288.00 MALE SUBSCRIBER 1 BCC 3559 CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST DISORDERS WITH OUTPATIENT/HOSPITAL MATERIAL RADICULOPATHY, LUMBAR REGION 1/30/2017 1/23/2017 1/24/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5416 RADICULOPATHY, PROFESSIONAL OFFICE $99.69 $464.00 MALE SUBSCRIBER 1 BCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED LUMBAR REGION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 21112017 12/2/2016 1/31/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M7712 LATERAL EP ICON DYLITIS, PROFESSIONAL HOSPITAL OUTPATIENT $211.09 EVALUATION AND MANAGEMENT OF AN ESTABLISHED SUBSCRIBER LEFT ELBOW OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SYNDROME, LEFT UPPER COMPONENTS: AN EXPANDED PROBLEM FOCUSED Q! HISTORY; AN EXPANDED PROBLEM FOCUSED LIMB EXAMINATION; MEDICAL DECISION MAKING OF LOW $254.37 $326.11 MALE COMPLEXITY. COUNSELING AND COOED 1 BCC 3559 7 2/1/2017 12/2/2016 1/31/2017- - M7712 LATERAL EPICONDYLITIS, HOSPITAL OUTPATIENT 4/28/2017 4/25/2017 4/27/2017 99244 OFFICE CONSULTATION FORA NEW DR ESTABLISHED LEFT ELBOW BARRETT'S ESOPHAGUS 2/13/2017 1/30/2017 2/3/2017 64483 INJECTION, ANESTHETIC AGENT AND /OR STEROID, M5416 RADICULOPATHY, PROFESSIONAL OFFICE TRANSFORAMINAL EPI DURAL; LUMBARORSACRAL, PATIENT,WHICH REQUIRES THESE 3 KEY COMPONENTS: A LUMBAR REGION W $442 $200.00 MALE SINGLE LEVEL 1 BCC 3559 } G. 2/13/2017 1/30/2017 2/3/2017 11030 INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG M5416 RADICULOPATHY, PROFESSIONAL OFFICE $99.69 $464.00 MALE SUBSCRIBER 1 BCC LUMBAR REGION Q, 3117/2017 3/6/2017 3/8/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5416 RADICULOPATHY, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LUMBAR REGION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY MODERATE COMPLEXITY. COUNSELING AND /OR COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF COORDINATION OF CARE WITH OTHER PROVIDERS OR MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER AGENCIES ARE PROVIDED CONS 3/31/2017 11/22/2016 3/30/2017 *' "'* 41712017 4/4/2017 4/5/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5416 RADICULOPATHY, PROFESSIONAL OFFICE OTHER MEDICAL $135.00 EVALUATION AND MANAGEMENT OF AN ESTABLISHED SUBSCRIBER LUMBAR REGION 3559 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY AND MANAGEMENT OF A PATIENT, WHICH REQUIRES COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER DETAILED EXAMINATION; AND MEDICAL DECISION 4/11/2017 2/23/2017 4/10/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE G5602 CARPAL TUNNEL PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED MAKING OF MODERATE COMPLEXITY. COUNSELING SYNDROME, LEFT UPPER OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LIMB COMPONENTS: AN EXPANDED PROBLEM FOCUSED AND /OR COORDINATION OF CARE WITH OTHER HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW PROVIDERS OR AGENCIES ARE PR COMPLEXITY, COUNSELING AND COORD C.7.f $58.55 $157.67 MALE SUBSCRIBER 1 BCC 3559 $73.13 $93.76 MALE SUBSCRIBER 1 BCC 3559 $99.69 $464.00 MALE SUBSCRIBER 1 BCC 3559 $44.07 $169.48 MALE SUBSCRIBER 1 BCC 3559 4/12/2017 2/23/2017 4/11/2017 - - G5602 41 HOSPITAL OUTPATIENT $211.09 $360.84 MALE SUBSCRIBER 1 BCC N SYNDROME, LEFT UPPER Q! LIMB $254.37 $326.11 MALE SUBSCRIBER 1 BCC 3559 7 HOSPITAL OUTPATIENT $1,803.73 $5,516.48 MALE SUBSCRIBER 1 BCC 3559 4/28/2017 4/25/2017 4/27/2017 99244 OFFICE CONSULTATION FORA NEW DR ESTABLISHED K2270 BARRETT'S ESOPHAGUS $318.54 $2,892.00 MALE SUBSCRIBER 1 BCC 3559 3559 PATIENT,WHICH REQUIRES THESE 3 KEY COMPONENTS: A W $442 $200.00 MALE SUBSCRIBER 1 BCC 3559 } G. COMPREHENSIVE HISTORY; A COMPREHENSIVE CL $99.69 $464.00 MALE SUBSCRIBER 1 BCC 3559 Q, EXAMINATION; AND MEDICAL DECISION MAKING OF Q $73.13 $93.76 MALE SUBSCRIBER 1 BCC 3559 $99.69 $464.00 MALE SUBSCRIBER 1 BCC 3559 $44.07 $169.48 MALE SUBSCRIBER 1 BCC 3559 4/12/2017 2/23/2017 4/11/2017 - - G5602 CARPALTUNNEL HOSPITAL OUTPATIENT $211.09 $360.84 MALE SUBSCRIBER 1 BCC 3559 SYNDROME, LEFT UPPER LIMB 4/28/2017 4/23/2017 4/27/2017 - - R51 HEADACHE HOSPITAL OUTPATIENT $1,803.73 $5,516.48 MALE SUBSCRIBER 1 BCC 3559 4/28/2017 4/25/2017 4/27/2017 99244 OFFICE CONSULTATION FORA NEW DR ESTABLISHED K2270 BARRETT'S ESOPHAGUS PROFE55IONAL OFFICE $155.30 $600.00 MALE SUBSCRIBER 1 BCC 3559 PATIENT,WHICH REQUIRES THESE 3 KEY COMPONENTS: A WITHOUT DYSPLASIA COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONS 5/3/2017 4/23/2017 5/2/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R51 HEADACHE OTHER MEDICAL $135.00 $994.00 MALE SUBSCRIBER IDOC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR C.7.f 5/12/2017 5/10/2017 5/11/2017 43239 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, R197 DIARRHEA, UNSPECIFIED PROFESSIONAL $115.06 $850.00 MALE SUBSCRIBER 1 BCC 3559 TRANSORAH W ITH BIDPSY, SINGLE DR MULTIPLE OUTPATIENT /HOSPITAL Z 5/12/2017 5/10/2017 5/11/2017 45380 COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLEOR 8197 DIARRHEA, UNSPECIFIED PROFESSIONAL $325.69 $1,300.00 MALE SUBSCRIBER 1BCC 3559 N MULTIPLE OUTPATIENT /HOSPITAL Q! 5/17/2017 5/10/2017 5/16/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC K2270 BARRETTS ESOPHAGUS PROFESSIONAL $0.00 $1,250.00 MALE SUBSCRIBER 1 BCC 3559 PROCEDURES, ENDOSCOPE INTRODUCED PROXIMALTO WITHOUT DYSPLASIA OUTPATIENT /HOSPITAL DUODENUM i 5/18/2017 5/10/2017 5/17/2017 - - C189 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,572.87 $17,400.00 MALE SUBSCRIBER 1 BCC 3559 OF COLON, UNSPECIFIED 5/24/2017 5/15/2017 5123/2017 - - C182 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $621.00 $828.00 MALE SUBSCRIBER 1 BCC 3559 OF ASCENDING COLON } fl 5/26/2017 5/23/2017 5/25/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K5100 ULCERATIVE (CHRONIC) PROFESSIONAL OFFICE $58.90 $350.00 MALE SUBSCRIBER 1BCC 3559 N. CL EVALUATION AND MANAGEMENTOFAN ESTABLISHED PANCOUTIS WITHOUT Q, PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPLICATIONS COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER F 5/30/2017 5/16/2017 5/24/2017 - - C182 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,559.75 $13,701.00 MALE SUBSCRIBER 1 BCC 3559 LL! OF ASCENDING COLON D 5/31/2017 5/20/2017 5/25/2017 - - C182 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $8,684.28 $16,993.00 MALE SUBSCRIBER 1 BCC 3559 OF ASCENDING COLON _ 6/7/2017 5 /10 /2017 6/2/2017 - - Z01812 ENCOUNTER FOR HOSPITAL OUTPATIENT $854.00 $5,055.37 MALE SUBSCRIBER 1 BCC 3559 PREPROCEDURAL LABORATORY Q EXAMINATION LJJ 6/12/2017 5/16/2017 6/9/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST C189 MALIGNANT NEOPLASM PROFESSIONAL $10237 $239.00 MALE SUBSCRIBER 1 BCC 3559 MATERIALS) OF COLON, UNSPECIFIED OUTPATIENT /HOSPITAL U`J 6/12/2017 5/16/2017 6/9/2017 74177 Computed tomography, a bdomen and pelvis; with C199 MALIGNANT NEOPLASM PROFESSIONAL $149.33 $360.00 MALE SUBSCRIBER 1 BCC 3559 contrast materials) OF COLON, UNSPECIFIED OUTPATIENT /HOSPITAL LLJ 6/13/2017 5/20/2017 6/12/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET )WITH C182 MALIGNANT NEOPLASM PROFESSIONAL $194.31 $477.00 MALE SUBSCRIBER IBCC 3559 CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY OF ASCENDING COLON OUTPATIENT /HOSPITAL (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL J LOCALIZATION IMAGING; SKULL BASE TO MID THIGH v 6/14/2017 5/10/2017 6/13/2017 88305 LEVEL IV -SURGICAL PATHOLOGY, GROSS AND 201812 ENCOUNTER FOR PROFESSIONAL $206.56 $1,700.00 MALE SUBSCRIBER 1 BCC 3559 MICROSCOPIC EXAMINATION ABORTION- PREPROCEDURAL OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE LABORATORY LLJ MARROW, BIOPSY, BONE EXDSTOSIS, BRAIN /MENINGES, EXAMINATION OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF �..� SURGICAL MARGINS, BREAST, REDUCTION 6/14/2017 5/10/2017 6/13/2017 88313 SPECI AL STA I N I NCLU DI N G I NTER P R ETATI O N AN D R EPORT; Z01812 ENCOUNTER FOR PROFESSIONAL $16.53 $125.00 MALE SUBSCRIBER 1BCC 3559 GROUP II,ALLOTHER(EG, IRON, TRICHROME), EXCEPT PREPROCEDURAL OUTPATIENT /HOSPITAL STAIN FOR MICROORGANISMS, STAINS FOR ENZYME LABORATORY hl CONSTITUENTS, OR IMMUNOCYTOCHEMISTRY AND EXAMINATION IMMUNOHISTOCH EMISTRY C 6114/2017 5/10/2017 6/13/2017 883421MMUNOHISTOC HEMISTRYORIMMUNO CYTOCHEMISTRY, Z01812 ENCOUNTERFOR PROFESSIONAL $48.47 $270.00 MALE SUBSCRIBER 1BCC 3559 PERSPECIMEN; INITIAL SINGLE ANTIBODY STAIN PREPROCEDURAL OUTPATIENT /HOSPITAL ._ PROCEDURE LABORATORY EXAMINATION �, 6/19/2017 6/7/2017 6/13/2017- - 201818 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT $909.00 $909.00 MALE SUBSCRIBER 1BCC PREPROCEOURAL EXAMINATION 6/21/2017 6/19/2017 6/20/2017 81002 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR C182 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $2.10 $35.00 MALE SUBSCRIBER 1 BCC BILIRUBIN GLUCOSE, HEMOGLOBIN, KETONES, OF ASCENDING COLON LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON AUTOMATED, WITHOUT MICROSCOPY 6/21/2017 6/19/2017 6120/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C182 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $127.40 $265.00 MALE SUBSCRIBER 1BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF ASCENDING COLON PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/26/2017 6/21/2017 6/23/2017 74177 Computed tomography, a bdomen and ROM,; With K5190 ULCERATIVE COLITIS, PROFESSIONAL $123.65 $356.00 MALE SUBSCRIBER 1 BCC contrast materials) UNSPECIFIED, WITHOUT OUTPATIENT /HOSPITAL COMPLICATIONS 6/29/2017 6/21/2017 6/28/2017 - - K5100 ULCERATIVE (CHRONIC) HOSPITAL OUTPATIENT $1,241.00 $4,287.95 MALE SUBSCRIBER 1 BCC PANCOUTIS WITHOUT COMPLICATIONS 7/3/2017 6/28/2017 6/30/2017 442101APAROSCOPY, SURGICAL; COLECTOMY, TOTAL, C182 MALIGNANT NEOPLASM PROFESSIONAL $2,717.83 $7,748.00 MALE SUBSCRIBER 1 BCC ABDOMINAL, WITHOUT PROCTECTOMY, WITH ILEOSTOMY OF ASCENDING COLON INPATIENT /HOSPITAL OR ILEOPROCTOSTOMY 71712017 6/28/2017 7/6/2017 790 ANESTHES IA FOR INTRAPERITONEAL PROCEDURES IN C192 MALIGNANT NEOPLASM OTHER MEDICAL $655.00 $1,048.00 MALE SUBSCRIBER 1BCC UPPER ABDOMEN INCLUDING LAPAROSCOPY; NOT OF ASCENDING COLON OTHERW ISE SPECIFIED 7/7/2017 6/28/2017 7/6/2017 790 ANESTHESIA FOR INTRAPERILDNEAL PROCEDURES IN C182 MALIGNANT NEOPLASM PROFESSIONAL $655.00 $1,572.00 MALE SUBSCRIBER 1 BCC UPPER ABDOMEN INCLUDING LAPAROSCOPY; NOT OF ASCENDING COLON INPATIENT /HOSPITAL OTHERWISE SPECIFIED 711012017 6/26/2017 7/4/2017 88321 CONSULTATION AND REPORT ON REFERRED SLIDES C180 MALIGNANT NEOPLASM PROFESSIONAL $114.92 $314.00 MALE SUBSCRIBER 1 BCC PREPARED ELSEWHERE OF CECUM OUTPATIENT /HOSPITAL 7/14/2017 6128/2017 711212017 88309 LEVELVI- SURGICAL PATHOLOGY, GROSS AND C180 MALIGNANT NEOPLASM PROFESSIONAL $387.80 $1,160.00 MALE SUBSCRIBER 1 BCC MICROSCOPIC EXAMINATION BONE RESECTION, BREAST, OF CECUM INPATIENT /HOSPITAL MASTECTOMY - WITH REGIONAL LYMPH NODES, COLON, SEGMENTAL RESECTION FOR TUMOR, COLON, TOTAL RESECTION, ESOPHAGUS, PARTIAL/TOTAL RESECTION, EXTREMITY, DISARTICULATION, FETUS, WITH DISSECTION, LARYNX, P 7/14/2017 6/28/2017 7/12/2017 883411MMUNOHISTOC HEMISTRY OR IMMUNO CYTOCHEMISTRY, C180 MALIGNANT NEOPLASM PROFE55IONAL $90.60 $267.00 MALE SUBSCRIBER 1BCC PERSPECIMEN; EACH. ADDITIONAL SINGLE ANTIBODY OF CECUM INPATIENT /HOSPITAL STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 7/14/2017 6/28/2017 7112/2017 883421MMUNOHISTO CHEMISTRY OR IMMUNOCYTOCHEMISTRY, C180 MALIGNANT NEOPLASM PROFESSIONAL $57.24 $171.00 MALE SUBSCRIBER 1 BCC PERSPECIMEN; INITIAL SINGLE ANTIBODY STAIN OF CECUM INPATIENT /HOSPITAL PROCEDURE 7/20/2017 6/7/2017 7/18 /2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $11.07 $70.00 MALE SUBSCRIBER 1 BCC LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 7/28/2017 6128/2017 7/18/2017- - C182 MALIGNANT NEOPLASM HOSPITAL INPATIENT 6/28/2017 7/8/2017 $35,593.46 $70,528.42 MALE SUBSCRIBER 1BCC OF ASCENDING COLON C.7.f 3559 w N 3559 ®' 3559 3559 3559 3559 3559 3559 3559 III 3559 3559 3559 61412017 7/14/2017 8/3/2017 - - Z0000 ENCOUNTER FOR HOSPITAL OUTPATIENT $1,250.00 MALE SUBSCRIBER 1 BCC GENERAL ADULT MEDICAL $1,296.32 MALE SUBSCRIBER 1 BCC $547.05 EXAMINATION WITHOUT SUBSCRIBER 1 BCC $547.05 $1,29632 MALE ABNORMAL FINDINGS 1 BCC 8/29/2017 8/24/2017 812812017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K219 CASTRO- ESOPHAGEAL PROFESSIONAL OFFICE $166.00 MALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC REFLUX DISEASE $350.00 MALE SUBSCRIBER PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY WITHOUT ESOPHAGITIS COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 10/2/2017 5/101 5/16/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC K2270 BARRETT'S ESOPHAGUS PROFESSIONAL PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO WITHOUT DYSPLASIA OUTPATIENT /HOSPITAL DUODENUM 10/2/2017 5/10/2017 9/29/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC K2270 BARRETT'S ESOPHAGUS PROFESSIONAL PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO WITHOUT DYSPLASIA OUTPATIENT /HOSPITAL DUODENUM 10/6/2017 6/19/2017 101 - - 1301 ALLERGIC RHINITIS DUE HOSPITAL OUTPATIENT TO POLLEN 10/6/2017 6/26/2017 10/4/2017- - 1301 ALLERGIC RHINITIS DUE HOSPITAL OUTPATIENT TO POLLEN 101 7/17/2017 10/4/2017- - 1301 ALLERGIC RHINITIS DUE HOSPITAL OUTPATIENT TO POLLEN 10/10/2017 9/28/2017 10/4/2017- - G43909 MIGRAINE, UNSPECIFIED, HOSPITAL OUTPATIENT NOT INTRACTABLE, WITHOUT STATUS MIGRAINOSUS 10/11/2017 9/28/2017 10/10/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT 643909 MIGRAINE, UNSPECIFIED, PROFESSIONAL CONTRAST MATERIAL NOT INTRACTABLE, OUTPATIENT /HOSPITAL WITHOUT STATUS MIGRAINOSUS 10120/2017 10/16/2017 10/19/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C198 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF OVERLAPPING SITES PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY OFCOLON COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 11/20/2017 7/5/2017 11/18/2017 74000 RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE R140 ABDOMINAL DISTENSION PROFESSIONAL ANTEROPOSTERIOR VIEW (GASEOUS) INPATIENT /HOSPITAL 1112712017 9/28/2017 11/21/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 643909 MIGRAINE, UNSPECIFIED, PROFESSIONAL AND MANAGEMENTOF A PATIENT, WHICH REQUIRES NOT INTRACTABLE, OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS WITHOUTSTATUS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL MIGRAINOSUS CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DELIS 12/28/2017 9/1/2017 12/27/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C192 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, OF ASCENDING COLON WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE $751.50 $1,780.83 MALE SUBSCRIBER 1 BCC $83.90 $350.00 MALE SUBSCRIBER 1 BCC $0.00 ($1,250, Oft) MALE SUBSCRIBER 1 BCC $364.00 $1,250.00 MALE SUBSCRIBER 1 BCC $547.05 $1,296.32 MALE SUBSCRIBER 1 BCC $547.05 $1,296.32 MALE SUBSCRIBER 1 BCC $547.05 $1,29632 MALE SUBSCRIBER 1 BCC $7,168.53 $7,168.53 MALE SUBSCRIBER 1 BCC $70.32 $166.00 MALE SUBSCRIBER 1 BCC $83.90 $350.00 MALE SUBSCRIBER 1 BCC $43.79 $59.00 MALE SUBSCRIBER 1 BCC $266.40 $1,481.00 MALE SUBSCRIBER 1 BCC $27732 $684.67 MALE SUBSCRIBER 1 BCC C.7.f 3559 im 3559 3559 3559 3559 3559 3559 IM wo 3559 3559 III C.7.f Sub Total PROFESSIONAL $76,231.15 $191,203.29 SUBSCRIBER R01 1.875E +10 1/5/2017 11/4/2016 1/2/2017 * * * ** * * * ** $0.00 1/5/2017 11/4/2016 11/10/2016 * * « ** * * *•• +«« +* 115/2017 11/4/2016 11/10/2016 SUBSCRIBER R01 OTC 1/6/2017 11/4/2016 1/4/2017 1036F CURRENT TOBACCO NONUSER (CAD, CAP, CORD, PV) D869 SUBSCRIBER R01 OTC 3559 (DM) (IBD) PROFESSIONAL 1/6/2017 11/4/2016 1/4/20171126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" D869 UNSPECIFIED OUTPATIENT /HOSPITAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR SARCOIDOSIS, DIRECT FLAP, AT EYELIDS NOSE, $0.00 1/6/2017 11/4/2016 1/4/2017 99212 OFFICE DR OTHER OUTPATIENT VISIT FOR THE D869 OUTPATIENT /HOSPITAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED SARCOIDOSIS, PROFESSIONAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $99.00 FEMALE SUBSCRIBER R01 OTC 3559 COMPONENTS: A PROBLEM FOCUSED HISTORY; A OUTPATIENT /HOSPITAL SLOB $24,486.00 FEMALE SUBSCRIBER R01 PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD 3559 SHORTNESS OF BREATH OTHER MEDICAL $0.00 MEDICAL DECISION MAKING. COUNSELING AND /OR SUBSCRIBER R01 OTC 3559 *** ** COORDINATION OF CARE WIT $2,249.24 1/6/2017 11/4/2016 1/4/2017 68420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS D869 PROFESSIONAL $11.20 $36.00 FEMALE AND NO FOLLOW -UP PLAN IS REQUIRED OTC 1/6/2017 11/4/2016 1/4/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN D869 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR HOSPITAL INPATIENT 1/4/2017 1/8/2017 $9,579.20 $51,790.11 FEMALE SUBSCRIBER RO1 REVIEWED THE PATIENT'S CURRENT MEDICATIONS 3559 1/6/2017 11/4/2016 1/4/201768731 PAIN ASSESSMENT USING ASTANDARDIZED TOOL IS D869 OTC 3559 DOCUMENTED AS NEGATIVE, NO FOLLOW -UP PLAN REQUIRED SARCOIDOSIS OF LUNG 1/9/2017 12/27/2016 1/6/2017 - - D869 1/12/2017 12/21/2016 1/11/2017 E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL D860 1/17/2017 1/4/2017 1/9/2017 A0431 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, 80602 $0.00 $10.40 FEMALE SUBSCRIBER R01 TRANSPORT, ONE WAY (ROTARY W I NG) 3559 1/17/2017 1/4/2017 1/9/2017 A0436 ROTARYWING AIR MILEAGE, PER STATUTE MILE R060 1/30/2017 1/4/2017 1/11/2017 PROFESSIONAL $93.63 1/30/2017 1/4/2017 1/13/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLEVIEW, R079 INPATIENT /HOSPITAL FRONTAL 1/30/2017 1/4/2017 1/13/2017 - - D860 1/30/2017 1/4/2017 1/19/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST D860 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (92374), CHL0RIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 1/30/2017 1/4/2017 1119/2017 83880 NATRIURETIC PEPTIDE D860 1/30/2017 1/4/2017 1/19/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D860 HCT, BBC, W BC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL W BC COUNT 1/30/2017 1/4/2017 1/21/2017 71250 COMPUTED TOMOGRAPHY, THORAX; WITHOUT 8918 CONTRAST MATERIAL SARCOIDOSIS, PROFESSIONAL $76,231.15 $191,203.29 SUBSCRIBER R01 OTC 3559 * * * ** * * * ** $0.00 $280.55 FEMALE SUBSCRIBER ROl OTC 3559 SARCOIDOSIS, PROFESSIONAL $39.28 $432.30 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED OUTPATIENT /HOSPITAL {$151.75) FEMALE SUBSCRIBER R01 OTC 3559 SARC0ID0515, PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER RO1 OTC 3559 UNSPECIFIED OUTPATIENT /HOSPITAL SARCOIDOSIS, PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED OUTPATIENT /HOSPITAL SARCOIDOSIS, PROFESSIONAL $37.71 $99.00 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED OUTPATIENT /HOSPITAL SLOB $24,486.00 FEMALE SUBSCRIBER R01 OTC 3559 SARCOIDOSIS, PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED OUTPATIENT/HOSPITAL SARCOIDOSIS, PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED OUTPATIENT /HOSPITAL SARCOIDOSIS, PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED OUTPATIENT /HOSPITAL SARCOIDOSIS, HOSPITAL OUTPATIENT $1,700.28 $1,700.28 FEMALE SUBSCRIBER RO1 OTC 3559 UNSPECIFIED SARCOIDOSIS OF LUNG OTHER MEDICAL $37.10 $37.10 FEMALE SUBSCRIBER RO1 OTC 3559 SHORTNESS OF BREATH OTHER MEDICAL SLOB $24,486.00 FEMALE SUBSCRIBER R01 OTC 3559 SHORTNESS OF BREATH OTHER MEDICAL $0.00 $22,737.00 FEMALE SUBSCRIBER R01 OTC 3559 *** ** * * * ** $2,249.24 $6,277.44 FEMALE SUBSCRIBER RO1 OTC 3559 CHEST PAIN, UNSPECIFIED PROFESSIONAL $11.20 $36.00 FEMALE SUBSCRIBER R01 OTC 3559 OUTPATIENT/HOSPITAL SARCOIDOSIS OF LUNG HOSPITAL INPATIENT 1/4/2017 1/8/2017 $9,579.20 $51,790.11 FEMALE SUBSCRIBER RO1 OTC 3559 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $26.00 FEMALE SUBSCRIBER R01 OTC 3559 OUTPATIENT/HOSPITAL SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $18.00 FEMALE SUBSCRIBER R01 OTC 3559 OUTPATIENT /HOSPITAL SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $10.40 FEMALE SUBSCRIBER R01 OTC 3559 OUTPATIENT /HOSPITAL OTHER NONSPECIFIC PROFESSIONAL $93.63 $193.00 FEMALE SUBSCRIBER RD1 OTC 3559 ABNORMAL FINDING OF INPATIENT /HOSPITAL LUNG FIELD C.7.f 1/30/2017 1/4/2017 112412017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION D869 SARCOIDOSIS, PROFESSIONAL $313.41 $1,481.00 FEMALE SUBSCRIBER R01 OTC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES UNSPECIFIED OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 1/30/2017 1/4/2017 1/25/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION D860 SARCOIDOSIS OF LUNG PROFESSIONAL $126.16 $520.00 FEMALE SUBSCRIBER R01 OTC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR 113012017 1/5/2017 1/19/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 8918 OTHER NONSPECIFIC PROFESSIONAL $14.52 $35.00 FEMALE SUBSCRIBER R01 OTC 3559 FRONTAL ABNORMAL FINDING OF INPATIENT /HOSPITAL LUNG FIELD 1/30/2017 1/5/2017 1/20/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLEVIEW, 8918 OTHER NONSPECIFIC PROFESSIONAL $14.52 $35.00 FEMALE SUBSCRIBER RO1 OTC 3559 FRONTAL ABNORMAL FINDING OF INPATIENT /HOSPITAL LUNG FIELD 1/30/2017 1/6/2017 1/19/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, P02, D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $11.30 FEMALE SUBSCRIBER R01 OTC 3559 CO2, HCO3 (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL 1/30/2017 1/6/2017 111912017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $26.00 FEMALE SUBSCRIBER R01 OTC 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL )82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (94D75), POTASSIUM (84132), PROTEIN, 1/30/2017 1/6/2017 1/19/2017 82330 CALCIUM; IONIZED D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $10.80 FEMALE SUBSCRIBER R01 OTC 3559 INPATIENT /HOSPITAL 1/30/2017 1/6/2017 1/19/2017 83605 LACTATE (LACTIC ACID) D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $7.60 FEMALE SUBSCRIBER R01 OTC 3559 INPATIENT /HOSPITAL 1130/2017 1/6/2017 1/19/2017 83735 MAGNESIUM D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $10.80 FEMALE SUBSCRIBER R01 OTC 3559 INPATIENT /HOSPITAL 1/30/2017 1/6/2017 1/19/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $4.30 FEMALE SUBSCRIBER R01 OTC 3559 INPATIENT /HOSPITAL 113012017 116/2017 1/19/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $9.70 FEMALE SUBSCRIBER R01 OTC 3559 HCF, BBC, W BC AND PLATELET COUNT) INPATIENT /HOSPITAL 1/30/2017 1/6/2017 1/19/2017 85610 PROTHROMBIN TIME; D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $4.30 FEMALE SUBSCRIBER R01 OTC 3559 INPATIENT /HOSPITAL 1/30/2017 1/6/2017 1/19/2017 85730 THROMBOPIASTIN TIME, PARTIAL (PTT); PLASMA OR D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $6.50 FEMALE SUBSCRIBER R01 OTC 3559 WHOLE BLOOD INPATIENT /HOSPITAL 1/30/2017 1/6/2017 1/19/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 8918 OTHER NONSPECIFIC PROFE55IONAL $14.52 $35.00 FEMALE SUBSCRIBER RO1 OTC 3559 FRONTAL ABNORMAL FINDING OF INPATIENT /HOSPITAL LUNG FIELD 1/30/2017 1/7/2017 1/19/2017 82330 CALCIUM; IONIZED D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $10.80 FEMALE SUBSCRIBER R01 OTC 3559 INPATIENT / HDSPITAL 1/30/2017 1/7/2017 1119/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, P02, D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $11.30 FEMALE SUBSCRIBER R01 OTC 3559 CO2, HCO3 (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL 1/30/2017 1/7/2017 1/19/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $26.00 FEMALE SUBSCRIBER R01 OTC 3559 INCLUDE THE FOLLOWING: ALBUMIN (8204D), BILIRUBIN, INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE �BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, C.7.f 1/30/2017 1/7/2017 1/19/2017 83735 MAGNESIUM D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $10.80 FEMALE SUBSCRIBER R01 OTC 3559 INPATIENT /HOSPITAL 1/30/2017 1/7/2017 1/19/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $4.30 FEMALE SUBSCRIBER R01 OTC 3559 C! INPATIENT /HOSPITAL N 1/30/2017 1/7/2017 1/19/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HER, D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $9.70 FEMALE SUBSCRIBER R01 OTC 3559 OR HCT, REG, WBC AND PLATELET COUNT) INPATIENT /HOSPITAL SIR 1/30/2017 11712017 111912017 85610 PROTHROMBIN TIME; D960 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $4.30 FEMALE SUBSCRIBER R01 OTC 3559 INPATIENT /HOSPITAL t 1/30/2017 1/7/2017 1/19/2017 85730 THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $6.50 FEMALE SUBSCRIBER R01 OTC 3559 } WHOLE BLOOD INPATIENT /HDSPITAL 1/30/2017 1/7/2017 1119/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R918 OTHER NONSPECIFIC PROFESSIONAL $14.52 $35.00 FEMALE SUBSCRIBER R01 OTC 3559 OR FRONTAL ABNORMAL FINDING OF INPATIENT /HOSPITAL LUNG FIELD 1/30/2017 1/8/2017 1/19/2017 82330 CALCIUM; IONIZED D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $10.80 FEMALE SUBSCRIBER R01 OTC 3559 fl } INPATIENT /HOSPITAL 1/30/2017 1/8/2017 1/19/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, P02, D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $11.30 FEMALE SUBSCRIBER R01 OTC 3559 U. CL COX, LOCH (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL Q, Q 1/30/2017 1/8/2017 1/19/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 8918 OTHER NONSPECIFIC PROFESSIONAL $14.52 $35.00 FEMALE SUBSCRIBER R01 OTC 3559 v FRONTAL ABNORMAL FINDING OF INPATIENT /HOSPITAL LUNG FIELD rf 1/30/2017 1/12/2017 1/17/2017 - - Z7682 AWAITING ORGAN HOSPITAL OUTPATIENT $276.55 $276.55 FEMALE SUBSCRIBER R01 OTC 3559 TRANSPLANT STATUS F 1/30/2017 1/19/2017 1/24/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D869 SARCOIDOSIS, PROFESSIONAL OFFICE $83.13 $275.90 FEMALE SUBSCRIBER R01 OTC 3559 W EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY Z COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF _ MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER O 1/30/2017 1/21/2017 1/24/2017 E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $37.10 $37.10 FEMALE SUBSCRIBER R01 OTC 3559 Q 1/30/2017 1/21/2017 1/24/2017 E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $11936 $119.76 FEMALE SUBSCRIBER R01 OTC 3559 {li CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW UJ RATE cn 1131/2017 1/4/2017 1/19/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 1439 EMPHYSEMA, PROFESSIONAL $0.00 $35.00 FEMALE SUBSCRIBER R01 OTC 3559 FRONTAL UNSPECIFIED INPATIENT /HOSPITAL 1/31/2017 1/4/2017 1/19/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $148.53 $399.00 FEMALE SUBSCRIBER R01 OTC 3559 W EVALUATION AND MANAGEMENT OF PATIENT, WHICH REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM DON ENTS: A � DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; J MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH v OTHER PROVI 1/31/2017 1/5/2017 1/19/2017 99291 CRITICAL C ARE, EVALUATION AND MANAGEMENT OF THE D860 SARCOIDOSIS OF LUNG PROFE55IONAL $337.84 $877.00 FEMALE SUBSCRIBER R01 OTC 3559 LLJ CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- INPATIENT /HOSPITAL 74 MINUTES 1/31/2017 1/5/2017 1/19/2017 99255 INPATIENT CONSULTATION FOR ANEW OR ESTABLISHED R0602 SHORTNESS OF BREATH PROFESSIONAL $320.58 $700.00 FEMALE SUBSCRIBER R01 OTC 3559 (' PATIENT, W H ICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT /HDSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR CDDRDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSI N 1/31/2017 1/5/2017 1/19/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $12.00 FEMALE SUBSCRIBER R01 EVALUATION AND MANAGEMENT OF PATIENT, WHICH 3559 $0.00 $12.00 FEMALE SUBSCRIBER R01 OTC REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A $0.00 $10.80 FEMALE SUBSCRIBER R01 OTC 3559 DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; $11.30 FEMALE SUBSCRIBER R01 OTC 3559 MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 1/31/2017 1/6/2017 1/19/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R0602 SHORTNESS OF BREATH PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 113112017 1/6/2017 112012017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D860 SARCOIDOSIS OF LUNG PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT 15 STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 1/31/2017 1/7/2017 112012017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D860 SARCOIDOSIS OF LUNG PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 1/31/2017 1/8/2017 1/19/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R0602 SHORTNESS OF BREATH PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 2/13/2017 1/4/2017 2/7/2017 87633 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR D860 SARCOIDOSIS OF LUNG PROFESSIONAL RNA(; RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZA INPATIENT/HOSPITAL VIRUS, CORONAVIRUS, METAPNEUMOVIRUS, PARAI NFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS, RHINOVIRUS), INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFO 2/13/2017 1/4/2017 2/7/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITHATLEAST12 19690 RESPIRATORY FAILURE, PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY UNSPECIFIED, OUTPATIENT /HOSPITAL UNSPECIFIED WHETHER WITH HYPDXIA OR HYPERCAPNIA 2/13/2017 1/5/2017 2/7/2017 80051 ELECTROLYTE PANEL D860 SARCOIDOSIS OF LUNG PROFESSIONAL INPATIENT /HOSPITAL 2/13/2017 1/6/2017 2/7/2017 80051 ELECTROLYTE PANEL D860 SARCOIDOSIS OF LUNG PROFESSIONAL INPATIENT /HOSPITAL 2113/2017 1/6/2017 2/7/2017 82330 CALCIUM; IONIZED D860 SARCOIDOSIS OF LUNG PROFESSIONAL INPATIENT /HOSPITAL 2/13/2017 1/6/2017 2/7/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, P02, D860 SARCOIDOSIS OF LUNG PROFESSIONAL CO2, HCO3 (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL $148.53 $399.00 FEMALE SUBSCRIBER R01 OTC $145.53 $399.00 FEMALE SUBSCRIBER R01 OTC $58.53 $149.00 FEMALE SUBSCRIBER R01 OTC $58.53 $149.00 FEMALE SUBSCRIBER R01 OTC $103.51 $276.00 FEMALE SUBSCRIBER R01 OTC $0.00 $397.00 FEMALE SUBSCRIBER R01 OTC C.7.f 3559 ®' WE mm ®' WE $11.07 $70.00 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $12.00 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $12.00 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $10.80 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $11.30 FEMALE SUBSCRIBER R01 OTC 3559 C.7.f 2/13/2017 1/6/2017 2/7/2017 2/13/2017 1/8/2017 2/7/2017 2/13/2017 1/8/2017 2/7/2017 2/13/2017 1/8/2017 2/7/2017 2/13/2017 1/8/2017 2/7/2017 2/16/2017 10/14/2016 10/19/2016 - 2/21/2017 1/4/2017 1/9/2017 A0431 2/21/2017 1/4/2017 1/9/2017 A0436 2/21/2017 1/4/2017 1/25/2017 A0431 212112017 1/4/2017 1/25/2017 A0436 2/27/2017 2/15/2017 212212017 2/27/2017 2/21/2017 2/22/2017 E1392 2/27/2017 2/21/2017 2122/2017 E1390 3/7/2017 12/21/2016 3/6/2017 3/10/2017 11/21/2016 3/8/2017 * ° "" 3/13/2017 1/27/2017 2/3/2017 - 3/13/2017 1/30/2017 2/3/2017 - 3/17/2017 2/15/2017 3/3/2017 - 3/17/2017 2/28/2017 3/3/2017 - 3/22/2017 3/16/2017 3/21/2017 - 3/23/2017 3/21/2017 3/22/2017 E1392 3/23/2017 3/21/2017 3122/2017 E1390 3/24/2017 3/16/2017 312312017 3/24/2017 3/16/2017 3/23/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $6.40 FEMALE SUBSCRIBER R01 OTC 3559 STRIP) INPATIENT /HOSPITAL 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $18.00 FEMALE SUBSCRIBER R01 OTC 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE(82565) GLUCOSE (82947) POTASSIUM )84132) 50DIUM (84295) UREA NITROGEN (BUN) (84520) 83735 MAGNESIUM D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $10.80 FEMALE SUBSCRIBER R01 OTC 3559 INPATIENT / HDSPITAL 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $4.30 FEMALE SUBSCRIBER R01 OTC 3559 INPATIENT /HOSPITAL 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $9.70 FEMALE SUBSCRIBER R01 OTC 3559 HOT, RBC, WBC AND PLATELET COUNT) INPATIENT /HOSPITAL - D860 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT ($1,590,00) $2,573.00 FEMALE SUBSCRIBER RUE OTC 3559 AMBULANCE SERVICE , CONVENTIONAL AIR SERVICES, R0602 SHORTNESS OF BREATH OTHER MEDICAL $0.00 {$24,456.00; FEMALE SUBSCRIBER R01 OTC 3559 TRANSPORT, ONE WAY (ROTARY WING) ROTARY WING AIR MILEAGE, PER STATUTE MILE R0602 SHORTNESS OF BREATH OTHER MEDICAL $0.00 ,$22,757.00! FEMALE SUBSCRIBER R01 OTC 3559 AMBULANCE SERVICE , CONVENTIONAL AIR SERVICES, R0602 SHORTNESS OF BREATH OTHER MEDICAL $4,115.98 $24,486.00 FEMALE SUBSCRIBER R01 OTC 3559 TRANSPORT, ONE WAY (ROTARY WING) ROTARY WING AIR MILEAGE, PER STATUTE MILE 80602 SHORTNESS OF BREATH OTHER MEDICAL $5,938.40 $22,737.00 FEMALE SUBSCRIBER R01 OTC 3559 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R0602 SHORTNESS OF BREATH PROFESSIONAL $108.44 $299.00 FEMALE SUBSCRIBER R01 OTC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PORTABLE OXYGEN CONCENTRATOR, RENTAL D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $37.10 $37.10 FEMALE SUBSCRIBER R01 OTC 3559 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $119.76 $119.76 FEMALE SUBSCRIBER R01 OTC 3559 CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE - Z01S12 ENCOUNTER FOR HOSPITAL OUTPATIENT $509.00 $509.00 FEMALE SUBSCRIBER R01 OTC 3559 PREPROCEDURAL LABORATORY EXAMINATION $15,892.00 $19,25115 FEMALE SUBSCRIBER R01 OTC 3559 - D869 5ARCOIDOSIS, HOSPITAL OUTPATIENT $65.31 $65.31 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT $1,634.97 $1,634.97 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED - D860 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT $539.55 $539.55 FEMALE SUBSCRIBER R01 OTC 3559 - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT $2,172.85 $2,172.85 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT $1,995.35 $1,99535 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED PORTABLE OXYGEN CONCENTRATOR, RENTAL D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $37.10 $37.10 FEMALE SUBSCRIBER R01 OTC 3559 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $119.76 $119.76 FEMALE SUBSCRIBER R01 OTC 3559 CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE 82375 CARBOXYHEMOGLOBIN; QUANTITATIVE D869 SARCOIDOSIS, PROFESSIONAL $0.00 $10.80 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED OUTPATIENT /HOSPITAL 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, P02, D869 SARCOIDOSIS, PROFESSIONAL $0.00 $11.30 FEMALE SUBSCRIBER R01 OTC 3559 OFF, HCO3 (INCLUDING CALCULATED 02 SATURATION); UNSPECIFIED OUTPATIENTIH05PITAL C.7.f 3/24/2017 3/16/2017 3/23/2017 83050 HEMOGLOBIN; METHEMOGLOBIN, QUANTITATIVE D869 SARCOIDOSIS, PROFESSIONAL $0.00 $9.20 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED OUTPATIENT /HOSPITAL Z 3/28/2017 3/15/2017 3/27/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 80602 SHORTNESS OF BREATH PROFESSIONAL $155.24 $429.00 FEMALE SUBSCRIBER R01 OTC 3559 N EVALUATION AND MANAGEMENT OF AN ESTABLISHED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR 7 COORDINATION OF CARE WITH "a 3/30/2017 11/21/2016 3/28/2017 * * * ** * * * ** * * * ** * * *" * *` ** $0.00 $19,253.15 FEMALE SUBSCRIBER R01 OTC 3559 3/31/2017 3/15/2017 3/29/2017 - - Z942 LUNG TRANSPLANT HOSPITAL OUTPATIENT $278.00 $278.00 FEMALE SUBSCRIBER R01 OTC 3559 STATUS 4/5/2017 3/17/2017 4/4/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE D860 SARCOIDOSIS OF LUNG PROFESSIONAL OFFICE $1.80 $22.31 FEMALE SUBSCRIBER ROE OTC 3559 A. CL 4110/2017 3/31/2017 4/8/2017 - - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT $2,645.42 $2,645.42 FEMALE SUBSCRIBER R01 OTC 3559 CL UNSPECIFIED 4/18/2017 4/12/2017 4/17/2017- - D860 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT $263.00 $263.00 FEMALE SUBSCRIBER R01 OTC 3559 4/24/2017 4/21/2017 4/23/2017 E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $119.76 $119.76 FEMALE SUBSCRIBER R01 OTC 3559 CAPABLE OF DELIVERING 85 PERCENTOR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE uj 4/24/2017 4/21/2017 4/23/2017 E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $37.10 $37.10 FEMALE SUBSCRIBER R01 OTC 3559 h 4/26/2017 4/11/2017 4/24/2017 - - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT $5,202.00 $6,936.00 FEMALE SUBSCRIBER R01 OTC 3559 5/4/2017 4/28/2017 5/3/2017 - - D869 UNSPECIFIED SARCOIDOSIS, HOSPITAL OUTPATIENT $1,634.97 $1,634.97 FEMALE SUBSCRIBER R01 OTC 3559 _ UNSPECIFIED S/8/2017 4/20/2017 5/5/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z7682 AWAITING ORGAN PROFESSIONAL OFFICE $83.13 $275.90 FEMALE SUBSCRIBER R01 OTC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED TRANSPLANT STATUS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY Q COMPONENTS: A DETAILED HISTORY; A DETAILED LU EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR J COORDINATION OF CARE WITH OTHER 5123/2017 5/17/2017 5/22/2017- - D860 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT $263.00 $263.00 FEMALE SUBSCRIBER R01 OTC 3559 LLJ 5/24/2017 S/21/2017 5/23/2017 E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $37.10 $37.10 FEMALE SUBSCRIBER R01 OTC 3559 5/24/2017 5/21/2017 5/23/2017 E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, D860 SARCOIDOSIS OF LUNG OTHER MEDICAL $119.76 $119.76 FEMALE SUBSCRIBER R01 OTC 3559 � CAPABLE OF DELIVERING 85 PERCENT OR GREATER J OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE 5/25/2017 5/17/2017 5/24/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R0602 SHORTNESS OF BREATH PROFESSIONAL $155.24 $429.00 FEMALE SUBSCRIBER R01 OTC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LLJ COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR (' COORDINATION OF CARE WITH 5/30/2017 S/23/2017 5125/2017 - - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT $5,202.00 $6,936.00 FEMALE SUBSCRIBER R01 OTC 3559 UNSPECIFIED N 6/14/2017 10/5/2016 10/11/2016 - - D869 SARCOIDOSIS, UNSPECIFIED HOSPITAL OUTPATIENT $10,066.00 $17,22100 FEMALE SUBSCRIBER R01 OTC 3559 N 6/14/2017 10/5/2016 10/11/2016 - - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT $0.00 1$17,223.00) FEMALE SUBSCRIBER R01 OTC 3559 = UNSPECIFIED 6/15/2017 2/10/2017 6/14/2017 * * "x+ *.a+. +.x ++ * * *x* + *sa+ $24.28 $151.75 FEMALE SUBSCRIBER R01 OTC 3559 6/19/2017 2/10/2017 6/16/20171036F CURRENTTOBACCO NON- USER (CAD, CAP, CORD, PV) D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 ._ )DM) (IBD) OUTPATIENT /HOSPITAL m 6/19/2017 2/10/2017 6/16/20171126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $0.01 FEMALE OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR $0.00 $0.01 FEMALE OUTPATIENT /HOSPITAL $37.10 $37.10 FEMALE DIRECT FLAP, AT EYELIDS NOSE, $119.76 $119.76 FEMALE SUBSCRIBER R01 OTC 6/19/2017 2/10/2017 6/16/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D860 SARCOIDOSIS OF LUNG PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/19/2017 2/10/2017 6/16/2017 G8420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS D860 SARCOIDOSIS OF LUNG PROFESSIONAL AND NO FOLLOW -UP PLAN IS REQUIRED OUTPATIENT /HOSPITAL 6/19/2017 2/10/2017 6/16/2017 08427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN D860 SARCOIDOSIS OF LUNG PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS 6/19/2017 2/10/2017 6/16/2017 G8484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, D860 SARCOIDOSIS OF LUNG PROFESSIONAL REASON NOT GIVEN OUTPATIENT /HOSPITAL 6/19/2017 2/10/2017 6/16/2017 68731 PAIN ASSESSMENT USING ASTANDARDIZED TOOL IS D860 SARCOIDOSIS OF LUNG PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW -UP PLAN OUTPATIENT /HOSPITAL REQUIRED 6/23/2017 6/21/2017 6/22/2017 E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL D860 SARCOIDOSIS OF LUNG OTHER MEDICAL 6/23/2017 6/21/2017 6/22/2017 E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, D860 SARCOIDOSIS OF LUNG OTHER MEDICAL CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE 6/28/2017 6/21/2017 6/27/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z7682 AWAITING ORGAN PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED TRANSPLANT STATUS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY, COUNSELING AND /DR COORDINATION OF CARE WITH OTHER 7/10/2017 6128/2017 7/8/2017 71250 COMPUTED TOMOGRAPHY, THORAX; WITHOUT 8918 OTHER NONSPECIFIC PROFESSIONAL OFFICE CONTRAST MATERIAL ABNORMAL FINDING OF LUNG FIELD 7/10/2017 6/28/2017 7/8/2017 1036F CURRENTTOBACCO NON-USER (CAD, CAP, COPD, PV) D869 SARCOIDOSIS, PROFESSIONAL (DM) (IBD) UNSPECIFIED OUTPATIENT /HOSPITAL 711012017 6/28/2017 71812017 1126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" D869 SARCOIDOSIS, PROFESSIONAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR UNSPECIFIED OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, 7/10/2017 6/28/2017 7/8/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D869 SARCOIDOSIS, PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 7/10/2017 6/28/2017 7/8/2017 68420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS D869 SARCOIDOSIS, PROFESSIONAL AND NO FOLLOW -UP PLAN IS REQUIRED UNSPECIFIED OUTPATIENT /HOSPITAL 7/10/2017 6/28/2017 7/8/2017 G9427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN D869 SARCOIDOSIS, PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR UNSPECIFIED OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC $108.44 $299.00 FEMALE SUBSCRIBER R01 OTC $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC $0.00 $0.01 FEMALE SUBSCRIBER 301 OTC $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC $37.10 $37.10 FEMALE SUBSCRIBER R01 OTC $119.76 $119.76 FEMALE SUBSCRIBER R01 OTC $8113 $275.90 FEMALE SUBSCRIBER R01 OTC $93.63 $193.00 FEMALE SUBSCRIBER R01 OTC $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC $0.00 $0.01 FEMALE SUBSCRIBER RO1 OTC $155.24 $429.00 FEMALE SUBSCRIBER R01 OTC C.7.f 3559 w Z 3559 N 3559 3559 3559 3559 3559 3559 im 3559 3559 3559 3559 $000 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $0.01 FEMALE SUBSCRIBER RO1 OTC 3559 rl 7/10/2017 6/28/2017 71812017 G8731 PAIN ASSESSMENT USING A STANDARDIZED TOOL IS D869 SARCOIDOSIS, PROFESSIONAL $400.00 FEMALE SUBSCRIBER R01 OTC $1.80 DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN SUBSCRIBER R01 OTC UNSPECIFIED OUTPATIENT /HOSPITAL SUBSCRIBER R01 OTC $278.00 $278.00 FEMALE REQUIRED $1,586.00 $1,586.00 FEMALE SUBSCRIBER R01 OTC 7/14/2017 7/5/2017 7/12/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 80602 SHORTNESS OF BREATH PROFESSIONAL $1,628.30 FEMALE SUBSCRIBER R01 OTC EVALUATION AND MANAGEMENT OF AN ESTABLISHED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 7/14/2017 7 11112017 7/12/2017 92557 COMPREHENSIVE AUDIOMETRY THRESHOLD EVALUATION R221 LOCALIZED SWELLING, PROFESSIONAL OFFICE AND SPEECH RECOGNITION (92553 AND 92S56 MASS AND LUMP, NECK COMBINED) 7/14/2017 7/11/2017 7/12/2017 92567 TYMPANOMETRY(IMPEDANCE TESTING) R221 LOCALIZED SWELLING, PROFESSIONAL OFFICE MASS AND LUMP, NECK 7/14/2017 711112017 711212017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 8221 LOCALIZED SWELLING, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MASS AND LUMP, NECK PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 711812017 6/30/2017 7/17/2017 - - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT UNSPECIFIED 7/24/2017 7/5/2017 7/21/2017- - D860 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT 7/25/2017 6/28/2017 7/7/2017 * " *" * * * ** * " ** * ** ** *** ** 7/25/2017 7/21/2017 7/24/2017 E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL D860 SARCOIDOSIS OF LUNG OTHER MEDICAL 7/25/2017 7/21/2017 7/24/2017 E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, D860 SARCOIDOSIS OF LUNG OTHER MEDICAL CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE 8/1/2017 7/19/2017 7/24/2017- - R221 LOCALIZED SWELLIN(i, HOSPITAL OUTPATIENT MASS AND LUMP, NECK 8/3/2017 7/19/2017 81112017 70491 COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH R221 LOCALIZED SWELLING, PROFESSIONAL CONTRAST MATERIALS) MASS AND LUMP, NECK OUTPATIENT /HOSPITAL 8/7/2017 8/1/2017 8/4/2017 82565 CREATININE; BLOOD 1984 OTHER DISORDERS OF OTHER MEDICAL LUNG 81712017 8/1/2017 8/4/2017 84520 UREA NITROGEN; QUANTITATIVE 1984 OTHER DISORDERS OF OTHER MEDICAL LUNG 81812017 8/1/2017 8/7/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE Z01812 ENCOUNTERFOR PROFESSIONAL OFFICE PREPROCEOURAL LABORATORY EXAMINATION 8/9/2017 7/1/2017 8/8/2017 - - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT UNSPECIFIED 8/22/2017 8/16/2017 8/21/2017- - D860 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT 8/23/2017 8/17/2017 8/22/2017- - Z942 LUNG TRANSPLANT HOSPITAL OUTPATIENT STATUS 8/23/2017 8/21/2017 8122/2017 E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, D860 SARCOIDOSIS OF LUNG OTHER MEDICAL CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE 812312017 812112017 812212017 E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL D860 SARCOIDOSIS OF LUNG OTHER MEDICAL 8/24/2017 5/31/2017 8/23/2017 - - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT UNSPECIFIED $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC $155.24 $429.00 FEMALE SUBSCRIBER R01 OTC $31.91 $164.00 FEMALE SUBSCRIBER R01 OTC $12.35 $68.00 FEMALE SUBSCRIBER 301 OTC $140.53 $400.00 FEMALE SUBSCRIBER R01 OTC $1,628.30 $1,769.30 FEMALE SUBSCRIBER R01 OTC $768.10 $768.10 FEMALE SUBSCRIBER R01 OTC $34.36 $4,235.62 FEMALE SUBSCRIBER R01 OTC $37.10 $37.10 FEMALE SUBSCRIBER R01 OTC $11936 $119.76 FEMALE SUBSCRIBER R01 OTC $3,413.00 $5,695.00 FEMALE SUBSCRIBER R01 OTC $114.04 $269.00 FEMALE SUBSCRIBER R01 OTC $0.00 $22.05 FEMALE SUBSCRIBER R01 OTC $0.00 $17.00 FEMALE SUBSCRIBER R01 OTC $1.80 $22.31 FEMALE SUBSCRIBER R01 OTC $1,628.30 $1,769.30 FEMALE SUBSCRIBER R01 OTC $278.00 $278.00 FEMALE SUBSCRIBER R01 OTC $1,586.00 $1,586.00 FEMALE SUBSCRIBER R01 OTC $119.76 $119.76 FEMALE SUBSCRIBER RO1 OTC $37.10 $37.10 FEMALE SUBSCRIBER R01 OTC $1,628.30 $1,628.30 FEMALE SUBSCRIBER R01 OTC C.7.f 3559 w Z 3559 N 3559 3559 3559 1, I W, 3559 3559 3559 3559 0 rl 8/24/2017 8/16/2017 8/23/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R0602 SHORTNESS OF BREATH PROFESSIONAL $9.20 FEMALE SUBSCRIBER 301 OTC $22.49 EVALUATION AND MANAGEMENT OF AN ESTABLISHED SUBSCRIBER R01 OTC $19.03 OUTPATIENT /HOSPITAL SUBSCRIBER R01 OTC $12.99 $35.00 FEMALE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $83.13 $275.90 FEMALE SUBSCRIBER R01 OTC COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 8/25/2017 8/17/2017 8/24/2017 82375 CARBOXYHEMOGLOBIN; QUANTITATIVE Z942 LUNG TRANSPLANT PROFESSIONAL STATUS OUTPATIENT /HOSPITAL 8/25/2017 811712017 8/24/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, EGA, Z942 LUNG TRANSPLANT PROFESSIONAL C0E, HCO3 (INCLUDING CALCULATED 02 SATURATION); STATUS OUTPATIENT /HOSPITAL 8/25/2017 8/17/2017 8/24/2017 83050 HEMOGLOBIN; METHEMOGLOBIN, QUANTITATIVE Z942 LUNG TRANSPLANT PROFESSIONAL STATUS OUTPATIENT /HOSPITAL 9/5/2017 811712017 9/1/2017 94375 RESPIRATORY FLOW VOLUME LOOP D860 SARCOIDOSIS OF LUNG PROFESSIONAL OUTPATIENT/HOSPITAL 9/5/2017 8/17/2017 9/1/2017 94727 GAS DILUTION DR WASHOUT FOR DETERMINATION OF D860 SARCOIDOSIS OF LUNG PROFESSIONAL LUNG VOLUMES AND, WHEN PERFORMED, DISTRIBUTION OUTPATIENT /HOSPITAL OF VENTILATION AND CLOSING VOLUMES 9/5/2017 811712017 9/1/2017 94729 DIFFUSING CAPACITY (EG, CARBON MONOXIDE, D860 SARCOIDOSIS OF LUNG PROFESSIONAL MEMBRANE) (LIST SEPARATELY IN ADDITION TO CODE OUTPATIENT /HOSPITAL FOR PRIMARY PROCEDURE) 9/6/2017 7/19/2017 9/5/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1776 ARTERITIS, UNSPECIFIED PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 9/25/2017 9/21/2017 9/22/2017 E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL D860 SARCOID05150F LUNG OTHER MEDICAL 9/25/2017 9121/2017 9/22/2017 E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, D860 SARCOIDOSIS OF LUNG OTHER MEDICAL CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE 9/29/2017 9/20/2017 9/28/2017- - 19610 CHRONIC RESPIRATORY HOSPITAL OUTPATIENT FAILURE, UNSPECIFIED WHETHER WITH HYPDXIA OR HYPERCAPNIA 10/6/2017 9/20/2017 10/5/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D869 SARCOIDOSIS, PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 10/9/2017 9/28/2017 10/6/2017 - - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT UNSPECIFIED $155.24 $429.00 FEMALE SUBSCRIBER R01 OTC $0.00 $10.80 FEMALE SUBSCRIBER R01 OTC SLOB $11.30 FEMALE SUBSCRIBER R01 OTC $0.00 $9.20 FEMALE SUBSCRIBER 301 OTC $22.49 $55.00 FEMALE SUBSCRIBER R01 OTC $19.03 $46.00 FEMALE SUBSCRIBER R01 OTC $12.99 $35.00 FEMALE SUBSCRIBER R01 OTC $83.13 $275.90 FEMALE SUBSCRIBER R01 OTC $39.33 $39.33 FEMALE SUBSCRIBER R01 OTC $126.95 $126.95 FEMALE SUBSCRIBER RO1 OTC $394.70 $394.70 FEMALE SUBSCRIBER R01 OTC $54.53 $167.00 FEMALE SUBSCRIBER R01 OTC $1,628.30 $1,628.30 FEMALE SUBSCRIBER RO1 OTC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 Em III. 10/12/2017 10/2/2017 1011012017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE B0233 ZOSTER KERATITIS PROFESSIONAL OFFICE $278.00 $278.00 FEMALE EVALUATION AND MANAGEMENT OF A NEW PATIENT, $129.78 $140.00 FEMALE SUBSCRIBER RO1 OTC $17.99 $76.08 FEMALE WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 10/13/2017 8/28/2017 10/12/2017 - - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT UNSPECIFIED 10/13/2017 9/29/2017 10112/2017 E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, 1441 CHRONIC OBSTRUCTIVE OTHER MEDICAL CAPABLE OF DELIVERING 85 PERCENTOR GREATER PULMONARY DISEASE OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW WITH (ACUTE) RATE EXACERBATION 10/13/2017 9/29/2017 10/12/2017 E1392 PORTABLE OXYGEN CONCENTRATOR, RENTAL 1441 CHRONIC OBSTRUCTIVE OTHER MEDICAL PULMONARY DISEASE WITH (ACUTE) EXACERBATION 10/16/2017 10/12/2017 10/13/2017 92012 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H538 OTHER VISUAL PROFESSIONAL OFFICE AND EVALUATION, W ITH INITIATION OR CONTINUATION DISTURBANCES OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT 10/17/2017 10/10/2017 10/16/2017- - B029 ZOSTER WITHOUT HOSPITAL OUTPATIENT COMPLICATIONS 10/17/2017 10/11/2017 10/16/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE B0230 ZOSTER OCULAR DISEASE, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 10/18/2017 1011012017 10/17/2017 99283 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION B029 ZOSTER WITHOUT PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES COMPLICATIONS OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 10/24/2017 9/20/2017 10/3/2017 k}b.. * * * ** " * * ** * * * ** * * * ** 10/24/2017 10/18/2017 10/23/2017- - D860 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT 10/25/2017 10/18/2017 10/23/2017- - D860 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT 10/25/2017 10/23/2017 1012412017 92014 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H538 OTHER VISUAL PROFESSIONAL OFFICE AND EVALUATION, WITH INITIATION OR CONTINUATION DISTURBANCES OF DIAGNOSTIC AND TREATMENT PROGRAM; COMPREHENSIVE, ESTABLISHED PATIENT, ONE OR MORE VISITS 11/2/2017 10/30/2017 11/1/2017 96372 Therapeutic, prophylactic, or diagnostic injection (specify 1776 ARTERITIS, UNSPECIFIED PROFESSIONAL OFFICE substance or drug); subcutaneous or intramuscular $173.99 $250.00 FEMALE SUBSCRIBER R01 OTC $3,060.19 $3,201.19 FEMALE SUBSCRIBER R01 OTC $126.95 $126.95 FEMALE SUBSCRIBER RO1 OTC $39.33 $39.33 FEMALE SUBSCRIBER R01 OTC $89.13 $115.00 FEMALE SUBSCRIBER RO1 OTC $426.00 $426.00 FEMALE SUBSCRIBER R01 OTC $83.13 $275.90 FEMALE SUBSCRIBER R01 OTC $111.53 $520.00 FEMALE SUBSCRIBER R01 OTC $24.28 $151.75 FEMALE SUBSCRIBER R01 OTC $24.28 $151.75 FEMALE SUBSCRIBER R01 OTC $278.00 $278.00 FEMALE SUBSCRIBER R01 OTC $129.78 $140.00 FEMALE SUBSCRIBER RO1 OTC $17.99 $76.08 FEMALE SUBSCRIBER R01 OTC C.7.f 11/2/2017 10/30/2017 11/1/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1776 ARTERITIS, UNSPECIFIED PROFESSIONAL OFFICE $83.13 $275.90 FEMALE SUBSCRIBER R01 OTC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED N EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER t 11/2/2017 10/30/2017 111112017 J1071 INI TESTOSTERONE CYPIONATE 1776 ARTERITIS, UNSPECIFIED PROFESSIONAL OFFICE $6.00 $40.00 FEMALE SUBSCRIBER R01 OTC 3559 7 11/2/2017 10/30/2017 11/1/201713420 INJECTION, VITAMIN B- 12CYAN0C0BAIAMIN, UPT0 1776 ARTERITIS, UNSPECIFIED PROFESSIONAL OFFICE $2.65 $24.00 FEMALE SUBSCRIBER R01 OTC 3559 1000 MCG 11/6/2017 10/18/2017 11/3/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R0602 SHORTNESS OF BREATH PROFESSIONAL $170.75 $429.00 FEMALE SUBSCRIBER R01 OTC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OUTPATIENT /HOSPITAL } PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A CL COMPREHENSIVE EXAMINATION; MEDICAL DECISION Q, MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 11/7/2017 10/26/2017 11/6/2017 77080 DUAL ENERGY X -RAY ABSORPTIOMETRY(DXA), BONE M8589 OTHER SPECIFIED PROFESSIONAL $16.57 $42.00 FEMALE SUBSCRIBER R01 OTC 3559 DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON(EG, DISORDERS OF BONE OUTPATIENT /HOSPITAL HIPS, PELVIS, SPINE) DENSITY AND STRUCTURE, MULTIPLE SITES {LJ 11/10/2017 10/26/2017 11/9/2017 - - ZO1810 ENCOUNTER FOR HOSPITAL OUTPATIENT $4,817.00 $4,817.00 FEMALE SUBSCRIBER RO1 OTC 3559 PREPROCEOURAL CARDIOVASCULAR _ EXAMINATION 11/10/2017 10/29/2017 111912017 E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, 1441 CHRONIC OBSTRUCTIVE OTHER MEDICAL $126.95 $126.95 FEMALE SUBSCRIBER R01 OTC 3559 CAPABLE OF DELIVERING 85 PERCENT OR GREATER PULMONARY DISEASE OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW WITH (ACUTE) IL RATE EXACERBATION ui m 11/17/2017 9/20/2017 11/10/20171036F CURRENTTOBACCO NON- USER(CAD, CAP,COPD, PV) D860 SARCOIDOSIS OF LUNG PROFESSIONAL SO.OD $0.01 FEMALE SUBSCRIBER ROT OTC 3559 UJ (DM) (IBD) OUTPATIENT /HOSPITAL Q 11117/2017 9/20/2017 11/10/2017 1126F INTERMEDIATE "DEIAY" OF ANY FLAP, PRIMARY "DELAY" D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 J OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OUTPATIENT /HOSPITAL LLJ DIRECT FLAP, AT EYELIDS NOSE, 11/17/2017 9/20/2017 11/10/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D860 SARCOIDOSIS OF LUNG PROFESSIONAL $120.11 $299.00 FEMALE SUBSCRIBER R01 OTC 3559 � EVALUATION AND MANAGEMENT OF AN ESTABLISHED OUTPATIENT /HOSPITAL J PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED v EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER W M 11/17/2017 9/20/2017 1111012017 G9420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 AND NO FOLLOW -UP PLAN IS REQUIRED OUTPATIENT /HOSPITAL (' Q 11/17/2017 9/20/2017 11110/2017 68427 ELIGIBLE PROFESSIDNALATTESTSTO DOCUMENTING IN D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS N N 11/17/2017 9/20, 17 11/10/2017 69731 PAIN ASSESSMENT USING A STANDARDIZED T00L IS D860 SARCOIDOSIS OF LUNG PROFESSIONAL $0CD $0.01 FEMALE SUBSCRIBER R01 OTC 3559 DOCUMENTED AS NEGATIVE, NO FOLLO W -UP PLAN OUTPATIENT /HOSPITAL = REQUIRED 11/17/2017 10/18/2017 11/10/20171036F CURRENT TDBACCO NON- USER(CAD,CAP,COPD, PV) D860 SARCOID0515 OF LUNG PROFESSIONAL $0.00 $0.01 FEMALE SUBSCRIBER RO1 OTC 3559 (DM) (IBM OUTPATIENT /HOSPITAL 11/17/2017 10/18/2017 11110120171126F INTERMEDIATE "DELAY" OFANY FLAP, PRIMARY "DELAY" D860 SARCOIDOSIS OF LUNG PROFESSIONAL SUBSCRIBER RO1 OTC OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR $299.00 FEMALE SUBSCRIBER R01 OTC OUTPATIENT /HOSPITAL OTC DIRECT FLAP, AT EYELIDS NOSE, $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 11/17/2017 10/18/2017 11/10/2017 1220F PATIENTSCREENED FOR DEPRESSION (SUD) D860 SARCOIDOSIS OF LUNG PROFESSIONAL $106.40 $216.00 FEMALE SUBSCRIBER R01 OTC 3559 OUTPATIENT /HOSPITAL 11/17/2017 10/18/2017 11/10/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D860 SARCOIDOSIS OF LUNG PROFESSIONAL OTC EVALUATION AND MANAGEMENT OF AN ESTABLISHED $0.00 $151.00 FEMALE SUBSCRIBER R01 OUTPATIENT /HOSPITAL 3559 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $153.00 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 COMPONENTS: A DETAILED HISTORY; A DETAILED OTC 3559 EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 11/17/2017 10/18/2017 11/30/2017 08420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS D860 SARCOIDOSIS OF LUNG PROFESSIONAL AND NO FOLLOW -UP PLAN 15 REQUIRED OUTPATIENT /HOSPITAL 11/17/2017 10 /18 /2017 1111012017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN D860 SARCOIDOSIS OF LUNG PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS 11/17/2017 10/18/2017 11/10/2017 68484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, D860 SARCOIDOSIS OF LUNG PROFESSIONAL REASON NOT GIVEN OUTPATIENT /HOSPITAL 11/17/2017 1011812017 1111012017 G8731 PAIN ASSESSMENT USING ASTANDARDIZED TOOL IS D860 SARCOIDOSIS OF LUNG PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW -UP PLAN OUTPATIENT /HOSPITAL REQUIRED 11/17/2017 10/31/2017 11/10/2017 - - D869 SARCOIDOSIS, HOSPITAL OUTPATIENT UNSPECIFIED 11/27/2017 10/26/2017 11/24/2017 93306 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH R0600 DYSPNEA, UNSPECIFIED PROFESSIONAL IMAGE DOCUMENTATION (2D), INCLUDES M -MODE OUTPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 11/27/2017 11/7/2017 11/15/2017 92012 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H538 OTHER VISUAL PR0FE55IONAL OFFICE AND EVALUATION, WITH INITIATION OR CONTINUATION DISTURBANCES OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT 11/27/2017 11/14/2017 11/22/2017 76705 ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE 170203 UNSPECIFIED PROFESSIONAL DOCUMENTATION; LIMITED LEG, SINGLE ORGAN, ATHEROSCLEROSIS OF OUTPATIENT /HOSPITAL QUADRANT, FOLLOW -UP) NATIVE ARTERIES OF EXTREMITIES, BILATERAL LEGS 11/27/2017 11/14/2017 1112212017 93880 DUPLEXSCAN OF EXTRACRANIAL ARTERIES; COMPLETE 170203 UNSPECIFIED PROFESSIONAL BILATERALSTUDY ATHEROSCLEROSIS OF OUTPATIENT /HOSPITAL NATIVE ARTERIES OF EXTREMITIES, BILATERAL LEGS 11/27/2017 11/14/2017 11/22/2017 93925 DUPLEXSCAN OF LOWER EXTREMITY ARTERIES OR 170203 UNSPECIFIED PROFESSIONAL ARTERIAL BYPASS GRAFTS; COMPLETE BILATERALSTUDY ATHEROSCLEROSIS OF OUTPATIENT /HOSPITAL NATIVE ARTERIES OF EXTREMITIES, BILATERAL LEGS 11/27/2017 11/14/2017 11/22/2017 93306 ECHOCARDIOGRAPHY ,TRANSTHORACIC,REAL -TIME WITH D860 SARCOIDOSIS OF LUNG PROFESSIONAL IMAGE DOCUMENTATION (2D), INCLUDES M -MODE OUTPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC $0.00 $0.01 FEMALE SUBSCRIBER RO1 OTC $120.11 $299.00 FEMALE SUBSCRIBER R01 OTC C.7.f 3559 w Z 3559 N m Q! 3559 $0.00 $0.01 FEMALE SUBSCRIBER 301 OTC 3559 $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $0.01 FEMALE SUBSCRIBER R01 OTC 3559 $1,562.99 $1,562.99 FEMALE SUBSCRIBER R01 OTC 3559 $106.40 $216.00 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $115.00 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $112.00 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $151.00 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $153.00 FEMALE SUBSCRIBER R01 OTC 3559 $0.00 $235.00 FEMALE SUBSCRIBER RD1 OTC 3559 E C.7.f 1112812017 11/14/2017 11/2012017- - D860 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT $0.00 $2,573.00 FEMALE SUBSCRIBER R01 OTC 3559 11/28/2017 11/14/2017 11120/2017- - D860 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT $0.00 $4,387.00 FEMALE SUBSCRIBER R01 OTC 3559 w C! N 12/4/2017 11/29/2017 11/30/2017 E1390 OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, 1441 CHRONIC OBSTRUCTIVE OTHER MEDICAL $0.00 $126.95 FEMALE SUBSCRIBER R01 OTC 3559 CAPABLE OF DELIVERING 85 PERCENT OR GREATER PULMONARY DISEASE OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW WITH (ACUTE) RATE EXACERBATION i 12/8/2017 11/15/2017 11/28/2017- - 201818 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT $0.00 $337.00 FEMALE SUBSCRIBER R01 OTC 3559 "a PREPROCEOURAL EXAMINATION 12/15/2017 11/14 /2017 12/7/2017- - D860 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT $1,981.00 $1,981.00 FEMALE SUBSCRIBER R01 OTC 3559 > } fl 12/18/2017 11/7/2017 12/14/2017 92012 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H538 OTHER VISUAL PROFESSIONAL OFFICE $8534 $115.00 FEMALE SUBSCRIBER R01 OTC 3559 E. CL AND EVALUATION, WITH INITIATION OR CONTINUATION DISTURBANCES Q, OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT 12/19/2017 12/13/2017 1211812017- - D960 SARCOIDOSIS OF LUNG HOSPITAL OUTPATIENT $0.00 $278.00 FEMALE SUBSCRIBER R01 OTC 3559 Sub Total $102,723.11 $232,682.52 1.875E +10 1/4/2017 12/13/2016 1/3/2017 93306 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL -TIME WITH 12510 ATHEROSCLEROTIC HEART PROFESSIONAL $74.41 $521.00 FEMALE SUBSCRIBER 1 ESE, 3559 Lij IMAGE DOCUMENTATION (2D), INCLUDES M -MODE DISEASE OF NATIVE INPATIENT /HOSPITAL h RECORDING, WHEN PERFORMED, COMPLETE, WITH CORONARY ARTERY SPECTRAL DOPPLER ECHOCARDIOGRAPHY , AND WITH WITHOUT ANGINA COLOR FLOW DOPPLER ECHOCARDIOGRAPHY PECTORIS _ 1/4/2017 12/29/2016 1/3/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE $1.80 $22.31 FEMALE SUBSCRIBER 1050 3559 HYPERTENSION 1/5/2017 12/11/2016 1/4/2017 93010 ELECTRDCARDIOGRAM,ROUTINEECG WITHATLEAST12 14581 LONGQTSVNDROME PROFESSIONAL $9.42 $29.00 FEMALE SUBSCRIBER 1050 3559 Q LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL LLD m 1/5/2017 12/12/2016 1/4/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1214 NON -ST ELEVATION PROFESSIONAL $139.69 $652.00 FEMALE SUBSCRIBER 1050 3559 a) AND MANAGEMENT OF A PATIENT, WHICH REQUIRES (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL cfnY THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL INFARCTION DECISION MAKING OF HIGH COMPLEXITY. COUNSELING e lELJ AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN Q J 1/5/2017 12/13/2016 1/4/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON -ST ELEVATION PROFESSIONAL $49.74 $228.00 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL V REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENT&AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL LLJ DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR U 11512017 12/14/2016 1/4/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON -ST ELEVATION PROFESSIONAL $49.74 $228.00 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN INFARCTION Q EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN CN! EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL fV DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR C 1/5/2017 12/30/2016 1/3/201]- - N186 END STAGE RENAL HOSPITAL OUTPATIENT $66200 $14,025.35 FEMALE SUBSCRIBER 1050 3559 DISEASE 1/6/2017 11/21/2016 1/4/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 N19 UNSPECIFIED KIDNEY PROFESSIONAL $11.04 $70.00 FEMALE SUBSCRIBER 1050 3559 LEADS; INTERPRETATION AND REPORT ONLY FAILURE OUTPATIENT /HOSPITAL 1/6/2017 12/8/2016 1/5/2017 145 ANESTHESIA FOR PROCEDURES ON EYE; VITREORETINAL E113592 TYPE 2 DIABETES OTHER MEDICAL $1,959.74 $3,360.00 FEMALE SUBSCRIBER 1050 SURGERY MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, LEFT EYE 1/6/2017 12/11/2016 1/4/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1214 NON -ST ELEVATION PROFESSIONAL $11.04 $70.00 FEMALE SUBSCRIBER 1050 LEADS; INTERPRETATION AND REPORT ONLY (NSTEMH MYOCARDIAL OUTPATIENT /HOSPITAL INFARCHON 1/6/2017 12/31/2016 1/4/2017 90961 END STAGE RENAL DISEASE IESRDI RELATED SERVICES N196 ENO STAGE RENAL PROFESSIONAL $289.19 $607.00 FEMALE SUBSCRIBER 1050 MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH 1/10/2017 12/14/2016 1/9/2017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN N186 END STAGE RENAL PROFESSIONAL $61.63 $156.50 FEMALE SUBSCRIBER 1050 EVALUATION DISEASE INPATIENT /HOSPITAL 1111/2017 12/11/2016 1/10/2017 " "` * * "* " "' * *' ** * * "' 12/11/2016 4####44# $30,436.00 $141,185.49 FEMALE SUBSCRIBER 1 050 111212017 12/11/2016 1/11/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1214 NON ST ELEVATION OTHER MEDICAL $0.00 $776.16 FEMALE SUBSCRIBER 1 OSO AND MANAGEMENT OF A PATIENT, WHICH REQUIRES (NSTEMH MYOCARDIAL THESE KEYCDMPDNENTS: A COMPREHENSIVE HISTORY; INFARCFION A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 111212017 12/12/2016 1/11/2017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN N196 END STAGE RENAL PROFESSIONAL $63.06 $195.63 FEMALE SUBSCRIBER 1050 EVALUATION DISEASE INPATIENT /HOSPITAL 1/12/2017 12/12/2016 1/1112017 99222 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION N186 END STAGE RENAL PROFESSIONAL $0.00 $376.60 FEMALE SUBSCRIBER 1 050 AND MANAGEMENT OF A PATIENT, WHICHREQUIRES DISEASE INPATIENT / HDSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITV. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 1/12/2017 12/12/2016 1/11/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON -ST ELEVATION OTHER MEDICAL $85.95 $273.46 FEMALE SUBSCRIBER 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH (NSTEMH MYOCARDIAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 111212017 12/15/2016 1/11/2017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN 1120 HYPERTENSIVE CHRONIC PROFESSIONAL $61.63 $156.50 FEMALE SUBSCRIBER 1050 EVALUATION KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGE 5 CHRONIC (KIDNEY DISEASE OR END STAGE RENAL DISEASE 111212017 12/16/2016 1/11/2017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN 1120 HYPERTENSIVE CHRONIC PROFESSIONAL $61.63 $156.50 FEMALE SUBSCRIBER 1050 EVALUATION KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGES CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE 1/12/2017 12/17/2016 1/11/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N186 ENO STAGE RENAL PROFESSIONAL $3103 $86.58 FEMALE SUBSCRIBER 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH DISEASE INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD N ENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ C.7.f 3559 3559 3559 e I III I1 CMTI Ix. C.7.f 1/12/2017 12/18/2016 1/11/2017 90935 HEMO DIALYSIS PROCEDURE WITH SINGLE PHYSICIAN N186 END STAGE RENAL PROFESSIONAL $61.63 $156.50 FEMALE SUBSCRIBER 1050 3559 EVALUATION DISEASE INPATIENT /HOSPITAL 1/12/2017 12/21/2016 1/11/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON ST ELEVATION OTHER MEDICAL $97.67 $273.46 FEMALE SUBSCRIBER 1050 3559 C! EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMI) MYOCARDIAL N REQU I R ES AT LEAST 2 O F TH ESE 3 KEY CUM PO N E FEES AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXIN. COUNSELING AND /OR 7 1/12/2017 12/22/2016 1111/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON ST ELEVATION OTHER MEDICAL $97.67 $273.46 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMI) MYOCARDIAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN } EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. CL COUNSELING AND /OR Q, Q 1/12/2017 12/23/2016 1/11/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON ST ELEVATION OTHER MEDICAL $97.67 $273.46 FEMALE SUBSCRIBER 1 0S 3559 v EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMI) MYOCARDIAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS: AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. h COUNSELING AND /OR D 1/12/2017 12/24/2016 1/11/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON ST ELEVATION OTHER MEDICAL $97.67 $273.46 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMI) MYOCARDIAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NES:AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXIN. Q COUNSELING AND /OR LU 1/17/2017 12/19/2016 1113/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1120 HYPERTENSIVE CHRONIC PROFESSIONAL $62.88 $156.26 FEMALE SUBSCRIBER 1050 3559 U`J EVALUATION AND MANAGEMENTOFA PATIENT, WHICH KIDNEY DISEASE WITH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS AN STAGE S CHRONIC KIDNEY EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN DISEASE OR END STAGE EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL RENAL DISEASE LLJ DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 4 J 1/17/2017 12/20/2016 1/13/2017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN 1120 HYPERTENSIVE CHRONIC PROFESSIONAL $61.63 $156.50 FEMALE SUBSCRIBER 1050 3559 EVALUATION KIDNEY DISEASE WITH INPATIENT /HOSPITAL v STAGE 5 CHRONIC (KIDNEY DISEASE OR END STAGE RENAL DISEASE W 1/17/2017 12/21/2016 1/13/2017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN 1120 HYPERTENSIVE CHRONIC PROFESSIONAL $61.63 $156.50 FEMALE SUBSCRIBER 1050 3559 EVALUATION KIDNEY DISEASE WITH INPATIENT / HDSPITAL 0 STAGE 5 CHRONIC (KIDNEY DISEASE OR END STAGE RENAL DISEASE Q 1/18/2017 11/23/2016 1/16/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E1122 TYPE 2 DIABETES PROFESSIONAL $0.00 $41.00 FEMALE SUBSCRIBER 1050 3559 N MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL N (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CHRONIC KIDNEY DISEASE CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 111812017 11/23/2016 1/16/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED INGE, E1122 TYPE 2 DIABETES PROFESSIONAL $0.00 $27.00 FEMALE SUBSCRIBER 1050 HET, RBC, WBC AND PLATELET COUNT) MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL CHRONIC KIDNEY DISEASE 1/18/2017 11/23/2016 1/16/2017 85610 PROTHRDMBIN TIME; E1122 TYPE 2 DIABETES PROFESSIONAL $0.00 $18.00 FEMALE SUBSCRIBER 1 RISE, MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL CHRONIC KIDNEY DISEASE 1/18/2017 11/23/2016 1/16/2017 85730 THR0MB0PLASTIN TIME, PARTIAL(PTT); PLASMA OR E1122 TYPE 2 DIABETES PROFESSIONAL $0.00 $21.00 FEMALE SUBSCRIBER 1050 WHOLE BLOOD MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL CHRONIC KIDNEY DISEASE 1/20/2017 12/11/2016 1/19/2017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, 1132 HYPERTENSIVE HEART PROFESSIONAL $0.00 $39.00 FEMALE SUBSCRIBER 1 050 FRONTAL AND CHRONIC KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/20/2017 12/15/2016 1/19/2017 71275 COMPUTED TDMDGRAPHIC ANGIDGRAPHY, CHEST 12699 OTHER PULMONARY PROFESSIONAL $123.57 $423.00 FEMALE SUBSCRIBER 1050 (NONCORONARY), WITH CONTRAST MATERIAL(S), EMBOLISM WITHOUT INPATIENT /HOSPITAL INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND ACUTE COR PULMONALE IMAG E POSTPRDCESSING 1/20/2017 12/15/2016 1/19/2017 73630 RADIOLDGIC EXAMINATION, FOOT; COMPLETE, M79671 PAIN IN RIGHT FOOT PROFESSIONAL $11.50 $37.00 FEMALE SUBSCRIBER 1 050 MINIMUM OF THREE VIEWS INPATIENT / HDSPITAL 1/20/2017 12/21/2016 1/19/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT R200 ANESTHESIA OF SKIN PROFESSIONAL $58.41 $183.00 FEMALE SUBSCRIBER 1050 CONTRAST MATERIAL INPATIENT /HOSPITAL 1/21/2017 10/10/2016 10/13/2016- - N186 ENO STAGE RENAL HOSPITAL OUTPATIENT ($3,2 =396) $8,192.45 FEMALE SUBSCRIBER 1050 DISEASE 1/23/2017 12/11/2016 1/20/2017 80069 RENAL FUNCTION PANELTHIS PANEL MUST INCLUDE THE 1132 HYPERTENSIVE HEART PROFESSIONAL $CAD $29.00 FEMALE SUBSCRIBER 1 EGO FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), AND CHRONIC KIDNEY INPATIENT /HOSPITAL CARBON DIOXIDE (BICARB0NATE)(92374), CHLORIDE DISEASE WITH HEART ( 82435), CREATININE(82565), GLUCOSE (82947), FAILURE AND WITH STAGE PHOSPHORUS INORGANIC (PH0SPHATE)(84100), SCHRONIC KIDNEY POTASSIUM (94132), SODIUM (84295), UREA NITROGEN DISEASE, OR END STAGE (BU RENAL DISEASE 112312017 12/11/2016 112012017 83036 HEMOGLOBIN; GLYC0SYLATED(A1C) 1132 HYPERTENSIVE HEART PROFESSIONAL $0.00 $24.00 FEMALE SUBSCRIBER 1 OSO AND CHRONIC KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC (KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/11/2016 112012017 83880 NATRIURETIC PEPTIDE 1132 HYPERTENSIVE HEART PROFESSIONAL $0.00 $22.00 FEMALE SUBSCRIBER 1 EGO AND CHRONIC (KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/11/2016 1/20/2017 84484 TROPONIN, QUANTITATIVE 1132 HYPERTENSIVE HEART PROFESSIONAL $C.OD $64.00 FEMALE SUBSCRIBER 1 EGO AND CHRONIC KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/11/2016 112012017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, 1132 HYPERTENSIVE HEART PROFESSIONAL HCT, RISC, WBC AND PLATELET COUNT) AND AUTOMATED AND CHRONIC KIDNEY INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/11/2016 112012017 85610 PROTHROMBIN TIME; 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HDSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/11/2016 112012017 85730 THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR 1132 HYPERTENSIVE HEART PROFESSIONAL WHOLE BLOOD AND CHRONIC KIDNEY INPATIENT/HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/12/2016 112012017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST 1132 HYPERTENSIVE HEART PROFESSIONAL INCLUDE THE FOLLOWING ALBUMIN (82040), BILIRUBIN, AND CHRONIC KIDNEY INPATIENT /HDSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DISEASE WITH HEART DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), FAILURE AND WITH STAGE CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, 5CHRONIC KIDNEY ALKALINE (84075), POTASSIUM (84132), PROTEIN, DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/12/2016 1/20/2017 83735 MAGNESIUM 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/12/2016 112012017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT/HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/12/2016 1/2012017 84484 TROPONIN, QUANTITATIVE 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HDSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE $0.00 $11.00 FEMALE SUBSCRIBER 1050 $0.00 $10.00 FEMALE SUBSCRIBER 1050 $0.00 $10.00 FEMALE SUBSCRIBER 1050 $0.00 $32.00 FEMALE SUBSCRIBER 1050 $0.00 $10.00 FEMALE SUBSCRIBER 1050 $0.00 $17.00 FEMALE SUBSCRIBER 1050 $0.00 $32.00 FEMALE SUBSCRIBER 1050 C.7.f 3559 ®' WE mm ®' WE ®' 1/23/2017 12/12/2016 112012017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, 1132 HYPERTENSIVE HEART PROFESSIONAL HCT, RISC, WBC AND PLATELET COUNT) AND AUTOMATED AND CHRONIC KIDNEY INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/12/2016 112012017 87340 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME 1132 HYPERTENSIVE HEART PROFESSIONAL IMMUNOASSAY TECHNIQUE, QUALITATIVE OR AND CHRONIC KIDNEY INPATIENT /HDSPITAL SEMIQUANTITATIVE, MULTIPLE -STEP METHOD; HEPATITIS DISEASE WITH HEART B SURFACE ANTIGEN (HBSAG) FAILURE AND WITH STAGE S CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/13/2016 112012017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL 1132 HYPERTENSIVE HEART PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL AND CHRONIC KIDNEY INPATIENT/HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) DISEASE WITH HEART CREATININE(82565) GLUCOSE (82947) POTASSIUM FAILURE AND WITH STAGE (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 5CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/13/2016 112012017 83735 MAGNESIUM 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HDSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/13/2016 1/20/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/13/2016 112012017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, 1132 HYPERTENSIVE HEART PROFESSIONAL HCT, RISC, WBC AND PLATELET COUNT) AND AUTOMATED AND CHRONIC KIDNEY INPATIENT/HOSPITAL DIFFERENTIAL W BC COUNT DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/15/2016 1/2012017 87070 CULTURE, BACTERIAL, ANY OTHER SOURCE EXCEPT URINE, 1132 HYPERTENSIVE HEART PROFESSIONAL BLOOD DR STOOL, AEROBIC, WITH ISOLATION AND AND CHRONIC KIDNEY INPATIENT /HDSPITAL PRESUMPTIVE IDENTIFICATION OF ISOLATES DISEASE WITH HEART FAILURE AND WITH STAGE S CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE $0.00 $11.00 FEMALE SUBSCRIBER 1050 $0.00 $24.00 FEMALE SUBSCRIBER 1050 $0.00 $26.00 FEMALE SUBSCRIBER 1050 $0.00 $10.00 FEMALE SUBSCRIBER 1050 $0.00 $17.00 FEMALE SUBSCRIBER 1050 $0.00 $11.00 FEMALE SUBSCRIBER 1050 $0.00 $23.00 FEMALE SUBSCRIBER 1050 C.7.f 3559 ®' WE mm ®' WE ®' 1/23/2017 12/15/2016 112012017 87077 CULTURE, BACTERIAL; AEROB I C ISOLATE, ADDITIONAL 1132 HYPERTENSIVE HEART PROFESSIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFI CATION, AND CHRONIC KIDNEY INPATIENT /HOSPITAL EACH ISOLATE DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/15/2016 112012017 87186 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; 1132 HYPERTENSIVE HEART PROFESSIONAL MICRODILUTION OR AGAR DILUTION (MINIMUM AND CHRONIC KIDNEY INPATIENT /HDSPITAL INHIBITORY CONCENTRATION AMICA" ORBREAKPOINT), DISEASE WITH HEART EACH MULTI - ANTIMICROBIAL, PER PLATE FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/15/2016 112012017 87205 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM 1132 HYPERTENSIVE HEART PROFESSIONAL OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELLTYPES AND CHRONIC KIDNEY INPATIENT/HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/16/2016 112012017 86920 COM PATI BILITY TEST EACH UNIT; IMMEDIATE SPIN 1132 HYPERTENSIVE HEART PROFESSIONAL TECHNIQUE AND CHRONIC KIDNEY INPATIENT /HDSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/16/2016 1/20/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL 1132 HYPERTENSIVE HEART PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL AND CHRONIC KIDNEY INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) DISEASE WITH HEART CREATININE(82565) GLUCOSE (82947) POTASSIUM FAILURE AND WITH STAGE (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 5CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/16/2016 112012017 82306 CALCIFEDIOL (25- OH VITAMIN D -3) 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT/HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/16/2016 1/2012017 82728 FERRITIN 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HDSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE $0.00 $23.00 FEMALE SUBSCRIBER 1050 $0.00 $18.00 FEMALE SUBSCRIBER 1050 $0.00 $24.00 FEMALE SUBSCRIBER 1 PSG $0.00 $50.00 FEMALE SUBSCRIBER 1050 $0.00 $26.00 FEMALE SUBSCRIBER 1050 $0.00 $24.00 FEMALE SUBSCRIBER 1050 $0.00 $18.00 FEMALE SUBSCRIBER 1050 C.7.f 3559 ®' WE mm ®' WE ®' 1/23/2017 12/16/2016 112012017 83540 IRON 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/16/2016 112012017 83550 IRON BINDING CAPACITY 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HDSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/16/2016 112012017 83735 MAGNESIUM 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT/HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/16/2016 112012017 83970 PARATHORMONE)PARATHYROID HORMONE) 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HDSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/16/2016 1/20/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/16/2016 112012017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, 1132 HYPERTENSIVE HEART PROFESSIONAL HCT,RBC,WBC AND PLATELET COUNT) AND AUTOMATED AND CHRONIC KIDNEY INPATIENT/HOSPITAL DIFFERENTIAL W BC COUNT DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/16/2016 1/2012017 86850 ANTI BO DY SC RE EN, REG, EAC H SE RU M TECH N I QU E 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HDSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE $0.00 $11.00 FEMALE SUBSCRIBER 1050 $0.00 $13.00 FEMALE SUBSCRIBER 1050 $0.00 $10.00 FEMALE SUBSCRIBER 1 PSG $0.00 $24.00 FEMALE SUBSCRIBER 1050 $0.00 $17.00 FEMALE SUBSCRIBER 1050 $0.00 $11.00 FEMALE SUBSCRIBER 1050 $0.00 $19.00 FEMALE SUBSCRIBER 1050 C.7.f 3559 ®' WE mm ®' WE ®' 1/23/2017 12/16/2016 112012017 86900 BLOOD TYPING, SEROLOGIC; ADO 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/16/2016 112012017 86901 BLOOD TYPING, SEROLOGIC; RH(D( 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HDSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/17/2016 112012017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE 1132 HYPERTENSIVE HEART PROFESSIONAL FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), AND CHRONIC KIDNEY INPATIENT/HOSPITAL CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE D15EASE WITH HEART (82435), CREATININE (82565), GLUCOSE (82947), FAILURE AND WITH STAGE PHOSPHORUS INORGANIC (PHOSPHATE) (84100), 5CHRONIC KIDNEY POTASSIUM (84132), SODIUM (84295), UREA NITROGEN DISEASE, OR END STAGE (BU RENAL DISEASE 1/23/2017 12/17/2016 112012017 82607 CYANOCOBALAMIN (VITAMIN B -12); 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HDSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/17/2016 1/20/2017 82746 FOLIC ACID; SERUM 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/17/2016 112012017 83735 MAGNESIUM 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT/HOSPITAL D15EASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/17/2016 1/2012017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, 1132 HYPERTENSIVE HEART PROFESSIONAL HUT, RBC,WBC AND PLATELET COUNT) AND AUTOMATED AND CHRONIC KIDNEY INPATIENT /HDSPITAL DIFFERENTIAL W BC COUNT DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE $0.00 $23.00 FEMALE SUBSCRIBER 1050 $0.00 $11.00 FEMALE SUBSCRIBER 1050 $0.00 $29.00 FEMALE SUBSCRIBER 1 PSG $0.00 $23.00 FEMALE SUBSCRIBER 1050 $0.00 $24.00 FEMALE SUBSCRIBER 1050 $0.00 $10.00 FEMALE SUBSCRIBER 1050 $0.00 $11.00 FEMALE SUBSCRIBER 1050 C.7.f 3559 ®' WE mm ®' WE ®' 1/23/2017 12/22/2016 112012017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL 1132 HYPERTENSIVE HEART PROFESSIONAL $767.25 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL SUBSCRIBER AND CHRONIC KIDNEY INPATIENT /HOSPITAL $380.00 FEMALE (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) 1050 DISEASE WITH HEART $215.00 FEMALE SUBSCRIBER CREATININE(82565) GLUCOSE (82947) POTASSIUM FAILURE AND WITH STAGE (84132) SODIUM (84295) UREA NITROGEN (BUN)(84520) 5CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/22/2016 112012017 83735 MAGNESIUM 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT /HDSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/22/2016 112012017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY INPATIENT/HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/23/2017 12/22/2016 112012017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (TEE, 1132 HYPERTENSIVE HEART PROFESSIONAL HCT, RISC, WBC AND PLATELET COUNT) AND AUTOMATED AND CHRONIC KIDNEY INPATIENT /HDSPITAL DIFFERENTIAL WEE COUNT DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 1/30/2017 1/5/2017 1/10/2017 92134 Scanning computerized ophthalmic diagnostic imaging, E113591 TYPE 2 DIABETES PROFESSIONAL OFFICE pOSterior segment, with interpretation and report, MELLITUS WITH unilateral or bilateral; retina PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE 1/30/2017 1/7/2017 1/11/2017- - N196 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 1/30/2017 1/14/2017 1/17/2017- - N186 ENO STAGE RENAL HOSPITAL OUTPATIENT DISEASE 1/30/2017 1/16/2017 1/17/2017 93880 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE E119 TYPE 20IABETES PROFESSIONAL OFFICE BILATERAL STUDY MELLITUS WITHOUT COMPLICATIONS 1/30/2017 1/16/2017 1/17/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E119 TYPE 2 DIABETES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MELLITUS WITHOUT PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPLICATIONS COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 1/30/2017 1/17/2017 1/24/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE N186 END STAGE RENAL OTHER MEDICAL THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL DISEASE (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (94075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) 1/30/2017 1/17/2017 1/24/2017 83615 LACTATE DEHYDRDGENASE (ED), (LDH); N186 ENO STAGE RENAL OTHER MEDICAL DISEASE $0.00 $26.00 FEMALE SUBSCRIBER 1050 $0.00 $10.00 FEMALE SUBSCRIBER 1050 $0.00 $17.00 FEMALE SUBSCRIBER 1050 $0.00 $11.00 FEMALE SUBSCRIBER 1050 $0.00 $116.00 FEMALE SUBSCRIBER 1050 $49939 $19,055.95 FEMALE SUBSCRIBER 1050 $767.25 $16,046.15 FEMALE SUBSCRIBER 1050 $217.62 $380.00 FEMALE SUBSCRIBER 1050 $97.22 $215.00 FEMALE SUBSCRIBER 1050 $11.21 $153,05 FEMALE SUBSCRIBER 1050 $8.28 $88.21 FEMALE SUBSCRIBER 1050 C.7.f 1/30/2017 1/17/2017 112412017 84450 TRANSFE RASE; ASPARTATE AM IND (AST) (SGOT) N186 END STAGE RENAL OTHER MEDICAL $0.00 $75.66 FEMALE SUBSCRIBER 1050 3559 DISEASE W 1/30/2017 1/17/2017 1/24/2017 84460 TRANSFERASE; ALANINE AMINO (ALT) (SGPT) N186 END STAGE RENAL OTHER MEDICAL $0.00 $77.39 FEMALE SUBSCRIBER 1050 3559 C! DISEASE N 1/30/2017 1/17/2017 1/24/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED N186 END STAGE RENAL OTHER MEDICAL $6.14 $65.34 FEMALE SUBSCRIBER 1 050 3559 m DISEASE CIR 1/30/2017 111812017 1/24/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE E118 TYPE 2 DIABETES PROFESSIONAL OFFICE $58.13 $275.90 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED MELLITUS WITH PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY UNSPECIFIED 7 COMPONENTS: A DETAILED HISTORY; A DETAILED COMPLICATIONS "a EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER W 1/31/2017 12/29/2016 1/30/2017 94761 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN R0600 DYSPNEA, UNSPECIFIED PROFESSIONAL $3.66 $50.00 FEMALE SUBSCRIBER 1050 } 3559 SATURATION; MULTIPLE DETERMINATIONS(EG, INPATIENT /HOSPITAL CL DURING EXERCISE) Q, 2/1/2017 1/21/2017 1/25/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT $767.25 $18,952.55 FEMALE SUBSCRIBER 1050 3559 DISEASE v 2/1/2017 1/24/2017 1/30/2017 73620 RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS L97512 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE $1647 $89.00 FEMALE SUBSCRIBER 1050 3559 ULCER OF OTHER PART OF RIGHT FOOT WITH FAT LAYER EXPOSED F W 2/1/2017 1/24/2017 1/30/2017 97597 DEBRIDEMENT IEG, HIGH PRESSURE WATERIET L97512 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE $18.31 $150.00 FEMALE SUBSCRIBER 1 ESE) 3559 F WITH /WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENTWITH SCISSORS, SCALPELAND FORCEPS), ULCER OF OTHER PART OF RIGHT FOOT WITH FAT OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS LAYER EXPOSED AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING F TOPICAL APPLICATION(S), O 2/9/2017 12/11/2016 1/11/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1214 NON ST ELEVATION OTHER MEDICAL $243.93 $776.16 FEMALE SUBSCRIBER 1 050 3559 a. AND MANAGEMENT OF A PATIENT, WHICH REQUIRES (NSTEMI) MYOCARDIAL uj THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; INFARCTION A COMPREHENSIVE EXAMINATION; AND MEDICAL UJ DECISION MAKING OF HIGH COMPLEXITY. COUNSELING cn AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN LLJ 2/9/2017 12/11/2016 1/11/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1214 NON ST ELEVATION OTHER MEDICAL $0.00 ($776.166) FEMALE SUBSCRIBER 1 050 n 3559 °✓ AND MANAGEMENT OF A PATIENT, WHICH REQUIRES (NSTEMI) MYOCARDIAL THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; INFARCTION J A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING v AND /OR COORDINATION OF CARE WITH OTHER F PROVIDERS OR AGEN W 2/9/2017 12/12/2016 1/11/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON AT ELEVATION OTHER MEDICAL $85.95 $273.46 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMI) MYOCARDIAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN Q EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR CNj N 2/9/2017 12/12/2016 1/11/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON AT ELEVATION OTHER MEDICAL ($85.911 (5273,46) FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMI) MYOCARDIAL = REQU I R ES AT LEAST 20 F TH ESE 3 KEY COM PO N E NTS: AN INFARCTION y EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR �, 2/10/2017 1/31/2017 2/2/2017 90960 END -STAGE RENAL DISEASE(ESRD) RELATED SERVICES N186 END STAGE RENAL PROFESSIONAL $384,37 FEMALE SUBSCRIBER MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; 3559 DISEASE OUTPATIENT /HOSPITAL 1050 WITH 4 O MORE FACE -TO -FACE PHYSICIAN VISITS PER $11.20 $36.00 FEMALE SUBSCRIBER Q $61.63 MONTH 1050 3559 2/10/2017 11/28/2016 11/30/2016 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E113591 TYPE 2 DIABETES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MELLITUS WITH PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY PROLIFERATIVE DIABETIC F COMPONENTS: AN EXPANDED PROBLEM FOCUSED RETINOPATHY WITHOUT W HISTORY; AN EXPANDED PROBLEM FOCUSED MACULAR EDEMA, RIGHT K $61.63 EXAMINATION; MEDICAL DECISION MAKING OF LOW 1050 EYE $61.63 COMPLEXITY. COUNSELING AND COORD 1050 3559 _ 2/13/2017 2/2/2017 2/7/2017 97597 DEBRIDEMENT(EG, HIGH PRESSURE WATERIET L97511 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE WITH /WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF DEBRIDEMENT WITH SCISSORS, SCALPELAND FORCEPS), RICHT FOOT LIMITED TO O OPEN WOUND,(EG, FIBRIN, DEVITALIZED EPIDERMIS BREAKDOWN OF SKIN IL AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING W $3,500.00 TOPICAL APPLICATION(S), 1050 3559 2/13/2017 12/22/2016 211012017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN 1120 HYPERTENSIVE CHRONIC PROFESSIONAL $4,224.00 EVALUATION 1050 KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGE 5 CHRONIC KIDNEY $18.31 $150.00 FEMALE SUBSCRIBER 1050 DISEASE OR ENO STAGE J RENAL DISEASE 2/13/2017 12/23/2016 2/10/2017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN N186 ENO STAGE RENAL PROFESSIONAL EVALUATION DISEASE INPATIENT /HOSPITAL 2/13/2017 12/24/2016 2/10/2017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN 1120 HYPERTENSIVE CHRONIC PROFESSIONAL EVALUATION KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE 2/14/2017 12/11/2016 1111/2017 A0431 AMBULANCE SERVICE , CONVENTIONAL AIR SERVICES, N179 ACUTE KIDNEY FAILURE, OTHER MEDICAL TRANSPORT, ONE WAY (ROTARY WING) UNSPECIFIED 2/14/2017 12/11/2016 111112017 A0436 ROTARYWINGAIR MILEAGE, PERSFATUTE MILE N179 ACUTE KIDNEY FAILURE, OTHER MEDICAL UNSPECIFIED 2/16/2017 1/26/2017 21112017 97597 DEBRIDEMENT(EG, HIGH PRESSURE WATERIET L97512 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE W ITH/WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), RIGHT FOOT WITH FAT OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS LAYER EXPOSED AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), 2/20/2017 2/10/2017 2/13/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H401133 PRIMARY OPEN -ANGLE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED GLAUCOMA, BILATERAL, PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY SEVERE STAGE COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 2/21/2017 12/11/2016 2/20/2017 A0425 GROUND MILEAGE, PER STATUTE MILE R079 CHEST PAIN, UNSPECIFIED OTHER MEDICAL 2/21/2017 12/11/2016 2/20/2017 A0427 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, R079 CHEST PAIN, UNSPECIFIED OTHERMEDICAL EMERGENCY TRANSPORT, LEVEL 1 (ALS1- EMERGENCY) 212712017 2/13/2017 212112017 2/27/2017 2/13/2017 212212017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 1509 HEART FAILURE, PROFESSIONAL FRONTAL UNSPECIFIED OUTPATIENT /HOSPITAL C.7.f $269.18 $753.00 FEMALE SUBSCRIBER 1 050 3559 P j$371.84j $110.00 FEMALE SUBSCRIBER 1 050 3559 Q! i ' $1831 $150.00 FEMALE SUBSCRIBER 1050 3559 fl } fl $48.74 $150.00 FEMALE SUBSCRIBER 1 OSO 3559 $730 $7.50 FEMALE SUBSCRIBER 1050 3559 CL $384,37 FEMALE SUBSCRIBER 1 050 3559 $235.06 CL 1050 3559 $11.20 $36.00 FEMALE SUBSCRIBER Q $61.63 $156.50 FEMALE SUBSCRIBER 1050 3559 Q, F W K $61.63 $156.50 FEMALE SUBSCRIBER 1050 3559 $61.63 $156.50 FEMALE SUBSCRIBER 1050 3559 _ O IL W $3,500.00 $12,000.00 FEMALE SUBSCRIBER 1050 3559 G� $4,224.00 $13,200.00 FEMALE SUBSCRIBER 1050 3559 $18.31 $150.00 FEMALE SUBSCRIBER 1050 3559 J $48.74 $150.00 FEMALE SUBSCRIBER 1 OSO 3559 $730 $7.50 FEMALE SUBSCRIBER 1050 3559 $384.37 $384,37 FEMALE SUBSCRIBER 1 050 3559 $235.06 $1,481.00 FEMALE SUBSCRIBER 1050 3559 $11.20 $36.00 FEMALE SUBSCRIBER 1050 3559 C.7.f 2/27/2017 2/16/2017 2/23/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, R0602 SHORTNESS OF BREATH PROFESSIONAL $13.23 $42.00 FEMALE SUBSCRIBER 1050 3559 FRONTAL AND LATERAL; OUTPATIENT /HOSPITAL Z 2/28/2017 12/13/2016 2/27/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON -ST ELEVATION PROFESSIONAL $83.14 $273.46 FEMALE SUBSCRIBER 1050 3559 N EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMI] MYOCARDIAL INPATIENT /HOSPITAL m REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN INFARCTION 4D EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITV. 7 COUNSELING AND /OR "a 2/28/2017 12/14/2016 2/27/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON -ST ELEVATION PROFESSIONAL $83.14 $273.46 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMIH MYOCARDIAL INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN INFARCTION } EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL E. CL DECISION MAKING OF MODERATE COMPLEXITY. Q, COUNSELING AND /OR 2/28/2017 12/15/2016 2/27/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON ST ELEVATION PROFESSIONAL $83.14 $273.46 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMID MYOCARDIAL INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL h DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 2/28/2017 12/16/2016 2/27/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON -ST ELEVATION PROFESSIONAL $83.14 $273.46 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMI] MYOCARDIAL INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN U' EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL Q DECISION MAKING OF MODERATE COMPLEXITY. NJ COUNSELING AND /OR 212812017 12/17/2016 2/27/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON ST ELEVATION PROFESSIONAL $83.14 $273.46 FEMALE SUBSCRIBER 1OSO 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMID MYOCARDIAL INPATIENT /HOSPITAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN LLJ EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. � w• COUNSELING AND /OR J 2/28/2017 12/18/2016 2/27/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON -ST ELEVATION PROFESSIONAL $83.14 $273.46 FEMALE SUBSCRIBER 1050 3559 v EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL r REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN INFARCTION Z EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN LLJ EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR (' 2/28/2017 12/19/2016 2/27/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON -ST ELEVATION PROFESSIONAL $83.14 $273.46 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (NSTEMIH MYOCARDIAL INPATIENT /HOSPITAL Q < REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL N DECISION MAKING OF MODERATE COMPLEXITY. _ COUNSELING AND /OR �j 2/28/2017 12/20/2016 2/27/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON -ST ELEVATION PROFESSIONAL SUBSCRIBER 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH $20,667.60 FEMALE (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL $3,286.97 $4,382.62 FEMALE REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENT&AN 1050 INFARCHON $13,594.55 FEMALE SUBSCRIBER 1050 EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN $36.00 FEMALE SUBSCRIBER 1050 EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 3/3/2017 2/16/2017 2/23/2017 97597 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET L97511 NON- PRESSURE CHRONIC PROFESSIONAL OFFICE WITH /WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), RIGHT FOOT LIMITED TO OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS BREAKDOWN OF SKIN AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), 3/6/2017 2/20/2017 212812017 315001NTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE 1132 HYPERTENSIVE HEART PROFESSIONAL AND CHRONIC KIDNEY OUTPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 3/6/2017 2/20/2017 2/28/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1132 HYPERTENSIVE HEART PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY AND CHRONIC (KIDNEY OUTPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 3/6/2017 2/20/2017 2/28/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 1132 HYPERTENSIVE HEART PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AND CHRONIC KIDNEY OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS DISEASE WITH HEART IMPOSED BY THE URGENCY OF THE PATIENTS CLINICAL FAILURE AND WITH STAGE CONDITION AND/OR MENTAL STATUS: ACOMPREHENSIVE SCHRONICKIDNEY HISTORY; A COMPREHENSIVE EXAMINATION; AND DISEASE, OR END STAGE MEDICAL DECIS RENAL DISEASE 3/8/2017 2/13/2017 3/3/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1132 HYPERTENSIVE HEART PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY AND CHRONIC (KIDNEY OUTPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 3/13/2017 2/6/2017 2/10/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 3/13/2017 2/13/2017 2117/2017 3/13/2017 2/13/2017 2/21/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 3/13/2017 2/16/2017 2/21/2017 - - 1517 CARDIOMEGALY HOSPITAL OUTPATIENT 3/13/2017 2/17/2017 2/23/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 3/13/2017 2/20/2017 3/7/2017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, Z4682 ENCOUNTER FOR FITTING PROFESSIONAL FRONTAL AND ADJUSTMENT OF INPATIENT /HOSPITAL NON - VASCULAR CATHETER $83.14 $273.46 FEMALE SUBSCRIBER 1050 $18.31 $150.00 FEMALE SUBSCRIBER 1050 $199.92 $971.00 FEMALE SUBSCRIBER 1050 $11.08 $69.00 FEMALE SUBSCRIBER 1050 $235.06 $1,481.00 FEMALE SUBSCRIBER 1050 $11.07 $70.00 FEMALE SUBSCRIBER 1050 $767.25 $20,667.60 FEMALE SUBSCRIBER 1050 $3,125.18 $4,466.91 FEMALE SUBSCRIBER 1050 $767.25 $20,667.60 FEMALE SUBSCRIBER 1050 $3,286.97 $4,382.62 FEMALE SUBSCRIBER 1050 $511.50 $13,594.55 FEMALE SUBSCRIBER 1050 $0.00 $36.00 FEMALE SUBSCRIBER 1050 C.7.f 3559 ®' im 9m ME III I C.7.f 3/13/2017 2/20/2017 3/7/2017 76700 ULTRASOUND, ABDOM I NAL, REAL TIME WITH IMAGE Z4682 ENCOUNTER FOR FITTING PROFESSIONAL $65.70 $158.00 FEMALE SUBSCRIBER 1050 3559 DOCUMENTATION; COMPLETE AND ADJUSTMENT OF INPATIENT /HOSPITAL NON- VASCULAR CATHETER N 3/13/2017 2/20/2017 3/8/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE 1132 HYPERTENSIVE HEART PROFESSIONAL $0.00 $12.00 FEMALE SUBSCRIBER 1 RISC 3559 FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), AND CHRONIC (KIDNEY INPATIENT /HOSPITAL CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE DISEASE WITH HEART (82435), CREATININE (92565), GLUCOSE (82947), FAILURE AND WITH STAGE PHOSPHORUS INORGANIC (PHOSPHATE) (84100), 5CHRONIC KIDNEY } POTASSIUM (84132), SODIUM (8429S), UREA NITROGEN DISEASE, OR END STAGE "a (BU RENAL DISEASE 3/13/2017 2/20/2017 3/8/2017 80074 ACUTE HEPATITIS PANELTHIS PANEL MUST INCLUDE THE 1132 HYPERTENSIVE HEART PROFESSIONAL $0.00 $131.00 FEMALE SUBSCRIBER 1050 3559 FOLLOWING: HEPATITIS A ANTIBODY(HAAB), IGM AND CHRONIC KIDNEY INPATIENT /HOSPITAL } ANTIBODY (86709), HEPATITIS BCORE ANTIBODY (HBCAB), DISEASE WITH HEART IGM ANTIBODY (86705), HEPATITIS B SURFACE ANTIGEN FAILURE AND WITH STAGE CL (HBSAG) ( 87340), HEPATITIS C ANTIBODY (86803) SCHRONICKIDNEY Q, DISEASE, OR END STAGE RENAL DISEASE 3/13/2017 2/20/2017 3/8/2017 86705 HEPATITIS B CORE ANTIBODY(HBCAB); IGM ANTIBODY 1132 HYPERTENSIVE HEART PROFESSIONAL $0.00 $27.00 FEMALE SUBSCRIBER 1050 3559 AND CHRONIC (KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE Lij ~ 5 CHRONIC (KIDNEY DISEASE, OR END STAGE RENAL DISEASE 3/13/2017 2/20/2017 3/8/2017 86803 HEPATITIS C ANTIBODY; 1132 HYPERTENSIVE HEART PROFESSIONAL $0.00 $40.00 FEMALE SUBSCRIBER 1050 3559 AND CHRONIC (KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE IL 5 CHRONIC KIDNEY uj DISEASE, OR END STAGE RENAL DISEASE a) 3/13/2017 2121/2017 3/772017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, Z4682 ENCOUNTER FOR FITTING PROFESSIONAL $14.94 $36.00 FEMALE SUBSCRIBER 1 050 3559 0 FRONTAL ANDADIUSTMENTOF INPATIENT /HOSPITAL NON - VASCULAR lJLJ e °✓ CATHETER 3/13/2017 2/22/2017 3/7/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, Z4682 ENCOUNTER FOR FITTING PROFESSIONAL $14.94 $36.00 FEMALE SUBSCRIBER 1050 3559 FRONTAL ANDADJUSTMENTOF INPATIENT /HOSPITAL J NON- VASCULAR CATHETER v 3/13/2017 2/24/2017 3/7/2017 71020 RADIOLDGIC EXAMINATION, CHEST, TWO VIEWS, 74682 ENCOUNTER FOR FITTING PROFESSIONAL $17.64 $42.00 FEMALE SUBSCRIBER 1050 3559 FRONTAL AND LATERAL; ANDADIUSTMENTOF INPATIENT /HOSPITAL NON- VASCULAR W CATHETER 3/13/2017 2/27/2017 3/8/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE E119 TYPE DIABETES OTHER MEDICAL $1111 $153.05 FEMALE SUBSCRIBER 1 050 3559 THE FO LLOW ING! ALBUMIN (92040), BI LI RUBIN, TOTAL MELLITUS WITHOUT 0 (822471, BILIRUBIN, DIRECT (82248), PHOSPHATASE, COMPLICATIONS ALKALINE (94075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (64460), Q TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 3/13/2017 2/27/2017 3/5/2017 83036 HEMOGLOBIN; GLYCOSYLATED(AlC) E119 TYPE DIABETES OTHER MEDICAL $13.32 $141.92 FEMALE SUBSCRIBER 1 050 3559 N MELLITUS WITHOUT C COMPLICATIONS 3/13/2017 212]/201] 3/5/2017 83615 LACTATE DEHVDROGENASE (ED), (LDH); E119 TYPE DIABETES OTHER MEDICAL $828 $88.21 FEMALE SUBSCRIBER 1 OSO 3559 MELLITUS WITHOUT ._ COMPLICATIONS t^ 3/13/2017 2/27/2017 3/8/2017 84450 TRANSFE RASE; ASPARTATE AM IND(AST)(SGOT) E119 TYPE DIABETES OTHER MEDICAL $0.00 $75.66 FEMALE SUBSCRIBER 1 050 MELLITUS WITHOUT COMPLICATIONS 3/13/2017 2/27/2017 3/8/2017 84460 TRANSFERASE; ALANINE AMINO (ALT)(SGPT) E119 TYPE DIABETES OTHER MEDICAL $0.00 $77.39 FEMALE SUBSCRIBER 1 OSO MELLITUS WITHOUT COMPLICATIONS 3/13/2017 2/27/2017 3/8/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED E119 TYPE 2 DIABETES OTHER MEDICAL $6.14 $65.34 FEMALE SUBSCRIBER 1 050 MELLITUS WITHOUT COMPLICATIONS 3/13/2017 2/28/2017 3/1/2017 90961 END STAGE RENAL DISEASE)ESRD) RELATED SERVICES N196 END STAGE RENAL PROFESSIONAL $216.89 $607.00 FEMALE SUBSCRIBER 1050 MONTHLY, FOR PATIENTS 20YEARS OFAGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH 3/16/2017 1/31/2017 2/1/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT $1,023.00 $28,045.00 FEMALE SUBSCRIBER 1050 DISEASE 3/17/2017 2120/2017 3/3/2017 - - 1132 HYPERTENSIVE HEART HOSPITAL INPATIENT 2/20/2017 # #88844# $15,296.62 $93,331.30 FEMALE SUBSCRIBER 1 050 AND CHRONIC KIDNEY DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 3/17/2017 2/201 3/7/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 19690 RESPIRATORY FAILURE, PROFESSIONAL $14.94 $36.00 FEMALE SUBSCRIBER 1 OSO FRONTAL UNSPECIFIED, INPATIENT /HOSPITAL UNSPECIFIED WHETHER WITH HYPDXIA OR HYPERCAPNIA 3/20/2017 2/20/2017 3117/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 1132 HYPERTENSIVE HEART PROFESSIONAL $11.07 $70.00 FEMALE SUBSCRIBER 1050 LEADS; INTERPRETATION AND REPORT ONLY AND CHRONIC KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE S CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 3120/2017 2/21/2017 3/17/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1132 HYPERTENSIVE HEART PROFESSIONAL $11.07 $70.00 FEMALE SUBSCRIBER 1050 LEADS; INTERPRETATION AND REPORT ONLY AND CHRONIC KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC KIDNEY DISEASE, OR END STAGE RENAL DISEASE 3/20/2017 2/25/2017 3/17/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1132 HYPERTENSIVE HEART PROFESSIONAL $11.07 $70.00 FEMALE SUBSCRIBER 1050 LEADS; INTERPRETATION AND REPORT ONLY AND CHRONIC (KIDNEY INPATIENT /HOSPITAL DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC (KIDNEY DISEASE, OR END STAGE RENAL DISEASE 3/23/2017 2/27/2017 3122/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT $341.00 $7,681.75 FEMALE SUBSCRIBER 1050 DISEASE 3/23/2017 12/11/2016 3/22/2017 99291 CRITICAL C ARE, EVALUATION AND MANAGEMENT OF THE 1214 NON -ST ELEVATION PROFESSIONAL $476.09 $2,844.00 FEMALE SUBSCRIBER 1050 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- (NSTEMI) MYOCARDIAL OUTPATIENT /HOSPITAL 74 MIN UTES INFARCTION 3/29/2017 3/20/2017 3/28/2017 ..... 3/20/2017 ######## $0.00 $32,326.94 FEMALE SUBSCRIBER ROl 0 150 3/30/2017 2/20/2017 3/28/2017 A0422 AMBULANCE)ALS OR BLS) OXYGEN AND OXYGEN R079 CHEST PAIN, UNSPECIFIED OTHER MEDICAL $0.00 $100.00 FEMALE SUBSCRIBER 1050 SUPPLIES, LIFE SUSTAINING SITUATION 3/30/2017 2/20/2017 3/28/2017 A0425 GROUND MILEAGE, PER STATUTE MILE 8079 CHEST PAIN, UNSPECIFIED OTHER MEDICAL $25.00 $36.25 FEMALE SUBSCRIBER 1050 3/30/2017 2/20/2017 3/28/2017 A0427 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, R079 CHEST PAIN, UNSPECIFIED OTHER MEDICAL EMERGENCY TRANSPORT, LEVEL 1 (AL51- EMERGENCY) 3/31/2017 3/20/2017 3/30/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1120 HYPERTENSIVE CHRONIC PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE 3/31/2017 3/22/2017 3130/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 1120 HYPERTENSIVE CHRONIC PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE 4/4/2017 3/23/2017 4/3/2017 36589 REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, Z452 ENCOUNTER FOR PROFESSIONAL OFFICE WITHOUT SUBCUTANEOUS PORT OR PUMP ADJUSTMENT AND MANAGEMENT OF VASCULAR ACCESS DEVICE 4/4/2017 3/23/2017 4/3/2017 37248 Transluminal balloon angioplasty (except dialysis circuit), Z452 ENCOUNTER FOR PROFESSIONAL OFFICE Open or percutaneous, Including all maging and ADJUSTMENT AND radiological supervision and interpretation MANAGEMENT OF VASCULAR ACCESS DEVICE 4/4/2017 3/23/2017 4/3/2017 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS Z452 ENCOUNTER FOR PROFESSIONAL OFFICE DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR ADJUSTMENT AND COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC MANAGEMENT OF GUIDANCE FOR VASCULAR ACCESS AND CATHETER VASCULAR ACCESS DEVICE MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE DR CATHETER WITH RELATED VENOGRAPHYR 4/4/2017 3/23/2017 4/3/2017 Q9967 LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG /ML Z452 ENCOUNTER FOR PROFESSIONAL OFFICE IODINE CONCENTRATION, PER ML ADJUSTMENT AND MANAGEMENT OF VASCULAR ACCESS DEVICE 4/6/2017 3120/2017 4/4/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R072 PRECORDIAL PAIN PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 4/6/2017 3/20/2017 4/4/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R072 PRECORDIAL PAIN PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTALSTATUS ACOMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 4/7/2017 3/31/2017 4/5/2017 90961 END -STAGE RENAL DISEASE(ESRD) RELATED SERVICES N186 END STAGE RENAL PROFESSIONAL MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH 4/10/2017 3/20/2017 4/6/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 1120 HYPERTENSIVE CHRONIC PROFESSIONAL FRONTAL 4ND LATERAL; KIDNEY DISEASE WITH OUTPATIENT /HOSPITAL STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE $402.94 $750.00 FEMALE SUBSCRIBER 1050 $0.00 $95.00 FEMALE SUBSCRIBER R01 OSO $0.00 $95.00 FEMALE SUBSCRIBER R01 OSO $90.38 $471.00 FEMALE SUBSCRIBER R01 OSO $1,527.07 $4,005.00 FEMALE SUBSCRIBER R01 OSO $106.58 $225.00 FEMALE SUBSCRIBER R01 OSO $630 $100.00 FEMALE SUBSCRIBER R01 OSO $0.00 $108.00 FEMALE SUBSCRIBER R01 OSO $376.94 $2,208.00 FEMALE SUBSCRIBER R01 OSO $289.19 $607.00 FEMALE SUBSCRIBER R01 OSO $1430 $47.00 FEMALE SUBSCRIBER POP OSO 4/10/2017 3/20/2017 4/6/2017 71275 COMPUTED TOM OG RAP HIC ANG I OG RAP HY, CHEST 1120 HYPERTENSIVE CHRONIC PROFESSIONAL $1,026.00 $21,752.40 FEMALE SUBSCRIBER R01 050 (NONCORONARY), WITH CONTRAST MATERIAL(S), $140.00 FEMALE SUBSCRIBER ROE EGO KIDNEY DISEASE WITH OUTPATIENT /HOSPITAL INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND STAGE S CHRONIC (KIDNEY IMAGE POSTPROCESSING DISEASE OR END STAGE RENAL DISEASE 4/10/2017 3/30/2017 4/6/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, R05 COUGH PROFESSIONAL FRONTAL AND LATERAL; OUTPATIENT /HOSPITAL 4/10/2017 3/30/2017 4/7/2017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, RES COUGH PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 4/12/2017 4/7/2017 4/11/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 4/13/2017 3/24/2017 4/12/2017 92014 OPHTHALMOLOCICAL SERVICES: MEDICAL EXAMINATION E113512 TYPE DIABETES PROFESSIONAL OFFICE AND EVALUATION, W ITH INITIATION OR CONTINUATION MELLITUS WITH OF DIAGNOSTIC AND TREATMENT PROGRAM; PROLIFERATIVE DIABETIC COMPREHENSIVE, ESTABLISHED PATIENT, ONE OR MORE RETINOPATHY WITH VISITS MACULAR EDEMA, LEFT EYE 4/13/2017 3/24/2017 4/12/2017 921345 canning computerized ophthalmic diagnostic imaging, E113512 TYPE 2 DIABETES PROFESSIONAL OFFICE posterior segment, with interpretation and report, MELLITUS WITH unilateral or bilateral; retina PROLIFERATIVE DIABETIC RETINOPATHY WITH MACULAR EDEMA, LEFT EYE 4/14/2017 3/20/2017 4113/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL( THIS PANEL 1120 HYPERTENSIVE CHRONIC PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL KIDNEY DISEASE WITH INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) STAGE S CHRONIC KIDNEY CREATININE(82565) GLUCOSE (82947) POTASSIUM DISEASE OR END STAGE (84132) SODIUM (84295) UREA NITROGEN (BUM) (84520) RENAL DISEASE 4/14/2017 3/20/2017 4/13/2017 84484 TROPONIN, QUANTITATIVE 1120 HYPERTENSIVE CHRONIC PROFESSIONAL KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE 4/14/2017 3/20/2017 4/13/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, 1120 HYPERTENSIVE CHRONIC PROFESSIONAL HCF,BBC, WBC AND PLATELET COUNT) AND AUTOMATED KIDNEY DISEASE WITH INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT STAGE 5 CHRONIC (KIDNEY DISEASE OR END STAGE RENAL DISEASE 4/14/2017 3/20/2017 4/13/2017 85610 PROTHROMBIN TIME; 1120 HYPERTENSIVE CHRONIC PROFE55IONAL KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE 4/14/2017 3/20/2017 4113/2017 85730 THROMBOPIASTIN TIME, PARTIAL (PTT); PLASMA OR 1120 HYPERTENSIVE CHRONIC PROFESSIONAL WHOLE BLOOD KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE $124.44 $423.00 FEMALE SUBSCRIBER R01 050 $17.64 $42.00 FEMALE SUBSCRIBER R01 0S0 $14.94 $36.00 FEMALE SUBSCRIBER R01 OSO $1,026.00 $21,752.40 FEMALE SUBSCRIBER R01 050 $104.85 $140.00 FEMALE SUBSCRIBER ROE EGO $42.85 $116.00 FEMALE SUBSCRIBER R01 OSO $0.00 $26.00 FEMALE SUBSCRIBER RO1 OSO $0.00 $32.00 FEMALE SUBSCRIBER R01 EGO $0.00 $11.00 FEMALE SUBSCRIBER R01 050 $0.00 $10.00 FEMALE SUBSCRIBER R01 OSO $0.00 $10.00 FEMALE SUBSCRIBER R01 O G, 4/14/2017 3/21/2017 4/13/2017 80053 COMP RE HE NSIVE METABOLIC PANEL THIS PANEL MUST 1120 HYPERTENSIVE CHRONIC PROFESSIONAL $10.00 FEMALE SUBSCRIBER R01 EGO $0.00 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, SUBSCRIBER R01 RED KIDNEY DISEASE WITH INPATIENT /HOSPITAL SUBSCRIBER R01 EGO $0.00 $26.00 FEMALE TOTAL (82247), CALCIUM, TOTAL (82310), CARBON $0.00 STAGE 5 CHRONIC (KIDNEY SUBSCRIBER R01 OSO $1,026.00 $23,691.35 FEMALE SUBSCRIBER R01 RED DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), $25,531.95 FEMALE DISEASE OR END STAGE $1,026.00 $25,74150 FEMALE SUBSCRIBER R01 O50 $342.00 CREATININE( 82565(, GLUCOSE (82947), PHOSPHATASE, SUBSCRIBER R01 OSO RENAL DISEASE $2,42176 FEMALE SUBSCRIBER R01 OSO $1,026.00 $24,37130 FEMALE ALKALINE (84075), POTASSIUM (84132(, PROTEIN, 4/14/2017 3/21/2017 4/13/2017 84484 TROPONIN, QUANTITATIVE 1120 HYPERTENSIVE CHRONIC PROFESSIONAL KIDNEY DISEASE WITH INPATIENT / HDSPITAL STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE 4/14/2017 3/21/2017 4/13/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, 1120 HYPERTENSIVE CHRONIC PROFESSIONAL HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED KIDNEY DISEASE WITH INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE 4/14/2017 3/21/2017 4/13/2017 85610 PROTHROMBIN TIME; 1120 HYPERTENSIVE CHRONIC PROFESSIONAL KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE 4/14/2017 3/21/2017 4/13/2017 85730 THROMBOPIASTIN TIME, PARTIAL (PTT); PLASMA OR 1120 HYPERTENSIVE CHRONIC PROFESSIONAL WHOLE BLOOD KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGE 5 CHRONIC (KIDNEY DISEASE OR END STAGE RENAL DISEASE 4/14/2017 3/21/2017 4/13/2017 87340 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME 1120 HYPERTENSIVE CHRONIC PROFESSIONAL IMMUNOASSAY TECHNIQUE, QUALITATIVE DR KIDNEY DISEASE WITH INPATIENT /HOSPITAL SEMIQUANTITATIVE ,MULTIPLE -STEP METHOD; HEPATITIS STAGE 5 CHRONIC KIDNEY B SURFACE ANTIGEN (HBSAG) DISEASE OR END STAGE RENAL DISEASE 4/14/2017 3/22/2017 4/13/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL 1120 HYPERTENSIVE CHRONIC PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL KIDNEY DISEASE WITH INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (92374) CHLORIDE (92435) STAGE 5 CHRONIC KIDNE'/ CREATININE(82565) GLUCOSE (82947) POTASSIUM DISEASE OR END STAGE (84132) SODIUM (84295) UREA NITROGEN (BUN)(84520) RENAL DISEASE 4/14/2017 3/22/2017 4/13/2017 80061 LIPID PANEL 1120 HYPERTENSIVE CHRONIC PROFESSIONAL (KIDNEY DISEASE WITH INPATIENT /HOSPITAL STAGE 5 CHRONIC KIDNEY DISEASE OR END STAGE RENAL DISEASE 4/17/2017 3/6/2017 4/13/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 4/17/2017 3/13/2017 4/13/2017- - N186 ENO STAGE RENAL HOSPITAL OUTPATIENT DISEASE 4/17/2017 3/20/2017 4/13/2017- - N196 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 4/17/2017 3/24/2017 4/13/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 4117/2017 3/30/2017 4/14/2017- - 1309 ALLERGIC RHINITIS, HOSPITAL OUTPATIENT UNSPECIFIED 4/17/2017 3131/2017 4/13/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE $0.00 $32.00 FEMALE SUBSCRIBER R01 050 $0.00 $32.00 FEMALE SUBSCRIBER R01 OSO $0.00 $11.00 FEMALE SUBSCRIBER R01 O50 $0.00 $10.00 FEMALE SUBSCRIBER R01 EGO $0.00 $10.00 FEMALE SUBSCRIBER R01 RED $0.00 $24.00 FEMALE SUBSCRIBER R01 EGO $0.00 $26.00 FEMALE SUBSCRIBER R01 OSO $0.00 $40.00 FEMALE SUBSCRIBER R01 OSO $1,026.00 $23,691.35 FEMALE SUBSCRIBER R01 RED $1,026.00 $25,531.95 FEMALE SUBSCRIBER R01 OSO $1,026.00 $25,74150 FEMALE SUBSCRIBER R01 O50 $342.00 $4,017.00 FEMALE SUBSCRIBER R01 OSO $2,423.76 $2,42176 FEMALE SUBSCRIBER R01 OSO $1,026.00 $24,37130 FEMALE SUBSCRIBER R01 OSO C.7.f 4/20/2017 3/21/2017 4/19/2017 99220 INITIAL OBSERVATION CARE, PER DAY, FORTH E R0602 SHORTNESS OF BREATH PROFESSIONAL $0.00 $711.17 FEMALE SUBSCRIBER R01 050 3559 EVALUATION AND MANAGEMENT OF PATIENT, WHICH OUTPATIENT /HOSPITAL REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE Z HISTORY; A COMPREHENSIVE EXAMINATION; AND N MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR A t 4/20/2017 3/22/2017 4/19/2017 99217 OBSERVATION CARE DISCHARGE DAY MANAGEMENT R0602 SHORTNESS OF BREATH PROFESSIONAL $0.00 $278.71 FEMALE SUBSCRIBER R01 OSO 3559 7 (THIS CODE IS TD BE UTILIZED BY THE PHYSICIAN TO OUTPATIENT /HOSPITAL REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OBSERVATION STATUS IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF OBSERVATION STATUS. TO REPORT SERVICES TO A } PATIENT DESIGNP,T N. CL 412012017 4/14/2017 4/19/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT $1,026.00 $21,632.10 FEMALE SUBSCRIBER RO1 PSG 3559 CL DISEASE 4/21/2017 3/30/2017 4/20/2017 * *' "* " "* * " " ** 111 # # $180.00 $994.00 FEMALE SUBSCRIBER RO1 OSB 3559 4/24/2017 3/20/2017 4/22/2017 80076 HEPATIC FUNCTION PANELTHIS PANEL MUST INCLUDE N186 ENO STAGE RENAL OTHER MEDICAL $11.21 $153.05 FEMALE SUBSCRIBER RO1 OSB 3559 THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL DISEASE .� (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), W TRANSFERASE, ASPARTATE AMINO (AST) (SGDT) (84450) F 4/24/2017 3/20/2017 4/22/2017 83615 LACTATE DEHVDROGENASE (ED), (LDH); N186 ENO STAGE RENAL OTHER MEDICAL $8.28 $88.21 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 4/24/2017 3/20/2017 4/22/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SCOT) N186 END STAGE RENAL OTHER MEDICAL $0.00 $75.66 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 4/24/2017 3/20/2017 4/22/2017 84460 TRANSFERASE; ALAN I NE AMINO (ALT) (SGPT) N186 ENO STAGE RENAL OTHER MEDICAL $0.00 $77.39 FEMALE SUBSCRIBER R01 OSB 3559 DISEASE IL 4/24/2017 3/20/2017 4122/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED N186 ENO STAGE RENAL OTHER MEDICAL $6.14 $65.34 FEMALE SUBSCRIBER R01 OSO 3559 {i DISEASE 4/26/2017 4/21/2017 4/25/2017- - N196 ENO STAGE RENAL HOSPITAL OUTPATIENT $1,026.00 $20,459.90 FEMALE SUBSCRIBER R01 EGO 3559 UJ DISEASE 5/1/2017 4/17/2017 4/27/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE N196 END STAGE RENAL OTHER MEDICAL $11.21 $153.05 FEMALE SUBSCRIBER R01 OSO 3559 THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL DISEASE (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, LLJ ALKALINE PROTEIN, TOTAL (84075), (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SPOT) (84450) 5/1/2017 4/17/2017 4/27/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); N186 END STAGE RENAL OTHER MEDICAL $8.28 $88.21 FEMALE SUBSCRIBER R01 050 3559 V DISEASE 5/1/2017 4/17/2017 4/27/2017 84450 TRANSFERASE; ASPARTATEAMINO(AST)(SGOT) N186 ENO STAGE RENAL OTHER MEDICAL $0.00 $75.66 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE W 5/1/2017 4/17/2017 4/27/2017 84460 TRANSFERASE; ALANINE AMINO (ALT)(SGPT) N186 ENO STAGE RENAL OTHER MEDICAL $0.00 $77.39 FEMALE SUBSCRIBER RO1 050 3559 DISEASE 5/1/2017 4/17/2017 4/27/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED N196 END STAGE RENAL OTHER MEDICAL $6.14 $65.34 FEMALE SUBSCRIBER R01 OSO 3559 (' DISEASE 5/4/2017 4/5/2017 5/2/2017 90970 END - STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL $1015 $180.00 FEMALE SUBSCRIBER R01 050 3559 DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL „p °+e FOR PATIENTS 20 YEARS OF AGE AND OLDER {hj S/4/2017 4/6/2017 5/2/2017 90970 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR N186 ENO STAGE RENAL PROFESSIONAL $1015 $20.00 FEMALE SUBSCRIBER RO1 050 3SS9 Cy DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL = FOR PATIENTS 20 YEARS OF AGE AND OLDER y E 5/4/2017 4/7/2017 5/2/2017 90970 END -STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL $10.25 $20.00 FEMALE SUBSCRIBER R01 OSO 3559 ._ DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL FOR PATIENTS 20 YEARS OF AGE AND OLDER 5/4/2017 4/8/2017 5/2/2017 90970 END -STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL SUBSCRIBER R01 050 $1015 DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; SUBSCRIBER R01 DISEASE OUTPATIENT /HOSPITAL $20.00 FEMALE SUBSCRIBER R01 050 FOR PATIENTS 20 YEARS OF AGE AND OLDER $20.00 FEMALE SUBSCRIBER R01 LSD 5/4/2017 4/9/2017 5/2/2017 90970 END STAGE RENAL DISEASE (ESRD( RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL 1 PRO DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL FOR PATIENTS 20 YEARS OF AGE AND OLDER 5/4/2017 4/10/2017 5/2/2017 90970 END -STAGE RENAL DISEASE (ESRD( RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL FOR PATIENTS 20 YEARS OF AGE AND OLDER 5/4/2017 4/11/2017 S/2/2017 90970 END STAGE RENAL DISEASE (ESRD( RELATED SERVICES FOR N186 ENO STAGE RENAL PROFESSIONAL DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL FOR PATIENTS 20 YEARS OF AGE AND OLDER 5/4/2017 4/12/2017 5/2/2017 90970 END -STAGE RENAL DISEASE (ESRD( RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL FOR PATIENTS 20 YEARS OF AGE AND OLDER 5/4/2017 4/26/2017 5/2/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 511212017 12/22/2016 5/11/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION R51 HEADACHE PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. 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COUNSELING AND /OR COORDINATION OF CARE WITH OTHER N. 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COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 6/7/2017 2/22/2017 6/6/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 15022 CHRONICSYSTOLIC PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (CONGESTIVE) HEART INPATIENT /HDSPITAL REQUIRESAT LEAST 20FTHESE 3 KEY COMPONENTS:A FAILURE PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 6/7/2017 5/30/2017 6/1/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION E1122 TYPE 2 DIABETES PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES MELLITUS WITH DIABETIC INPATIENT/HOSPITAL THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; CHRONIC KIDNEY DISEASE A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 6/7/2017 5/31/2017 6/1/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E1122 TYPE 2 DIABETES PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH MELLITUS WITH DIABETIC INPATIENT /HDSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS: AN CHRONIC KIDNEY DISEASE EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 6/7/2017 5/31/2017 6/1/2017 90961 END -STAGE RENAL DISEASE) ESRD) RELATED SERVICES N186 END STAGE RENAL PROFESSIONAL MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH 6/8/2017 5115/2017 6/5/2017- - N186 ENO STAGE RENAL HOSPITAL OUTPATIENT DISEASE 6/8/2017 5/29/2017 6/5/2017- - N196 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 6/8/2017 5/29/2017 6/6/2017 * * °'* 6/9/2017 5/30/2017 6/7/2017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, R0602 SHORTNESS OF BREATH PROFESSIONAL FRONTAL INPATIENT /HOSPITAL 6/23/2017 6/19/2017 6/21/2017 73630 RADIOLOGIC EXAMINATION, FOOT; COMPLETE, L97511 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE MINIMUM OF THREE VIEWS ULCER OF OTHER PART OF RIGHT FOOT LIMITED TO BREAKDOWN OF SKIN 6/23/2017 6/19/2017 6/21/2017 97597 DEBRIDEMENT IEG, HIGH PRESSURE WATERIET L97511 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE WITH /WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF DEBRIDEM ENT WITH SCISSORS, SCALPEL AND FORCEPS), RIGHT FOOT LIMITED TO OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS BREAKDOWN OF SKIN AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), 6/30/2017 6/19/2017 6/26/2017 80076 HEPATIC FUNCTION PANELTHIS PANEL MUST INCLUDE N186 ENO STAGE RENAL OTHER MEDICAL THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL DISEASE (82247), BILIRUBIN, DIRECT )82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SOFT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) $356.95 $652.00 FEMALE SUBSCRIBER 1050 $68.07 $128.00 FEMALE SUBSCRIBER 1050 $0.00 $286.00 FEMALE SUBSCRIBER R01 EGO $0.00 $151.00 FEMALE SUBSCRIBER R01 EGO $0.00 $607.00 FEMALE SUBSCRIBER R01 OSO $0.00 $17,754.60 FEMALE SUBSCRIBER R01 050 $0.00 $68,511.40 FEMALE SUBSCRIBER R01 OSO $0.00 $1,550.00 FEMALE SUBSCRIBER R01 OSO $14.94 $36.00 FEMALE SUBSCRIBER R01 OSO $0.00 $100.00 FEMALE SUBSCRIBER R01 OSO $0.00 $150.00 FEMALE SUBSCRIBER R01 050 $0.00 $15105 FEMALE SUBSCRIBER R01 050 C.7.f 3559 ®' WE mm ®' I I= C.7.f 6/30/2017 6/19/2017 6/26/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); N186 END STAGE RENAL OTHER MEDICAL $0.00 $88.21 FEMALE SUBSCRIBER R01 050 3559 DISEASE W 6/30/2017 6/19/2017 6/26/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) N186 ENO STAGE RENAL OTHER MEDICAL $0.00 $75.66 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE N 6/30/2017 6/19/2017 6/26/2017 84460 TRANSFERASE; ALANINE AMINO (ALT) (SGPT) N186 END STAGE RENAL OTHER MEDICAL $0.00 $77.39 FEMALE SUBSCRIBER R01 EGO 3559 m DISEASE 6/30/2017 6/19/2017 6/26/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED N196 END STAGE RENAL OTHER MEDICAL $0.00 $65.34 FEMALE SUBSCRIBER R01 OSO 3559 A DISEASE 71712017 6/30/2017 7/5/2017 90961 END -STAGE RENAL DISEASE( ESRD) RELATED SERVICES N186 END STAGE RENAL PROFESSIONAL $0.00 $607.00 FEMALE SUBSCRIBER R01 050 3559 7 MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH O 7/10/2017 3/20/2017 4/22/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); N186 ENO STAGE RENAL OTHER MEDICAL (525. &31 $88.21 FEMALE SUBSCRIBER R01 050 3559 DISEASE co 711012017 3/20/2017 5/3/2017 80076 H E PATIC F U ACTION PAN E L TH IS PAN EL M UST I N CLU DE N186 END STAGE RENAL OTHER MEDICAL $0.00 ($153,05, FEMALE SUBSCRIBER PEI ESE) 3559 0 THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL DISEASE D. CL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, CL ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SOFT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SECT) (84450) 711012017 3/20/2017 5/3/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); N196 END STAGE RENAL OTHER MEDICAL $0.00 (588.21) FEMALE SUBSCRIBER R01 050 3559 DISEASE 7/10/2017 3/20/2017 5/3/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SCOT) N186 END STAGE RENAL OTHER MEDICAL $0.00 (575, 56) FEMALE SUBSCRIBER R01 050 3559 uj DISEASE 7/10/2017 3/20/2017 5/3/2017 84460 TRANSFERASE; ALANINE AMINO (ALT) (SEPT) N186 END STAGE RENAL OTHER MEDICAL $0.00 ($77.391 FEMALE SUBSCRIBER R01 050 3559 ]/10/201] 3/20/2017 5/3/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED N186 DISEASE END STAGE RENAL OTHER MEDICAL $0.00 ($61.341 FEMALE SUBSCRIBER R01 RISE) 3559 DISEASE 7/10/2017 3/20/2017 7/7/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE N196 END STAGE RENAL OTHER MEDICAL $1111 $153.05 FEMALE SUBSCRIBER R01 DEC) 3559 THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL DISEASE U' (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, a. ALKALINE (84075), PROTEIN, TOTAL (84155), ui TRANSFERASE, ALANINE AMINO (ALT) (SOFT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SECT) (84450) (fJ � ]/10/201] 3/20/2017 7/7/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); N196 END STAGE RENAL OTHER MEDICAL $8.28 $88.21 FEMALE SUBSCRIBER R01 050 f 3559 fYY DISEASE 7/10/2017 3/20/2017 7/7/2017 84450 TRANSFERASE; ASPARTATEAMINO(AST)(SCOT) N196 END STAGE RENAL OTHER MEDICAL $0.00 $75.66 FEMALE SUBSCRIBER R01 050 3559 e LLJ DISEASE 7/10/2017 3/20/2017 7/7/2017 84460 TRANSFERASE; ALANINE AMINO (ALT) (SEPT) N186 END STAGE RENAL OTHER MEDICAL $0.00 $77.39 FEMALE SUBSCRIBER R01 OSO 3559 Q . DISEASE J ]/10/201] 3/20/2017 7/7/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED N186 ENO STAGE RENAL OTHER MEDICAL $6.14 $65.34 FEMALE SUBSCRIBER ROl OSO 3559 DISEASE V 7/10/2017 3/21/2017 5/19/2017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN N186 END STAGE RENAL PROFESSIONAL $0.00 IF 195.33) FEMALE SUBSCRIBER R01 OSO 3559 r EVALUATION DISEASE INPATIENT /HOSPITAL Z 7/10/2017 3/21/2017 5/19/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION N186 END STAGE RENAL PROFESSIONAL $0.00 ( „558,25) FEMALE SUBSCRIBER R01 OSO 3559 LLJ AND MANAGEMENT OF A PATIENT, WHICH REQUIRES DISEASE INPATIENT /HDSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL (' DECISION MAKING OF HIGH COMPLEXITY. COUNSELING Q AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN Q N 7/10/2017 3/21/2017 7/772017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN EVALUATION N186 END STAGE RENAL DISEASE PROFESSIONAL INPATIENT /HOSPITAL $63.06 $195,33 FEMALE SUBSCRIBER R01 050 3559 N 7/10/2017 3/21/2017 7/7/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FORTH EVALUATION N186 END STAGE RENAL PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES DISEASE INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGED 7/10/2017 3/23/2017 4/3/2017 37248 Transluminal balloon angioplasty (except dialysis circuit), Z452 ENCOUNTER FOR PROFESSIONAL OFFICE open or percutaneous, ncluding all maging and ADJUSTMENT AND radiological supervision and interpretation MANAGEMENT OF VASCULAR ACCESS DEVICE 7/10/2017 3/23/2017 S/3/2017 36589 REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, Z452 ENCOUNTER FOR PROFESSIONAL OFFICE WITHOUT SUBCUTANEOUS PORT OR PUMP ADJUSTMENT AND MANAGEMENT OF VASCULAR ACCESS DEVICE 7/10/2017 3/23/2017 5/3/2017 37248 Transluminal balloon angioplasty (except dialysis circuit), Z452 ENCOUNTER FOR PROFESSIONAL OFFICE open or percutaneous, 'including all imaging and ADIUSTMENTAND radiological supervision and interpretation MANAGEMENT OF VASCULAR ACCESS DEVICE 7/10/2017 3/23/2017 5/3/2017 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS Z452 ENCOUNTER FOR PROFESSIONAL OFFICE DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR ADIUSTMENTAND COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC MANAGEMENT OF GUIDANCE FOR VASCULAR ACCESS AND CATHETER VASCULAR ACCESS DEVICE MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHYR 7/10/2017 3/23/2017 5/3/2017 Q9967 LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG /ML Z452 ENCOUNTER FOR PROFESSIONAL OFFICE IODINE CONCENTRATION, PER ML ADJUSTMENT AND MANAGEMENT OF VASCULAR ACCESS DEVICE 7110/2017 3/23/2017 7/7/2017 36589 REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, Z452 ENCOUNTER FOR PROFESSIONAL OFFICE WITHOUT SUBCUTANEOUS PORT OR PUMP ADJUSTMENT AND MANAGEMENT OF VASCULAR ACCESS DEVICE 7/10/2017 3/23/2017 7/7/2017 37248 Transluminal balloon a ngioplasty (except dialysis circuit), Z452 ENCOUNTER FOR PROFESSIONAL OFFICE open or percutaneous, including all imaging and ADJUSTMENT AND radiological supervision and interpretation MANAGEMENT OF VASCULAR ACCESS DEVICE 7/10/2017 3/23/2017 7/7/2017 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS Z452 ENCOUNTERFOR PROFESSIONAL OFFICE DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR ADJUSTMENT AND COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC MANAGEMENT OF GUIDANCE FOR VASCULAR ACCESS AND CATHETER VASCULAR ACCESS DEVICE MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHYR 7/10/2017 3/23/2017 7/7/2017 Q9967 LOW OSMOLPR CONTRAST MATERIAL, 300-399 KJ Z452 ENCOUNTER FOR PROFESSIONAL OFFICE IODINE CONCENTRATION, PER ML ADJUSTMENT AND MANAGEMENT OF VASCULAR ACCESS DEVICE 711012017 3/30/2017 4/7/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R05 COUGH PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL $180.22 $558.25 FEMALE SUBSCRIBER R01 050 {$1,52335) $4,005.00 FEMALE SUBSCRIBER R01 050 $0.00 ($471.00) FEMALE SUBSCRIBER R01 OSO $0.00 ($4,005.001 FEMALE SUBSCRIBER R01 EGO $0.00 ($22.00) FEMALE SUBSCRIBER R01 ESE) $0.00 ( }500.001 FEMALE SUBSCRIBER R01 050 $90.38 $471.00 FEMALE SUBSCRIBER RO1 050 $1,527.07 $4,005.00 FEMALE SUBSCRIBER R01 (I $0.00 $225.00 FEMALE SUBSCRIBER R01 OSO $6.50 $100.00 FEMALE SUBSCRIBER R01 OSO ($14.91 $36.00 FEMALE SUBSCRIBER R01 OSO C.7.f 3559 w Z N m Q! 3559 7 3559 > } fl N. CL CL Q 3559 v 3559 3559 3559 3559 3559 3559 C.7.f 7/10/2017 3/30/2017 412012017 k * * * ** " * * ** * # # #. ..... 7/10/2017 3/30/2017 5/3/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R05 COUGH PROFESSIONAL N $0.00 FRONTAL OSO 3559 M OUTPATIENT /HOSPITAL 7/10/2017 3/30/2017 5/3/2017 *r... *. »».* *.... ...rr 7/10/2017 3/30/2017 7/7/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R05 COUGH PROFESSIONAL 3559 7 ($289,19) $607.00 FEMALE SUBSCRIBER R01 FRONTAL 3559 OUTPATIENT /HOSPITAL 7/10/2017 3/30/2017 7/7/2017 * * * ** * *' *.. $0.00 7/10/2017 3/31/2017 4/5/2017 90961 END -STAGE RENAL DISEASE(ESRD( RELATED SERVICES N186 END STAGE RENAL PROFESSIONAL MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL CL $289.19 $607.00 FEMALE SUBSCRIBER R01 WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH 3559 7/10/2017 3/31/2017 5/3/2017 90961 END STAGE RENAL DISEASE(ESRD( RELATED SERVICES N186 ENO STAGE RENAL PROFESSIONAL ( $121.01 FEMALE SUBSCRIBER R01 OSO 3559 MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH 7/10/2017 3/31/2017 7/7/2017 90961 END -STAGE RENAL DISEASE(ESRD( RELATED SERVICES N196 END STAGE RENAL PROFESSIONAL OSO 3559 MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH ($100.001 FEMALE SUBSCRIBER R01 OSO 3559 7/10/2017 4/1/2017 5/11/2017 92012 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H2511 AGE - RELATED NUCLEAR PROFESSIONAL OFFICE a AND EVALUATION, W ITH INITIATION OR CONTINUATION W CATARACT, RIGHT EYE ($'125.00) FEMALE SUBSCRIBER R01 OSO 3559 OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT $125.00 FEMALE SUBSCRIBER R01 OSO 3559 Q 7/10/2017 4/1/2017 5/11/2017 92134 Sc... ing computerized ophthalmic diagnostic imaging, H2511 AGE - RELATED NUCLEAR PROFESSIONAL OFFICE W posterior segment, with interpretation and report, CATARACT, RIGHT EYE unilateral or bilateral; retina A $57.90 7/10/2017 4/1/2017 5/11/2017 92226 OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING H2511 AGE- RELATED NUCLEAR PROFESSIONAL OFFICE $27.70 $100.00 FEMALE SUBSCRIBER ROl OSO (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH CATARACT, RIGHT EYE INTERPRETATION AND REPORT; SUBSEQUENT W 7/10/2017 4/1/2017 5/11/2017 92250 FUNDUS PHOTOGRAPHY WITH INTERPRETATION AND H2511 AGE - RELATED NUCLEAR PROFESSIONAL OFFICE U REPORT CATARACT, RIGHT EYE Q 7/10/2017 4/1/2017 7/7/2017 92012 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H2511 AGE- RELATED NUCLEAR PROFESSIONAL OFFICE AND EVALUATION, WITH INITIATION OR CONTINUATION CATARACT, RIGHT EYE OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT 711012017 4/1/2017 7/7/2017 92134 Scanning computerized ophthalmic diagnostic imaging, H2511 AGE - RELATED NUCLEAR PROFESSIONAL OFFICE posterior segment, with interpretation and report, CATARACT, RIGHT EYE unilateral or bilateral; retina 7/10/2017 4/1/2017 7/7/2017 92226 OPHTHALMDSCOPY, EXTENDED, WITH RETINAL DRAWING H2511 AGE - RELATED NUCLEAR PROFESSIONAL OFFICE (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH CATARACT, RIGHT EYE INTERPRETATION AND REPORT; SUBSEQUENT 7/10/2017 4/1/2017 7/7/2017 92250 FUNDUS PHOTOGRAPHY WITH INTERPRETATION AND H2511 AGE- RELATED NUCLEAR PROFESSIONAL OFFICE REPORT CATARACT, RIGHT EYE 7/10/2017 4/15/2017 5/5/2017 - - E113593 TYPE DIABETES HOSPITAL OUTPATIENT MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL ($180.001 $994.00 FEMALE SUBSCRIBER R01 050 3559 $0.00 ($36.001) FEMALE SUBSCRIBER R01 OSO 3559 1 4 4! N $0.00 ($994.00) FEMALE SUBSCRIBER R01 OSO 3559 M $14.94 $36.00 FEMALE SUBSCRIBER R01 OSO 3559 tu $180.00 $994.00 FEMALE SUBSCRIBER R01 OSO 3559 7 ($289,19) $607.00 FEMALE SUBSCRIBER R01 OSO 3559 $0.00 ($60/.00) FEMALE SUBSCRIBER 1301 0SO 3559 > } O s® CL CL $289.19 $607.00 FEMALE SUBSCRIBER R01 OSO 3559 $0.00 ( $121.01 FEMALE SUBSCRIBER R01 OSO 3559 F W D $0.00 ($159.00) FEMALE SUBSCRIBER R01 OSO 3559 $0.00 ($100.001 FEMALE SUBSCRIBER R01 OSO 3559 O a W $0.00 ($'125.00) FEMALE SUBSCRIBER R01 OSO 3559 $96.13 $125.00 FEMALE SUBSCRIBER R01 OSO 3559 Q W A $57.90 $150.00 FEMALE SUBSCRIBER RO1 OSO 3559 v $27.70 $100.00 FEMALE SUBSCRIBER ROl OSO 3559 W $86.18 $125.00 FEMALE SUBSCRIBER R01 OSO 3559 U Q $0.00 ($54/.00( FEMALE SUBSCRIBER R01 OSO 3559 L C.7.f 7/10/2017 4/15/2017 7/7/2017 - - E113593 TYPE DIABETES HOSPITAL OUTPATIENT $478.00 $547.00 FEMALE SUBSCRIBER R01 050 3559 MELLITUS WITH PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL 7/10/2017 4/17/2017 4/27/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); N186 END STAGE RENAL OTHER MEDICAL ($25.63; $88.21 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 7/10/2017 4/17/2017 5/3/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE N186 END STAGE RENAL OTHER MEDICAL $0.00 (5151051 FEMALE SUBSCRIBER R01 OSO 3559 THE TO LLOWI NO: ALBUMIN (82040), BI LI RUBIN, TOTAL DISEASE (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (94075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SOFT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) 7110/2017 4/17/2017 5/3/2017 83615 LACTATE DEHYDROGENASE (LD), (LDH); N186 END STAGE RENAL OTHER MEDICAL $0.00 ($85211 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 7/10/2017 4/17 /2017 5/3/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SCOT) N186 END STAGE RENAL OTHER MEDICAL $0.00 (.575.661 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 711012017 4/17/2017 5/3/2017 84460 TRANSFERASE; ALAN I NE AMINO (ALT) (SOFT) N186 END STAGE RENAL OTHER MEDICAL $0.00 ($77AF) FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 7/10/2017 4/17/2017 5/3/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED N186 END STAGE RENAL OTHER MEDICAL $0.00 ($65,341 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 7/10/2017 4/17/2017 7/7/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE N186 END STAGE RENAL OTHER MEDICAL $11.21 $153.05 FEMALE SUBSCRIBER R01 OSO 3559 THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL DISEASE (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (94075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SOFT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 7/10/2017 4/17/2017 7/7/2017 83615 LACTATE DEHYDROGENASE (LID), (LDH); N186 END STAGE RENAL OTHER MEDICAL $8.28 $88.21 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 7/10/2017 4/17/2017 7/7/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST)(SGOT) N186 END STAGE RENAL OTHER MEDICAL $0.00 $75.66 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 711012017 411712017 7/7/2017 84460 TRANSFERASE; ALANINE AMINO (ALT) (SGPT) N186 END STAGE RENAL OTHER MEDICAL $0.00 $77.39 FEMALE SUBSCRIBER R01 050 3559 DISEASE 7110/2017 4/17/2017 7/7/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED N186 END STAGE RENAL OTHER MEDICAL $6.14 $65.34 FEMALE SUBSCRIBER R01 050 3559 DISEASE 7/10/2017 4/28/2017 5/3/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT $0.00 {$12,56&70) FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 7/10/2017 4/28/2017 7/7/2017- - N196 END STAGE RENAL HOSPITAL OUTPATIENT $684.00 $12,56830 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 711012017 5/15/2017 6/5/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT $0.00 (517,754.607 FEMALE SUBSCRIBER R01 EGO 3559 DISEASE 7/10/2017 5/15/2017 7/7/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT $1,026.00 $17,754.60 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 7/10/2017 5/22/2017 5/31/2017 83036 HEMOGLOBIN; GLYCOSYLATED(A1C) E119 TYPE DIABETES OTHER MEDICAL $0.00 1$14'.921 FEMALE SUBSCRIBER R01 OSO 3559 MELLITUS WITHOUT COMPLICATIONS 7/10/2017 5/22/2017 5/31/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); E119 TYPE DIABETES OTHER MEDICAL $0.00 ($85.21) FEMALE SUBSCRIBER R01 050 3559 MELLITUS WITHOUT COMPLICATIONS 7/10/2017 5/22/2017 5/31/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST)(SGOT) E119 TYPE DIABETES OTHER MEDICAL $0.00 (57`;.661 FEMALE SUBSCRIBER RD1 OSO 3559 MELLITUS WITHOUT COMPLICATIONS 7/10/2017 5/22/2017 5/31/2017 84460 TRANSFERASE; ALAN I NE AMINO (ALT) (SGPT) E119 TYPE DIABETES OTHER MEDICAL $0.00 ($77.39) FEMALE SUBSCRIBER R01 OSO 3559 MELLITUS WITHOUT COMPLICATIONS 711012017 5/22/2017 5/31/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED E119 TYPE 2 DIABETES OTHER MEDICAL $0.00 (565.3 -.) FEMALE SUBSCRIBER R01 OSO 3559 MELLITUS WITHOUT COMPLICATIONS C.7.f 7/10/2017 5/22/2017 5/31/2017 86803 HEPATITIS C ANTIBODY; E119 7/10/2017 5/22/2017 7/7 /2017 83036 HEMOGLOBIN; GLYCOSYLATED(A1C) E119 7/10/2017 5/22/2017 7/7/2017 83615 LACTATE DEHYDROGENASE(ED),(EDH); E119 7/10/2017 5/22/2017 7/7/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SCOT) E119 7/10/2017 S/22/2017 7/7/2017 84460 TRANSFERASE; AI4NINE AMINO (ALT) (SEPT) E119 7/10/2017 5/22/2017 7/7/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED E119 7/10/2017 5/22/2017 7/7/2017 86803 HEPATITIS C ANTIBODY; E119 7/10/2017 5/29/2017 6/5/2017 - - N186 7/10/2017 5/29/2017 6/6/2017 7/10/2017 5/29/2017 7/7/2017 - - N186 7/10/2017 5/29/2017 7/7/2017 rt%b "* * *' *" » " "'• 7/10/2017 5/30/2017 6/1/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION E1122 MELLITUS WITHOUT AND MANAGEMENT OF A PATIENT, WHICH REQUIRES COMPLICATIONS THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; TYPE 2 DIABETES OTHER MEDICAL A COMPREHENSIVE EXAMINATION; AND MEDICAL $77.39 FEMALE SUBSCRIBER R01 OSO 3559 DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH COMPLICATIONS OTHER PROVIDERS OR 7/10/2017 5/30/2017 7/7/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION E1122 3559 CL MELLITUS WITHOUT AND MANAGEMENT OF A PATIENT, WHICH REQUIRES Q, COMPLICATIONS THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL $19.57 $208.69 FEMALE SUBSCRIBER R01 OSO DECISION MAKING OF MODERATE COMPLEXITY. MELLITUS WITHOUT COUNSELING AND /OR COORDINATION OF CARE WITH COMPLICATIONS OTHER PROVIDERS OR 7/10/2017 5/31/2017 6/1/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E1122 OSO 3559 �+ DISEASE EVALUATION AND MANAGEMENT OF PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN $0.00 ($1,550.001 FEMALE SUBSCRIBER R01 OSO EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL END STAGE RENAL HOSPITAL OUTPATIENT $3,420.00 $68,511.40 FEMALE DECISION MAKING OF MODERATE COMPLEXITY. OSO 3559 DISEASE COUNSELING AND /OR 7/10/2017 5/31/2017 7/7/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E1122 SUBSCRIBER R01 SUBSCRIBER R01 DEC OSO 3559 3559 _ EVALUATION AND MANAGEMENT OF PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN CHRONIC KIDNEY DISEASE EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL O DECISION MAKING OF MODERATE COMPLEXITY. IL COUNSELING AND /OR TYPE 2 DIABETES OTHER MEDICAL $0.00 (.$208.69) FEMALE SUBSCRIBER R01 050 3559 MELLITUS WITHOUT W COMPLICATIONS TYPE DIABETES OTHER MEDICAL $13.32 $141.92 FEMALE SUBSCRIBER R01 OSO 3559 N MELLITUS WITHOUT m COMPLICATIONS TYPE 2 DIABETES OTHER MEDICAL $8.28 $88.21 FEMALE SUBSCRIBER RO1 OSO 3559 MELLITUS WITHOUT COMPLICATIONS TYPE DIABETES OTHER MEDICAL $7.10 $75.66 FEMALE SUBSCRIBER R01 OSO 3559 "a MELLITUS WITHOUT COMPLICATIONS TYPE 2 DIABETES OTHER MEDICAL $717 $77.39 FEMALE SUBSCRIBER R01 OSO 3559 MELLITUS WITHOUT } COMPLICATIONS TYPE 2 DIABETES OTHER MEDICAL $6.14 $65.34 FEMALE SUBSCRIBER R01 050 3559 CL MELLITUS WITHOUT Q, COMPLICATIONS TYPE DIABETES OTHER MEDICAL $19.57 $208.69 FEMALE SUBSCRIBER R01 OSO 3559 MELLITUS WITHOUT COMPLICATIONS END STAGE RENAL HOSPITAL OUTPATIENT $0.00 ,$68,511.401 FEMALE SUBSCRIBER R01 OSO 3559 �+ DISEASE • + + +« * * *x. $0.00 ($1,550.001 FEMALE SUBSCRIBER R01 OSO 3559 F END STAGE RENAL HOSPITAL OUTPATIENT $3,420.00 $68,511.40 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE Z TYPE 2 DIABETES PROFESSIONAL $313.41 $0.00 $1,550.00 FEMALE ($236,001 FEMALE SUBSCRIBER R01 SUBSCRIBER R01 DEC OSO 3559 3559 _ MELLITUS WITH DIABETIC INPATIENT /HDSPITAL CHRONIC KIDNEY DISEASE O IL W TYPE 2 DIABETES PROFESSIONAL $165.55 $286.00 FEMALE SUBSCRIBER R01 OSO 3559 MELLITUS WITH DIABETIC INPATIENT /HOSPITAL 0 CHRONIC KIDNEY DISEASE W J TYPE DIABETES PROFESSIONAL $0.00 ($151.00) FEMALE SUBSCRIBER R01 OSO 3559 V MELLITUS WITH DIABETIC INPATIENT /HOSPITAL CHRONIC KIDNEY DISEASE W U Q TYPE DIABETES PROFESSIONAL $85.67 $151.00 FEMALE SUBSCRIBER RO1 OSO 3559 MELLITUS WITH DIABETIC INPATIENT /HDSPITAL CHRONIC KIDNEY DISEASE _. 7/10/2017 6/19/2017 6/21/2017 73630 RADIOLOGIC EXAMINATION, FOOT; COMPLETE, L97511 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE $0.00 ($7739) FEMALE SUBSCRIBER R01 OSO MINIMUM OF THREE VIEWS ($65.34) FEMALE ULCER OF OTHER PART OF $25.56 $100.00 FEMALE SUBSCRIBER R01 OSO $4331 $150.00 FEMALE SUBSCRIBER R01 O5O RIGHT FOOT LIMITED TO BREAKDOWN OF SKIN 7/10/2017 6/19/2017 6/21/2017 97597 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET L97511 NON- PRESSURE CHRONIC PROFESSIONAL OFFICE W ITH/WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), RIGHT FOOT LIMITED TO OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS BREAKDOWN OF SKIN AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), 7/10/2017 6/19/2017 6/26/2017 80076 HEPATIC FUNCTION PANELTHIS PANEL MUST INCLUDE N186 END STAGE RENAL OTHER MEDICAL THE FOLLOW ING: ALBUMIN (8204D), BILIRUBIN, TOTAL DISEASE (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (94075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SPOT) (84450) 711012017 6/19/2017 61 83615 LACTATE DEHYDROGENASE (ED), (LDH); N186 END STAGE RENAL OTHER MEDICAL DISEASE 7/10/2017 6/19/2017 6/26/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) N186 END STAGE RENAL OTHER MEDICAL DISEASE 7/10/2017 6/19/2017 6/26/2017 84460 TRANSFERASE; ALANINE AMINO (ALT)(SGPT) N186 END STAGE RENAL OTHER MEDICAL DISEASE 711012017 6/19/2017 6/26/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED N196 END STAGE RENAL OTHER MEDICAL DISEASE 7/10/2017 6/19/2017 7/7/2017 73630 RADIOLOGIC EXAMINATION, FOOT; COMPLETE, L97511 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE MINIMUM OF THREE VIEWS ULCER OF OTHER PART OF RIGHT FOOT LIMITED TO BREAKDOWN OF SKIN 7/10/2017 6/19/2017 7/7/2017 97597 DEBRIDEMENT (EG, HIGH PRESSURE WATERJET L97511 NON- PRESSURE CHRONIC PROFESSIONAL OFFICE WITH /WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), RIGHT FOOT LIMITED TO OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS BREAKDOWN OF SKIN AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), 711012017 6/19/2017 7/7/2017 80076 HEPATIC FUNCTION PANELTHIS PANEL MUST INCLUDE N196 END STAGE RENAL OTHER MEDICAL THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL DISEASE (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SPOT) (84450) 7/10/2017 6/19/2017 7/7/2017 83615 LACTATE DEHYDROGENASE (ED), (LDHT N186 END STAGE RENAL OTHER MEDICAL DISEASE 7/10/2017 6/19/2017 7/7/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SECT) N186 END STAGE RENAL OTHER MEDICAL DISEASE 7/10/2017 6/19/2017 7/7/2017 84460 TRANSFERASE; ALANINE AMINO (ALT) (SGPT) N186 END STAGE RENAL OTHER MEDICAL DISEASE 7/10/2017 6/19/2017 7/7/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED N196 END STAGE RENAL OTHER MEDICAL DISEASE 7/10/2017 6/28/2017 7/5/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 7/10/2017 6/30/2017 7/6/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE $0.00 (.$100.110) FEMALE SUBSCRIBER R01 050 $0.00 (5150.091 FEMALE SUBSCRIBER R01 DEC) $0CD (.$153.05) FEMALE SUBSCRIBER R01 050 $0.00 ($88.21) FEMALE SUBSCRIBER R01 OSO $0.00 ($75,66) FEMALE SUBSCRIBER R01 OSO $0.00 ($7739) FEMALE SUBSCRIBER R01 OSO $0.00 ($65.34) FEMALE SUBSCRIBER R01 OSO $25.56 $100.00 FEMALE SUBSCRIBER R01 OSO $4331 $150.00 FEMALE SUBSCRIBER R01 O5O $11.21 $153.05 FEMALE SUBSCRIBER R01 O5O $828 $88.21 FEMALE SUBSCRIBER R01 OSO $0.00 $75.66 FEMALE SUBSCRIBER R01 OSO $0.00 $77.39 FEMALE SUBSCRIBER R01 OSO $6.14 $65.34 FEMALE SUBSCRIBER R01 OSO $684.00 $9,182.10 FEMALE SUBSCRIBER R01 OSO $3,078.00 $48,057.10 FEMALE SUBSCRIBER R01 OSO C.7.f 3559 0=1 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 7/14/2017 7/10/2017 7/12/2017 97597 DEBRIDEMENT(EG, HIGH PRESSURE WATERJET L97521 NON- PRESSURE CHRONIC PROFESSIONAL OFFICE WITH /WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), LEFT FOOT LIMITED TO OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS BREAKDOWN OF SKIN AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), 7/15/2017 3/23/2017 4/3/2017 37248 Transluminal ball oon.. gioplas ty(exrept dialysis circuit), Z452 ENCOUNTER FOR PROFESSIONAL OFFICE open ar percutaneous, including all imaging and ADJUSTMENT AND radiological supervision and interpretation MANAGEMENT OF VASCULAR ACCESS DEVICE 7/15/2017 3/30/2017 4/6/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, R05 COUGH PROFESSIONAL FRONTAL AND LATERAL; OUTPATIENT /HOSPITAL 7/17/2017 5130/2017 7/7/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION E1122 TYPE 20IABETES PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES MELLITUS WITH DIABETIC INPATIENT /HOSPITAL THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; CHRONIC KIDNEY DISEASE A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 7/17/2017 5/30/2017 7/7/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION E1122 TYPE 20IABETES PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES MELLITUS WITH DIABETIC OUTPATIENT/HOSPITAL THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; CHRONIC KIDNEY DISEASE A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 7/17/2017 5/31/2017 6/1/2017 90961 END STAGE RENAL DISEASE(ESRD) RELATED SERVICES N186 END STAGE RENAL PROFESSIONAL MONTHLY, FOR PATIENTS 20 YEA RS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH 711712017 5/31/2017 7/7/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E1122 TYPE 2 DIABETES PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH MELLITUS WITH DIABETIC INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN CHRONIC KIDNEY DISEASE EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 711712017 5/31/2017 7/7/2017 90961 END -STAGE RENAL DISE.ASE(ESRD) RELATED SERVICES N186 END STAGE RENAL PROFESSIONAL MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH 7/17/2017 5/31/2017 7/7/2017 90961 END STAGE RENAL DISEASE(ESRD) RELATED SERVICES E1122 TYPE DIABETES PROFESSIONAL MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH CHRONIC KIDNEY DISEASE 7/17/2017 5/31/2017 7/7/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E1122 TYPE 2 DIABETES PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN CHRONIC KIDNEY DISEASE EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR $43.31 $150.00 FEMALE SUBSCRIBER R01 050 ($105.58) $4,005.00 FEMALE SUBSCRIBER R01 OSO (517.64) $42.00 FEMALE SUBSCRIBER R01 0SO ($16555) (,$286.0: FEMALE SUBSCRIBER R01 050 $165.55 $286.00 FEMALE SUBSCRIBER R01 OSO $0.00 (5607.00) FEMALE SUBSCRIBER R01 OSO ($35.67) ($15-,00) FEMALE SUBSCRIBER R01 050 $0.00 $607.00 FEMALE SUBSCRIBER R01 OSO $289.19 $607.00 FEMALE SUBSCRIBER R01 OSO $0.00 $151.00 FEMALE SUBSCRIBER R01 OSO C.7.f 3559 w Z N Q! 3559 i' 3559 fl } fl 3559 CL CL Q Q F 3559 uj P D O 3559 Q W 3559 J W 4 J 3559 v W 3559 U Q 3559 7/17/2017 7/11/2017 7/14/2017 369031 ntroduction of needle(s)and /or catheter(s), dialysis T82898A OTHER SPECIFIED PROFESSIONAL OFFICE cult, with diagnostic a.giography fthe dialysis circuit, COMPLICATION OF including all direct puncture(,) and catheter VASCULAR PROSTHETIC DEVICES, IMPLANTSAND GRAFTS, INITIAL ENCOUNTER 7/17/2017 7/11/2017 7/14/2017 99152 Moderate sedation services provided by the same T82898A OTHER SPECIFIED PROFESSIONAL OFFICE physician or other qualified health care professorial COMPLICATION OF performing the diagnostic or therapeutic service that VASCULAR PROSTHETIC DEVICES, IMPLANTSAND GRAFTS, INITIAL ENCOUNTER 7/17/2017 7/11/2017 7/14/2017 Q9967 LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG /ML T82898A OTHER SPECIFIED PROFESSIONAL OFFICE IODINE CONCENTRATION, PER ML COMPLICATION OF VASCULAR PROSTHETIC DEVICES, IMPLANTSAND GRAFTS, INITIAL ENCOUNTER 7/20/2017 7/13/2017 7/19/2017 36902 Introduction of.ccdlb (,)and /or catheter(,(, dialysis T82898A OTHER SPECIFIED PROFESSIONAL OFFICE circuit, with diagnostic angiography ofthe dialysis circuit, COMPLICATION OF including all direct punctures) and catheter VASCULAR PROSTHETIC DEVICES, IMPLANTSAND GRAFTS, INITIAL ENCOUNTER 7/20/2017 7/13/2017 7119/2017 99152 Maderate sedation services provided by the same T82898A OTHER SPECIFIED PROFESSIONAL OFFICE physician or other qualified health care professional COMPLICATION OF performing the diagnostic or therapeutic service that VASCULAR PROSTHETIC DEVICES, IMPLANTSAND GRAFTS, INITIAL ENCOUNTER 7/20/2017 7/13/2017 7/19/2017 Q9967 LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG /ML T82898A OTHER SPECIFIED PR0FE55IONAL OFFICE IODINE CONCENTRATION, PER ML COMPLICATION OF VASCULAR PROSTHETIC DEVICES, IMPLANTSAND GRAFTS, INITIAL ENCOUNTER 7/21/2017 7/18/2017 7/20/2017 97597 DEBRIDEMENT( EG, HIGH PRESSURE WATERIET L97511 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE WITH /WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF DEBRIDEM ENT WITH SCISSORS, SCALPEL AND FORCEPS), RIGHT FOOT LIMITED TO OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS BREAKDOWN OF SKIN AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), 7/25/2017 7/17/2017 7/24/2017 80076 HEPATIC FUNCTION PANELTHIS PANEL MUST INCLUDE N186 ENO STAGE RENAL OTHER MEDICAL THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL DISEASE (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 7/25/2017 711712017 7/24/2017 83615 LACTATE DEHVDROGENASE (LD), (LDH); N186 END STAGE RENAL OTHER MEDICAL DISEASE 7/25/2017 711712017 7/24/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) N196 END STAGE RENAL OTHER MEDICAL DISEASE 7/25/2017 7/17/2017 7/24/2017 84460 TRAIN SEE RAS E; ALAN I N E AM I NO(ALT)(SO PT) N196 END STAGE RENAL OTHER MEDICAL DISEASE $5,608.74 $14,710.00 FEMALE SUBSCRIBER R01 050 $51.90 $137.00 FEMALE SUBSCRIBER R01 OSO $13.00 $200.00 FEMALE SUBSCRIBER 301 EGO $1,245.03 $3,266.00 FEMALE SUBSCRIBER R01 OSO $51.90 $137.00 FEMALE SUBSCRIBER RO1 OSO $9.75 $150.00 FEMALE SUBSCRIBER RO1 050 $43.31 $150.00 FEMALE SUBSCRIBER R01 OSO $11.21 $153.05 FEMALE SUBSCRIBER R01 OSO $8.28 $88.21 FEMALE SUBSCRIBER R01 ESE) $0.00 $75.66 FEMALE SUBSCRIBER R01 050 $0.00 $77.39 FEMALE SUBSCRIBER R01 050 C.7.f 7/25/2017 711712017 7/24/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED N186 END STAGE RENAL OTHER MEDICAL EGO W 3559 ) DISEASE N 8/1/2017 7/27/2017 7/31/2017 97597 DEBRIDEMENTHG, HIGH PRESSURE WATERIET L97511 NON- PRESSURE CHRONIC PROFESSIONAL OFFICE Q! WITH /WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF DEBRIDEMENT WITH SCISSORS, SCALPELAND FORCEPS(, RIGHT FOOT LIMITED TO OPEN WOUND,(EG, FIBRIN, DEVITALIZED EPIDERMIS BREAKDOWN OF SKIN i $358.91 $753.00 FEMALE SUBSCRIBER ROl AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM(, INCLUDING 3559 "a TOPICAL APPLICATION(S), 8/1/2017 7/31/2017 7131/2017 90960 END STAGE RENAL DISEASE( ESRD( RELATED SERVICES N186 ENO STAGE RENAL PROFESSIONAL fl i® MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 40R MORE FACE -TO -FACE PHYSICIAN VISITS PER CL Q MONTH $155.00 FEMALE SUBSCRIBER RO1 060 3559 8/3/2017 5/15/2017 81112017 92134 Scanning computeriz d ophthalmic diagnostic imaging, E113S91 TYPE 2 DIABETES PROFESSIONAL OFFICE posterior segment, with interpretation and report, MELLITUS WITH unilateral or bilateral; retina PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE 8/3/2017 5/15/2017 81112017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E113591 TYPE 2 DIABETES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MELLITUS WITH PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY PROLIFERATIVE DIABETIC COMPONENTS: A DETAILED HISTORY; A DETAILED RETINOPATHY WITHOUT EXAMINATION; MEDICAL DECISION MAKING OF MACULAR EDEMA, RIGHT MODERATE COMPLEXITY. 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'•" *• ...xi.. ..xi.... 8/16/2017 8/7/2017 8/15/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST I2 N196 END STAGE RENAL PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY DISEASE OUTPATIENT /HOSPITAL $6.14 $65.34 FEMALE SUBSCRIBER R01 050 3559 $43.31 $150.00 FEMALE SUBSCRIBER RO1 EGO W 3559 ) N Q! i $358.91 $753.00 FEMALE SUBSCRIBER ROl OSO 3559 "a $42.85 $100.00 FEMALE SUBSCRIBER R01 050 3559 > } fl i® CL CL Q $94.56 $155.00 FEMALE SUBSCRIBER RO1 060 3559 $1,026.00 $14,069.40 FEMALE SUBSCRIBER R01 050 3559 $3,420.00 $60,071.05 FEMALE SUBSCRIBER R01 EGO 3559 $589.06 $28,514.34 FEMALE SUBSCRIBER RO1 OSO 3559 $4331 $150.00 FEMALE SUBSCRIBER R01 ONO 3559 $0.00 $711.17 FEMALE SUBSCRIBER RO1 050 3559 $0.00 $278.71 FEMALE SUBSCRIBER R01 0S0 3559 $3,658.01 $3,658.01 FEMALE SUBSCRIBER RO1 OSO 3559 $0.00 $69,00 FEMALE SUBSCRIBER R01 OSO 3559 8/16/2017 8/7/2017 8/15/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION N186 END STAGE RENAL PROFESSIONAL SUBSCRIBER R01 050 3559 W AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 3559 DISEASE OUTPATIENT /HOSPITAL Z 3559 $6.14 THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS OSD N $4,104.00 $74,224.55 FEMALE SUBSCRIBER R01 OSO 3559 IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL $753.00 FEMALE SUBSCRIBER R01 OSO 3559 $43.31 Q! 050 CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND $14.94 $36.00 FEMALE SUBSCRIBER R01 050 3559 7 MEDICAL DECIS 8/17/2017 8/7/2017 8/16/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R0989 OTHER SPECIFIED PROFESSIONAL FRONTAL $aDD SYMPTOMS AND SIGNS OUTPATIENT /HOSPITAL EGO 3559 > } INVOLVING THE O s® CL CIRCULATORY AND CL RESPIRATORY SYSTEMS 8/23/2017 8/18/2017 8/22/2017 97598 DEBRIDEMENT(EG, HIGH PRESSURE WATERJET L97511 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE WITH /WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), RIGHT FOOT LIMITED TO OPEN WOUND, BREAKDOWN OF SKIN 8/29/2017 8/21/2017 8/28/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE E119 TYPE DIABETES OTHER MEDICAL THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL MELLITUS WITHOUT (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, COMPLICATIONS ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) 8/29/2017 8/21/2017 812812017 83036 HEMOGLOBIN; GLYCOSYLATED(A1C) E119 TYPE DIABETES OTHER MEDICAL MELLITUS WITHOUT COMPLICATIONS 8/29/2017 8/21/2017 8128/2017 83615 LACTATE DEHYDROGENASE(LD),(LDH); E119 TYPE DIABETES OTHER MEDICAL MELLITUS WITHOUT COMPLICATIONS 8/29/2017 8/21/2017 8/28/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SCOT) E119 TYPE DIABETES OTHER MEDICAL MELLITUS WITHOUT COMPLICATIONS 8/29/2017 8/21/2017 8/28/2017 84460 TRANSFERASE; AIANINE AMINO (ALT) (SGPT) E119 TYPE DIABETES OTHER MEDICAL MELLITUS WITHOUT COMPLICATIONS 8/29/2017 8/21/2017 812812017 85049 BLOOD COUNT; PLATELET, AUTOMATED E119 TYPE DIABETES OTHER MEDICAL MELLITUS WITHOUT COMPLICATIONS 9/5/2017 8/30/2017 9/1/2017 9/5/2017 8/31/2017 9/2/2017 90960 END STAGE RENAL DISEASE(ESRD) RELATED SERVICES N186 END STAGE RENAL PROFESSIONAL MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 4 O MORE FACE -TO -FACE PHYSICIAN VISITS PER MONTH 9/6/2017 8/31/2017 9/5/2017 97597 DEBRIDEMENT IEG, HIGH PRESSURE WATERJET L97511 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE WITH /WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF DEBRIDEMENT WITH SCISSORS, SCALPELAND FORCEPS), RIGHT FOOT LIMITED TO OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS BREAKDOWN OF SKIN AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), 9/7/2017 8/23/2017 9/6/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 9/26/2017 3/20/2017 9/19/2017 a >sxs .xxww xxxss x.. u. x. xxxxw $13.32 $141.92 FEMALE SUBSCRIBER R01 OSD 3559 C.7.f $313.41 $1,481.00 FEMALE SUBSCRIBER R01 050 3559 W OSO 3559 $0.00 $77.39 FEMALE SUBSCRIBER R01 Z 3559 $6.14 $65.34 FEMALE SUBSCRIBER R01 OSD N $4,104.00 $74,224.55 FEMALE SUBSCRIBER R01 OSO 3559 m $753.00 FEMALE SUBSCRIBER R01 OSO 3559 $43.31 Q! 050 3559 $14.94 $36.00 FEMALE SUBSCRIBER R01 050 3559 7 $aDD $200.00 FEMALE SUBSCRIBER R01 EGO 3559 > } O s® CL CL Q $11.21 $153.05 FEMALE SUBSCRIBER R01 EGO 3559 v $13.32 $141.92 FEMALE SUBSCRIBER R01 OSD 3559 $8.28 $88.21 FEMALE SUBSCRIBER R01 OSO 3559 $0.00 $75.66 FEMALE SUBSCRIBER R01 OSO 3559 $0.00 $77.39 FEMALE SUBSCRIBER R01 OSO 3559 $6.14 $65.34 FEMALE SUBSCRIBER R01 OSD 3559 $4,104.00 $74,224.55 FEMALE SUBSCRIBER R01 OSO 3559 $358.91 $753.00 FEMALE SUBSCRIBER R01 OSO 3559 $43.31 $150.00 FEMALE SUBSCRIBER R01 050 3559 $342.00 $5,401.20 FEMALE SUBSCRIBER R01 OSO 3559 3/20/2017 # # # # # # ## $0DD $28,514.37 FEMALE SUBSCRIBER R01 EGO 3559 9/26/2017 3/21/2017 9/25/2017 992201N ITIALOBSERVATION CARE, PER DAY, FORTH E R0602 SHORTNESS OF BREATH PROFESSIONAL $14,854.80 FEMALE SUBSCRIBER R01 050 $989.01 EVALUATION AND MANAGEMENT OF PATIENT, WHICH SUBSCRIBER R01 OSO $989.01 OUTPATIENT /HOSPITAL SUBSCRIBER R01 OSO $224.23 $300.00 FEMALE REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE $47.83 $150.00 FEMALE SUBSCRIBER R01 OSO $21.96 $89.00 FEMALE SUBSCRIBER BUT OSO HISTORY; A COMPREHENSIVE EXAMINATION; AND $16,20160 FEMALE SUBSCRIBER R01 OSO $10.46 $27.00 FEMALE SUBSCRIBER R01 OSO $0.00 MEDICAL DECISION MAKING OF HIGH COMPLEXITY. SUBSCRIBER R01 OSO $187.35 $554.00 FEMALE SUBSCRIBER R01 OSO COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR A 9/26/2017 3/22/2017 9/25/2017 99217 OBSERVATION CARE DISCHARGE DAY MANAGEMENT R0602 SHORTNESS OF BREATH PROFESSIONAL (THIS CODE IS TD BE UTILIZED BY THE PHYSICIAN TO OUTPATIENT /HOSPITAL REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OBSERVATION STATUS IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF OBSERVATION STATUS. TO REPORT SERVICES TO A PATIENT DESIGNAT 10/6/2017 9/12/2017 10/5/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 10/10/2017 9/8/2017 10/9/2017- - N186 ENO STAGE RENAL HOSPITAL OUTPATIENT DISEASE 10/10/2017 9/15/2017 10/9/2017- - N186 ENO STAGE RENAL HOSPITAL OUTPATIENT DISEASE 1011012017 9/22/2017 101912017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 10/10/2017 9/29/2017 10/9/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 10/13/2017 9/18/2017 10/12/2017 90961 END STAGE RENAL DISEASE( ESRD) RELATED SERVICES E1122 TYPE DIABETES PROFESSIONAL MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO- FACE PHYSICIAN VISITS PER MONTH CHRONIC KIDNEY DISEASE 1011812017 10/13/2017 10/17/2017 11042 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES L97512 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM ULCER OF OTHER PART OF OR LESS RIGHT FOOT WITH FAT LAYER EXPOSED 1011812017 10/13/2017 10/17/2017 73620 RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS L97512 NON - PRESSURE CHRONIC PROFE55IONAL OFFICE ULCER OF OTHER PART OF RIGHT FOOT WITH FAT LAYER EXPOSED 10/20/2017 9/6/2017 10/19/2017- - N186 ENO STAGE RENAL HOSPITAL OUTPATIENT DISEASE 10/25/2017 9/12/2017 10/24/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 1509 HEART FAILURE, PROFESSIONAL FRONTAL UNSPECIFIED OUTPATIENT /HOSPITAL 10/25/2017 9/12/2017 10/24/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 N189 CHRONIC KIDNEY DISEASE, PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY UNSPECIFIED OUTPATIENT /HOSPITAL 10/25/2017 9/12/2017 1012412017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION N199 CHRONIC KIDNEY DISEASE, PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES UNSPECIFIED OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR CODRDINATIDN OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR 10/25/2017 10/16/2017 10/24/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE N186 END STAGE RENAL OTHER MEDICAL THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL DISEASE (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SOFT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SECT) (84450) $215.62 $711.17 FEMALE SUBSCRIBER R01 OSO $84.58 $278.71 FEMALE SUBSCRIBER R01 050 $2,279.09 $4,534.50 FEMALE SUBSCRIBER R01 PSG $329.67 $4,951.60 FEMALE SUBSCRIBER R01 OSO $989.01 $14,854.80 FEMALE SUBSCRIBER R01 050 $989.01 $15,054.20 FEMALE SUBSCRIBER R01 OSO $989.01 $14,954.50 FEMALE SUBSCRIBER R01 OSO $224.23 $300.00 FEMALE SUBSCRIBER R01 OSO $47.83 $150.00 FEMALE SUBSCRIBER R01 OSO $21.96 $89.00 FEMALE SUBSCRIBER BUT OSO $1,026.00 $16,20160 FEMALE SUBSCRIBER R01 OSO $10.46 $27.00 FEMALE SUBSCRIBER R01 OSO $0.00 $30.00 FEMALE SUBSCRIBER R01 OSO $187.35 $554.00 FEMALE SUBSCRIBER R01 OSO $11.21 $153.05 FEMALE SUBSCRIBER RUT OSO C.7.f 3559 w Z N Q! F_n 3559 7 fl } fl CL 3559 Q, Q 3559 v 3559 Q 3559 W 3559 3559 3559 O IL W 3559 3559 3559 3559 3559 I= C.7.f 10/25/2017 10/16/2017 10/24/2017 83615 LACTATE DEHYDROGENASE )ED), (LDH); N186 END STAGE RENAL OTHER MEDICAL $8.28 $88.21 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE W 10/25/2017 10/16/2017 10/24/2017 84450 TRANSFERASE; ASPARTATEAMINO (AST) (SGOT) N186 ENO STAGE RENAL OTHER MEDICAL $0.00 $75.66 FEMALE SUBSCRIBER R01 OSO 3559 {U DISEASE N 10/25/2017 10/16/2017 10/24/2017 84460 TRANSFERASE; AIANINE AMINO (ALT) (SGPT) N186 ENO STAGE RENAL OTHER MEDICAL $0.00 $77.39 FEMALE SUBSCRIBER R01 050 3559 m DISEASE 10/30/2017 81712017 10/27/2017 * *r «r . » »»w r« «rr w.»»r .. » »w $11.07 $70.00 FEMALE SUBSCRIBER RO1 EGO 3559 A 11/3/2017 10/31/2017 11/1/2017 90960 END -STAGE RENAL DISEASE) ESRD) RELATED SERVICES N186 END STAGE RENAL PROFESSIONAL $358.91 $753.00 FEMALE SUBSCRIBER RO1 EGO 3559 MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL } WITH 4 O MORE FACE -TO -FACE PHYSICIAN VISITS PER "a MONTH 11/6/2017 10/30/2017 11/3/2017- - N186 ENO STAGE RENAL HOSPITAL OUTPATIENT $4,446.00 $78,630.80 FEMALE SUBSCRIBER R01 OSO 3559 DISEASE 11/7/2017 11/2/2017 11/6/2017 11042 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES L97512 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE $4723 $150.00 FEMALE SUBSCRIBER RD1 ESE) 3SS9 lu } EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 205Q CM ULCER OF OTHER PART OF OR LESS RIGHT FOOT WITH FAT iL CL LAVER EXPOSED Q, Q 11/14/2017 11/9/2017 11/13/2017 11042 DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES L97512 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE $47.83 $150.00 FEMALE SUBSCRIBER R01 O5O 3559 v EPIDERMIS AND DERMIS, IF PERFORMED); FIRST205QCM ULCER OF OTHER PART OF OR LESS RIGHT FOOT WITH FAT rf w• LAVER EXPOSED F 11/21/2017 6/30/2017 7/5/2017 90961 END STAGE RENAL DISEASE)ESRD) RELATED SERVICES N186 ENO STAGE RENAL PROFESSIONAL $289.19 $607.00 FEMALE SUBSCRIBER R01 050 3559 uLl MONTHLY, FOR PATIENTS 20 YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH 11/21/2017 6/30/2017 7/5/2017 90961 END -STAGE RENAL DISEASE) ESRD) RELATED SERVICES N186 END STAGE RENAL PROFESSIONAL $0.00 (560].00) FEMALE SUBSCRIBER R01 050 3559 _ MONTHLY, FOR PATIENTS 2D YEARS OF AGE AND OLDER; DISEASE OUTPATIENT /HOSPITAL WITH 2 -3 FACE -TO -FACE PHYSICIAN VISITS PER MONTH O 11/21/2017 11/16/2017 11/20/2017 97597 DEBRIDEMENT IDS, HIGH PRESSURE WATERIET L97512 NON - PRESSURE CHRONIC PROFESSIONAL OFFICE $43.31 $150.00 FEMALE SUBSCRIBER R01 O5O 3559 Q WITH /WITHOUT SUCTION, SHARP SELECTIVE ULCER OF OTHER PART OF ui DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), RIGHT FOOT WITH FAT OPEN WOUND, )EG, FIBRIN, DEVITALIZED EPIDERMIS LAYER EXPOSED UJ AND /OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), 1112812017 11/20/2017 1112712017 83036 HEMOGLOBIN; GLYCOSYLATED(AlC) E119 TYPE DIABETES OTHER MEDICAL $13.32 $141.92 FEMALE SUBSCRIBER R01 050 3559 LLJ MELLITUS WITHOUT COMPLICATIONS 11/28/2017 11/20/2017 11/27/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); E119 TYPE DIABETES OTHER MEDICAL $8.28 $88.21 FEMALE SUBSCRIBER RO1 OSO 3559 J MELLITUS WITHOUT COMPLICATIONS V 1112812017 11/20/2017 11/27/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SCOT) E119 TYPE DIABETES OTHER MEDICAL $7.10 $75.66 FEMALE SUBSCRIBER R01 RISC 3559 MELLITUS WITHOUT Z COMPLICATIONS LLJ 11/28/2017 11/20/2017 11/27/2017 84460 TRANSFERASE; ALANINE AMINO (ALT)(SGPT) E119 TYPE DIABETES OTHER MEDICAL $7.27 $77.39 FEMALE SUBSCRIBER RO1 050 3559 MELLITUS WITHOUT COMPLICATIONS (' 11/28/2017 11/20/2017 11/27/2017 86803 HEPATITIS C ANTIBODY; E119 TYPE 2 DIABETES OTHER MEDICAL $19.57 $208.69 FEMALE SUBSCRIBER R01 050 3559 MELLITUS WITHOUT COMPLICATIONS 12/4/2017 11/1/2017 12/1/2017 90970 END STAGE RENAL DISEASE )ESRD) RELATED SERVICES FOR N186 ENO STAGE RENAL PROFESSIONAL $10.25 $180.00 FEMALE SUBSCRIBER R01 OSO 3559 DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL FOR PATIENTS 20 YEARS OF AGE AND OLDER hl C 12/4/2017 11/2/2017 12/1/2017 90970 END STAGE RENAL DISEASE )ESRD) RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL $10.25 $20.00 FEMALE SUBSCRIBER ROl OSO 3559 DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL FOR PATIENTS 20 YEARS OF AGE AND OLDER ._ 12/4/2017 11/3/2017 12/1/2017 90970 END -STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL SUBSCRIBER R01 OSO $1015 DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL $20.00 FEMALE SUBSCRIBER R01 O5O FOR PATIENTS 20 YEARS OF AGE AND OLDER $20.00 FEMALE SUBSCRIBER R01 LSD 12/4/2017 11/4/2017 12/1/2017 90970 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL SUBSCRIBER R01 OSO $4,104.00 DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL $29.00 FEMALE SUBSCRIBER R01 OSO FOR PATIENTS 20 YEARS OF AGE AND OLDER $257.00 FEMALE SUBSCRIBER R01 OSO 12/4/2017 11/5/2017 12/1/2017 90970 END -STAGE RENAL DISEASE )ESRD) RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL FOR PATIENTS 20 YEARS OF AGE AND OLDER 12/4/2017 11/6/2017 12/1/2017 90970 END STAGE RENAL DISEASE )ESRD) RELATED SERVICES FOR N186 ENO STAGE RENAL PROFESSIONAL DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL FOR PATIENTS 20 YEARS OF AGE AND OLDER 12/4/2017 111712017 12/1/2017 90970 END -STAGE RENAL DISEASE )ESRD) RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL FOR PATIENTS 20 YEARS OF AGE AND OLDER 12/4/2017 11/8/2017 12/1/2017 90970 END STAGE RENAL DISEASE )ESRD) RELATED SERVICES FOR N186 END STAGE RENAL PROFESSIONAL DIALYSIS LESS THAN A FULL MONTH OF SERVICE, PER DAY; DISEASE OUTPATIENT /HOSPITAL FOR PATIENTS 20 YEARS OF AGE AND OLDER 12/5/2017 11/22/2017 12/4/2017- - N186 END STAGE RENAL HOSPITAL OUTPATIENT DISEASE 12/6/2017 11/29/2017 12/4/2017 *Y ° "* # #d'* * " ** ' * * *« . 12/8/2017 11/29/2017 12/7/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 14581 LONG QT SYNDROME PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 12/8/2017 11/30/2017 12/7/2017 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE T82868A THROMBOSIS DUE TO PROFESSIONAL EVALUATION AND MANAGEMENT OF A NEW PATIENT, VASCULAR PROSTHETIC OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED DEVICES, IMPLANTSAND HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION GRAFTS, INITIAL MAKING OF LOW COMPLEXITY. COUNSELING AND /OR ENCOUNTER COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE P 12/12/2017 11/29/2017 12/4/2017 * *' "* 11 — *' " ** `. ". ""* 12/14/2017 11/29/2017 12/13/2017 93010 E LECTRDCA R D I OR RAM, ROUTI N E ECG WITH AT LEAST 12 1200 UNSTABLE ANGI NA PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 12/14/2017 11/29/2017 12/13/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 1200 UNSTABLE ANGINA PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENTS CLINICAL CONDITION AND /DR MENTALSTATUS: ACOMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 12/18/2017 11/29/2017 12/15/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION N186 END STAGE RENAL PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES DISEASE INPATIENT / HDSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 12/18/2017 11/30/2017 12/15/2017 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN N186 END STAGE RENAL PROFESSIONAL EVALUATION DISEASE INPATIENT /HOSPITAL $10.25 $20.00 FEMALE SUBSCRIBER R01 OSO $10.25 $20.00 FEMALE SUBSCRIBER R01 OSO $1015 $20.00 FEMALE SUBSCRIBER R01 050 $10.25 $20.00 FEMALE SUBSCRIBER R01 O5O $10.25 $20.00 FEMALE SUBSCRIBER R01 LSD $10.25 $20.00 FEMALE SUBSCRIBER R01 O5O $342.00 $5,918.20 FEMALE SUBSCRIBER R01 OSO $4,104.00 $78,806.80 FEMALE SUBSCRIBER R01 OSO $9.42 $29.00 FEMALE SUBSCRIBER R01 OSO $80.40 $257.00 FEMALE SUBSCRIBER R01 OSO $0.00 $78,806.80 FEMALE SUBSCRIBER R01 050 $0.00 $112.00 FEMALE SUBSCRIBER R01 O5O $376.94 $2,275.00 FEMALE SUBSCRIBER R01 OSO $120.33 $303.14 FEMALE SUBSCRIBER R01 OSO $61.63 $156.26 FEMALE SUBSCRIBER R01 OSO 12/18/2017 12/1/2017 12/15/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N186 END STAGE RENAL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH DISEASE INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 12/18/2017 12/2/2017 12/15/2017 90935 HEM0DIALYSIS PROCEDURE WITH SINGLE PHYSICIAN N186 END STAGE RENAL PROFESSIONAL EVALUATION DISEASE INPATIENT / HDSPITAL 12/19/2017 12/15/2017 12118/2017 92134 Scan. ing computerized ophth,lm'c d'agnostc imaging, E113591 TYPE DIABETES PROFESSIONAL OFFICE posterior segment, with interpretation and report, MELLITUS WITH unilateral or bilateral; retina PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE 12119/2017 12/15/2017 12/18/2017 92226 OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING E113591 TYPE DIABETES PROFESSIONAL OFFICE (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH MELLITUS WITH INTERPRETATION AND REPORT; SUBSEQUENT PROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, RIGHT EYE 12/19/2017 12/15/2017 12/18/2017 99214 OFFICE DR OTHER OUTPATIENT VISIT FOR THE E113591 TYPE 2 DIABETES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MELLITUS WITH PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY PROLIFERATIVE DIABETIC COMPONENTS: A DETAILED HISTORY; A DETAILED RETINOPATHY WITHOUT EXAMINATION; MEDICAL DECISION MAKING OF MACULAR EDEMA, RIGHT MODERATE COMPLEXITY. COUNSELING AND /OR EYE COORDINATION OF CARE WITH OTHER 12/20/2017 11/29/2017 12119/2017 71020 RADIOLDGIC EXAMINATION, CHEST, TWO VIEWS, T82868A THROMBOSIS DUE TO PROFESSIONAL FRONTAL AND LATERAL; VASCULAR PROSTHETIC OUTPATIENT /HOSPITAL DEVICES, IMPLANTS AND GRAFTS, INITIAL ENCOUNTER 12/20/2017 11/30/2017 12/19/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, T82868A THROMBOSIS DUE TO PROFESSIONAL FRONTAL VASCULAR PROSTHETIC OUTPATIENT /HOSPITAL DEVICES, IMPLANTSAND GRAFTS, INITIAL ENCOUNTER 12/21/2017 12/3/2017 1211812017 * + + ** * * * ** * + * ** • * *»r *. » ». 12/22/2017 12/1/2017 12/21/2017 36905 Percut ...... transluminal mechanical thrombectomy T82868A THROMBOSIS DUE TO PROFESSIONAL and /or Infusion for thrombolysls, dialysis circuit, any VASCULAR PROSTHETIC OUTPATIENT /HOSPITAL method, Including all imaging and radiological DEVICES, IMPLANTSAND GRAFTS, INITIAL ENCOUNTER 12/27/2017 11/29/2017 12/22/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL( THIS PANEL E1121 TYPE DIABETES PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) NEPHROPATHY CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN( (84520) 1212712017 1112912017 1212212017 85008 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC E1121 TYPE 2 DIABETES PROFESSIONAL EXAMINATION WITHOUT MANUAL DIFFERENTIALWBC MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL COUNT NEPHROPATHY $35.03 $86.90 FEMALE SUBSCRIBER R01 OSO $61.63 $156.26 FEMALE SUBSCRIBER R01 050 $42.85 $100.00 FEMALE SUBSCRIBER R01 OSO $20.71 $41.00 FEMALE SUBSCRIBER RO1 OSO $94.56 $155.00 FEMALE SUBSCRIBER R01 OSO $14.70 $47.00 FEMALE SUBSCRIBER R01 050 $12.45 $39.00 FEMALE SUBSCRIBER R01 050 $2,764.62 $51,139.48 FEMALE SUBSCRIBER R01 0S0 $2,000.00 $2,000.00 FEMALE SUBSCRIBER R01 OSO $0.00 $52.00 FEMALE SUBSCRIBER R01 OSO $0.00 $15.00 FEMALE SUBSCRIBER RD1 OSO C.7.f 3559 ®' KEW ®' Mw wo Fky M] III 12/27/2017 11/29/2017 1212212017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $22.00 FEMALE SUBSCRIBER R01 OSO LET, RBC,WBC AND PLATELET COUNT) AND AUTOMATED MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT NEPHROPATHY 12/27/2017 11/29/2017 12/22/2017 85610 PROTHRDMBIN TIME; E1121 TYPE 20IABETES PROFESSIONAL $0.00 $20.00 FEMALE SUBSCRIBER R01 050 MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL NEPHROPATHY 12/27/2017 11/29/2017 12/22/2017 85670 THROMBIN TIME; PLASMA E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $23.00 FEMALE SUBSCRIBER R01 050 MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL NEPHROPATHY 12/27/2017 11/29/2017 12/22/2017 85730 THROMBOPIASTIN TIME, PARTIAL (PTT); PLASMA OR E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $10.00 FEMALE SUBSCRIBER R01 OSO WHOLE BLOOD MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL NEPHROPATHY 12/27/2017 11/29/2017 1212212017 86850 ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $19.00 FEMALE SUBSCRIBER R01 EGG MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL NEPHROPATHY 12/27/2017 11/29/2017 12/22/2017 86900 BLOOD TYPING, SERDLOGIC; ABO E1121 TYPE 20IABETES PROFESSIONAL $0.00 $23.00 FEMALE SUBSCRIBER RO1 O5O MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL NEPHROPATHY 12/27/2017 11/29/2017 1212212017 86901 BLOOD TYPING, SEROLOGIC; RH(D) E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $11.00 FEMALE SUBSCRIBER R01 OSO MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL NEPHROPATHY 12/27/2017 11/29/2017 12/22/2017 87340 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $24.00 FEMALE SUBSCRIBER R01 OSO IMMUNOASSAY TECHNIQUE, QUALITATIVE OR MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL SEMIQUANTITATIVE ,MULTIPLE -STEP METHOD; HEPATITIS NEPHROPATHY B SURFACE ANTIGEN (HBSAG) 12/27/2017 11/30/2017 12/22/2017 80069 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE E1121 TYPE DIABETES PROFESSIONAL $0.00 $29.00 FEMALE SUBSCRIBER R01 OSO FOLLOWING: ALBUMIN (82040), CALCIUM, TOTAL (82310), MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL CARBON DIOXIDE )BICARBONATE) )82374), CHLORIDE NEPHROPATHY ( 82435), CREATININE (82565),GLUCOSE(82947), PHOSPHORUS INORGANIC (PHOSPHATE) (84100), POTASSIUM (84132), SODIUM (84295), UREA NITROGEN (BU 12/27/2017 11/30/2017 1212212017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $11.00 FEMALE SUBSCRIBER RO1 OSO LET, RBC,WEE AND PLATELET COUNT) AND AUTOMATED MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT NEPHROPATHY 12/27/2017 11/30/2017 12/22/2017 85610 PROTHRDMBIN TIME; E1121 TYPE 20IABETES PROFESSIONAL $0.00 $10.00 FEMALE SUBSCRIBER R01 050 MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL NEPHROPATHY 12/27/2017 11/30/2017 12/22/2017 85670 THROMBIN TIME; PLASMA E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $23.00 FEMALE SUBSCRIBER R01 USE) MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL NEPHROPATHY 12/27/2017 11/30/2017 12/22/2017 85730 THROMBOPIASTIN TIME, PARTIAL (PTT); PLASMA OR E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $10.00 FEMALE SUBSCRIBER R01 O5O WHOLE BLOOD MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL NEPHROPATHY 12/27/2017 11/30/2017 12/22/2017 87340 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $24.00 FEMALE SUBSCRIBER R01 RISC IMMUNOASSAY TECHNIQUE, QUALITATIVE OR MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL SEMIQUANTITATIVE ,MULTIPLE -STEP METHOD; HEPATITIS NEPHROPATHY B SURFACE ANTIGEN (HBSAG) C.7.f 12/27/2017 121112017 12/2212017 80048 BASIC METABOLIC PAN EL (CALCIUM, TOTAL) THIS PANEL E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $26.00 FEMALE SUBSCRIBER R01 OSO 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) NEPHROPATHY Z CREATININE(82565) GLUCOSE (82947) POTASSIUM N (84132) SODIUM )84295) UREA NITROGEN (BUN) (84520) tU 12/27/2017 12/2/2017 12/22/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E1121 TYPE 2 DIABETES PROFESSIONAL $0.00 $26.00 FEMALE SUBSCRIBER R01 OSO 3559 A MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL MELLITUS WITH DIABETIC OUTPATIENT /HOSPITAL 192310) CARBON DIOXIDE (92374) CHLORIDE (92435) NEPHROPATHY r CREATININE(82565) GLUCOSE (82947) POTASSIUM "a (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) m O 12/27/2017 12/18/2017 12/22/2017 71010 RADIDLOGIC EXAMINATION, CHEST; SINGLE VIEW, R0602 SHORTNESS OF BREATH PROFESSIONAL $14.94 $45.00 FEMALE SUBSCRIBER RD1 050 3559 FRONTAL INPATIENT /HOSPITAL 12/27/2017 12/18/2017 12/26/2017 315001NTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE 1132 HYPERTENSIVE HEART PROFESSIONAL $266.56 $971.00 FEMALE SUBSCRIBER ROl ESE) 3559 0 AND CHRONIC KIDNEY OUTPATIENT /HOSPITAL E. CL DISEASE WITH HEART Q, FAILURE AND WITH STAGE Q 5 CHRONIC (KIDNEY DISEASE, OR END STAGE RENAL DISEASE 4 12/27/2017 12/18/2017 12/26/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE 1132 HYPERTENSIVE HEART PROFESSIONAL $399.67 $1,870.00 FEMALE SUBSCRIBER R01 OSO 3559 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- AND CHRONIC (KIDNEY OUTPATIENT /HOSPITAL uj 74MINUTES DISEASE WITH HEART FAILURE AND WITH STAGE 5 CHRONIC (KIDNEY DISEASE, OR END STAGE RENAL DISEASE 12/27/2017 12/18/2017 12/26/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE E9770 FLUID OVERLOAD, PROFESSIONAL $275.07 $568.00 FEMALE SUBSCRIBER R01 OSO 3559 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- UNSPECIFIED INPATIENT /HOSPITAL Q 74 MINUTES {li 12/27/2017 12/19/2017 12/25/2017 71010 RADIDLOGIC EXAMINATION, CHEST; SINGLE VIEW, Z4682 ENCOUNTER FOR FITTING PROFESSIONAL $14.94 $45.00 FEMALE SUBSCRIBER R01 OSO 3559 FRONTAL ANDADJUSTMENTOF INPATIENT /HOSPITAL UJ NON - VASCULAR cfnY CATHETER 1212712017 12/19/2017 12/26/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE E9770 FLUID OVERLOAD, PROFESSIONAL $275.07 $568.00 FEMALE SUBSCRIBER RO1 050 3559 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- UNSPECIFIED INPATIENT /HOSPITAL een 0 74 MINUTES 12/27/2017 12/20/2017 12/26/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E8770 FLUID OVERLOAD, PROFESSIONAL $85.67 $151.00 FEMALE SUBSCRIBER R01 OSO 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL ..J REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD N ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN v EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR LLJ 12/27/2017 12/20/2017 12/26/2017 71010 RADIDLDGIC EXAMINATION, CHEST; SINGLE VIEW, 1509 HEART FAILURE, PROFESSIONAL $14.94 $45.00 FEMALE SUBSCRIBER RO1 ESE) 3559 FRONTAL UNSPECIFIED INPATIENT /HOSPITAL 0 12/27/2017 12/21/2017 12/26/2017 * * * ** * * * ** * * *** * * * *' * * *'* $169.42 $516.01 FEMALE SUBSCRIBER R01 OSO 3559 12/28/2017 12/21/2017 12/27/2017 A0422 AMBULANCE(ALS OR BLS) OXYGEN AND OXYGEN R6889 OTHER GENERAL OTHER MEDICAL $30.00 $30.00 FEMALE SUBSCRIBER R01 050 3559 F SUPPLIES, LIFE SUSTAINING SITUATION SYMPTOMS AND SIGNS Q 12/28/2017 12/21/2017 12/27/2017 A0425 GROUND MILEAGE, PER STATUTE MILE R6889 OTHER GENERAL OTHER MEDICAL $7.50 $7.50 FEMALE SUBSCRIBER R01 OSO 3559 SYMPTOMS AND SIGNS N 12/28/2017 12/21/2017 12/27/2017 A0429 AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY R6889 OTHER GENERAL OTHER MEDICAL $33932 $358.67 FEMALE SUBSCRIBER R01 050 3559 N TRANSPORT (BLS EMERGENCY) SYMPTOMS AND SIGNS = Sub TO I $141,640.37 $1,549,917.25 {� 1.875E +10 1/9/2017 12/19/2016 1/6/2017 - - Z5111 ENCOUNTER FOR HOSPITAL INPATIENT 12/19/2016 # # # # # # ## $18,586.73 $107,103.00 MALE SUBSCRIBER 1 OSO 3559 E ANTINEOPLASTIC ._ CHEMOTHERAPY 2 1/11/2017 12/20/2016 111012017 99223 INITIAL HOSPITAL CARE, PER DAY, FORTH EVALUATION C8318 MANTLE CELL PROFESSIONAL $10.40 MALE AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 1 OSO LYMPHOMA, LYMPH INPATIENT /HOSPITAL SUBSCRIBER THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; $0.00 NODES OF MULTIPLE SUBSCRIBER 1050 A COMPREHENSIVE EXAMINATION; AND MEDICAL SITES DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 1/11/2017 12/21/2016 111012017 99234 OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE C8318 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT LYMPHOMA, LYMPH INPATIENT /HDSPITAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME NODES OF MULTIPLE DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS :A SITES DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT 1/11/2017 12/22/2016 111012017 99234 OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE C8318 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT LYMPHOMA, LYMPH INPATIENT/HOSPITAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME NODES OF MULTIPLE DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS :A SITES DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT 1/13/2017 12/23/2016 111212017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE C8318 MANTLE CELL PROFESSIONAL THAN 3D MINUTES LYMPHOMA, LYMPH INPATIENT /HDSPITAL NODES OF MULTIPLE SITES 1/18/2017 11/10/2016 1/17/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C8310 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS: AN SITE EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 1/18/2017 11/11/2016 1/17/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE C8310 MANTLE CELL PROFESSIONAL THAN 30 MINUTES LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL SITE 1/30/2017 1/9/2017 1/11/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9310 MANTLE CELL PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SITE DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565(, GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 1/30/2017 1/9/2017 1/11/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); C8310 MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 1/30/2017 1/9/2017 1/11/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C9310 MANTLE CELL PROFESSIONAL HOT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED LYMPHOMA UNSPECIFIED OUTPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT SITE 1/30/2017 1/9/2017 1114/2017 1036F CURRENTTOBACEO NON - USER (CAD, CAP, COPP, PV) C8318 MANTLE CELL PROFESSIONAL (DM) (IBD) LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF MULTIPLE SITES 1/30/2017 1/9/2017 1/14/2017 1126F INTERMEDIATE 'DELAY" OF ANY FLAP, PRIMARY "DELAY" C8318 MANTLE CELL PROFESSIONAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, NODES OF MULTIPLE SITES $0.00 $783.00 MALE SUBSCRIBER 1 050 $20337 $519.00 MALE SUBSCRIBER 1 050 $203.77 $519.00 MALE SUBSCRIBER 1 OSO $151.13 $408.00 MALE SUBSCRIBER 1 EGO $103.51 $276.00 MALE SUBSCRIBER 1 OSO $151.13 $408.00 MALE SUBSCRIBER 1 050 $0.00 $26.00 MALE SUBSCRIBER 1 EGO $0.00 $5.70 MALE SUBSCRIBER 1050 $0.00 $10.40 MALE SUBSCRIBER 1 OSO $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 C.7.f 3559 Lm WE 3559 3559 3559 3559 3559 3559 3559 3559 1/30/2017 1/9/2017 111412017 1/30/2017 1/9/2017 1/14/2017 G8427 1/30/2017 1/9/2017 1/14/2017 68484 113012017 1/9/2017 111412017 G8731 1/30/2017 1/9/2017 1/14/2017 G8938 1/30/2017 1/13/2017 1/19/2017 1036F 1/30/2017 1/13/2017 1/19/2017 1126F 1/30/2017 1/13/2017 1/19/2017 1/30/2017 1/13/2017 1/19/2017 68427 1/30/2017 1/13/2017 1/19/2017 G8484 1/30/2017 1/13/2017 1/19/2017 G8731 1/30/2017 1/13/2017 111912017 G8938 1/30/2017 1/20/2017 1124/2017 1/30/2017 1/20/2017 1/24/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C8318 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED $0.01 MALE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY $0.01 MALE NODES OF MULTIPLE 1050 COMPONENTS: A DETAILED HISTORY; A DETAILED $0.01 MALE SITES 1050 EXAMINATION; MEDICAL DECISION MAKING OF $0.01 MALE SUBSCRIBER 1050 MODERATE COMPLEXITY. COUNSELING AND /OR $0.01 MALE SUBSCRIBER 1050 COORDINATION OF CARE WITH OTHER $429.00 MALE SUBSCRIBER 1 OSO ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C8318 MANTLE CELL PROFESSIONAL THE MEDIC AL RECORD THEY OBTAINED, UPDATED, OR LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS NODES OF MULTIPLE SITES INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C8318 MANTLE CELL PROFESSIONAL REASON NOT GIVEN LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF MULTIPLE SITES PAIN ASSESSMENT USING A STANDARDIZED TOOL IS C8318 MANTLE CELL PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL REQUIRED NODES OF MULTIPLE SITES BMI IS DOCUMENTED AS BEING OUTSIDE OF NORMAL C8318 MANTLE CELL PROFESSIONAL LIMITS, FOLLOW -UP PLAN IS NOT DOCUMENTED, LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL DOCUMENTATION THE PATIENT IS NOT ELIGIBLE NODES OF MULTIPLE SITES CURRENTTOBACCO NON-USER (CAD, CAP, CORD, PV) C8310 MANTLE CELL PROFESSIONAL (DM) (IBD) LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C8310 MANTLE CELL PROFESSIONAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, SITE 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C8310 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY SITE COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C9310 MANTLE CELL PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS SITE INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C8310 MANTLE CELL PROFESSIONAL REASON NOT GIVEN LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE PAIN ASSESSMENT USING ASTANDARDIZED TOOL IS C8310 MANTLE CELL PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL REQUIRED SITE BMI IS DOCUMENTED AS BEING OUTSIDE OF NORMAL C9310 MANTLE CELL PROFESSIONAL LIMITS, FOLLOW -UP PLAN IS NOT DOCUMENTED, LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DOCUMENTATION THE PATIENT IS NOT ELIGIBLE SITE 11402 EXCISION, BENIGN LESION, EXCEPTSKIN TAG (UNLESS D485 NEOPLASM OF PROFESSIONAL OFFICE LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; LESION UNCERTAIN BEHAVIOR OF DIAMETER 1.1 TO 2.0 CM SKIN 12032 REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, D485 NEOPLASM OF PROFESSIONAL OFFICE TRUNK AND /OR EXTREMITIES (EXCLUDING HANDS AND UNCERTAIN BEHAVIOR OF FEET); 2.6 CM TO 7.5 CM SKIN $0.00 $299.00 MALE SUBSCRIBER 1 050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $429.00 MALE SUBSCRIBER 1 OSO $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $61.74 $173.48 MALE SUBSCRIBER 1 050 $328.09 $328.09 MALE SUBSCRIBER 1 050 C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 MSS 3559 3559 3559 3559 3559 1/30/2017 1/20/2017 112412017 88304 LEVEL III - SORG I CAL PATHOLOGY, GROSS AND D485 NEOPLASM OF PROFESSIONAL OFFICE $10.80 MALE MICROSCOPIC EXAMINATION ABORTION, INDUCED, 1 OSO UNCERTAIN BEHAVIOR OF $10.40 MALE SUBSCRIBER ABSCESS, ANEURYSM ARTERIAL/VENTRICULAR, ANUS, $0.00 SKIN SUBSCRIBER 1 OSO TAG, APPENDIX, OTHER THAN INCIDENTAL, ARTERY, ATHEROMATOUS PLAQUE, BARTHOLIN'S GLAND CYST, BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE, BURSA/SYNOVIAL 1/30/2017 12/19/2016 1/25/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED SITE 2/10/2017 1/30/2017 2/1/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C8318 MANTLE CELL PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (8231D), CARBON NODES OF MULTIPLE DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), SITES CREATININE(REESE), GLUCOSE (82947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 211012017 1/30/2017 2/1/2017 83615 LACTATE DEHVDROGENASE(ED),(LDH; C8318 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF MULTIPLE SITES 2/10/2017 1/30/2017 2/1/2017 83735 MAGNESIUM C8318 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF MULTIPLE SITES 2/10/2017 1/30/2017 2/1/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C8318 MANTLE CELL PROFESSIONAL HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT NODES OF MULTIPLE SITES 2/10/2017 1/31/2017 2/2/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C8311 MANTLE CELL PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LYMPHOMA, LYMPH INPATIENT /HDSPITAL TOTAL ( 82247), CALCIUM, TOTAL )82310), CARBON NODES OF HEAD, FACE, DIOXIDE (BICARBONATQ (82374), CHLORIDE (82435), AND NECK CREATININE (82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 2110/2017 1/31/2017 2/2/2017 83735 MAGNESIUM C8311 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH INPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 211012017 1/31/2017 21212017 84550 URIC ACID; BLOOD C9311 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH INPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 2/10/2017 1/31/2017 2/2/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, 08311 MANTLE CELL PROFESSIONAL HUT, BBC, NBC AND PLATELET COUNT) AND AUTOMATED LYMPHOMA, LYMPH INPATIENT/HOSPITAL DIFFERENTIAL W BC COUNT NODES OF HEAD, FACE, AND NECK 211012017 1/31/2017 2/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9310 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A SITE DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM $69.25 $69.25 MALE SUBSCRIBER 1 050 $557.00 $1,356.00 MALE SUBSCRIBER 1050 $0.00 $26.00 MALE SUBSCRIBER 1 OSO $0.00 $5.70 MALE SUBSCRIBER 1050 $0.00 $10.80 MALE SUBSCRIBER 1 OSO $0.00 $10.40 MALE SUBSCRIBER 1 OSO $0.00 $26.00 MALE SUBSCRIBER 1 OSO $0.00 $10.80 MALE SUBSCRIBER 1 050 $0.00 $4.30 MALE SUBSCRIBER 1050 $0.00 $10.40 MALE SUBSCRIBER 1 OSO $111.40 $399.00 MALE SUBSCRIBER 1 OSO C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 KmTI 2/10/2617 2/1/2017 2/3/2017 2/10/2017 2/1/2017 2/3/2017 2/10/2017 2/112017 2/3/2017 2/10/2017 2/1/2017 2/3/2017 2/10/2017 2/1/2017 2/3/2017 2/10/2017 2/2/2017 2/3/2017 2/13/2017 111612017 2/2/2017 2/13/2017 1/27/2017 2/1/2017 2/13/2017 1/27/2017 2/1/2017 2/13/2017 1/27/2017 2/1/2017 2/13/2017 1/30/2017 2/4/2017 1036F 2/13/2017 1130/2017 2/4/2017 1126F 80053 COMPREHENSIVE METABOLIC PANELTHISPANEL MUST C8311 MANTLE CELL PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, $4.30 MALE LYMPHOMA, LYMPH INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON $10.40 MALE NODES OF HEAD, FACE, 1 OSO DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), $399.00 MALE AND NECK 1 OSO CREATININE( 82565(, GLUCOSE (82947), PHOSPHATASE, $0.01 MALE SUBSCRIBER 1050 ALKALINE (84075), POTASSIUM (84132(, PROTEIN, 83735 MAGNESIUM C8311 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH INPATIENT / HDSPITAL NODES OF HEAD, FACE, AND NECK 84550 URIC ACID; BLOOD C8311 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH INPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, C9311 MANTLE CELL PROFESSIONAL HOT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED LYMPHOMA, LYMPH INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT NODES OF HEAD, FACE, AND NECK 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE C8310 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A SITE DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C8310 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN SITE EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 99396 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z0000 ENCOUNTER FOR PROFE55IONAL OFFICE REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL GENERAL ADULT MEDICAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; 40 -64 YEARS 94010 SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND C8311 MANTLE CELL PROFESSIONAL TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL MEASUREMENT(S), W ITH OR WITHOUT MAXIMAL NODES OF HEAD, FACE, VOLUNTARY VENTILATION AND NECK 94726 PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG C8311 MANTLE CELL PROFESSIONAL VOLUMES AND, WHEN PERFORMED, AIRWAY RESISTANCE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 94729 DIFFUSING CAPA.CITY(EG, CARBON MONOXIDE, C8311 MANTLE CELL PROFESSIONAL MEMBRANE) (LIST SEPARATELY IN ADDITION TO CODE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL FOR PRIMARY PROCEDURE) NODES OF HEAD, FACE, AND NECK CURRENTTOBACCO NON-USER (CAD, CAP, CORD, PV) C8311 MANTLE CELL PROFESSIONAL (DM] (IBD) LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C8311 MANTLE CELL PROFESSIONAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, NODES OF HEAD, FACE, AND NECK $0.00 $26.00 MALE SUBSCRIBER 1 050 $0.00 $10.80 MALE SUBSCRIBER 1 OSO $0.00 $4.30 MALE SUBSCRIBER 1050 $0.00 $10.40 MALE SUBSCRIBER 1 OSO $11140 $399.00 MALE SUBSCRIBER 1 OSO $77.63 $276.00 MALE SUBSCRIBER 1 OSO $108.39 $538.64 MALE SUBSCRIBER 1 OSO $10.07 $32.00 MALE SUBSCRIBER 1 EGO $0.00 $46.00 MALE SUBSCRIBER 1 OSO $4.64 $35.00 MALE SUBSCRIBER 1 OSO $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 C.7.f 3559 3559 3559 3559 3559 m 3559 3559 3559 3559 3559 2/13/2017 1/30/2017 2/4/2017 1220F 2/13/2017 1/30/2017 2/4/2017 2/13/2017 1/30/2017 2/4/2017 68427 2/13/2017 1/30/2017 2/4/2017 G8484 2/13/2017 1/30/2017 2/4/2017 68731 2/13/2017 1/30/2017 2/4/2017 G8938 2/13/2017 1/31/2017 2/3/2017 2/13/2017 212/2017 2/3/2017 2/13/2017 2/2/2017 2/4/2017 2/13/2017 2/212017 2/4/2017 2/13/2017 2/2/2017 2/4/2017 2/13/2017 2/2/2017 2/4/2017 PATIENTSCREENED FOR DEPRESSION (SUD) C8311 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL $0.00 $0.01 MALE NODES OF HEAD, FACE, 1050 $0.00 $0.01 MALE AND NECK 1050 99214 OFFICE OR OTHER DUTPATIENTVISIT FOR THE C8311 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY NODES OF HEAD, FACE, COMPONENTS: A DETAILED HISTORY; A DETAILED AND NECK EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C8311 MANTLE CELL PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS NODES OF HEAD, FACE, AND NECK INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C8311 MANTLE CELL PROFESSIONAL REASON NOT GIVEN LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK PAIN ASSESSMENT USING ASTANDARDIZED TOOL IS C8311 MANTLE CELL PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN LYMPHOMA, LYMPH OUTPATIENT/HOSPITAL REQUIRED NODES OF HEAD, FACE, AND NECK BMI IS DOCUMENTED AS BEING OUTSIDE OF NORMAL C8311 MANTLE CELL PROFESSIONAL LIMITS, FOLLDW -UP PLAN IS NOT DOCUMENTED, LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL DOCUMENTATION THE PATIENT IS NOT ELIGIBLE NODES OF HEAD, FACE, AND NECK 99223 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION C8311 MANTLE CELL PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LYMPHOMA, LYMPH INPATIENT /HOSPITAL THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; NODES OF HEAD, FACE, A COMPREHENSIVE EXAMINATION; AND MEDICAL AND NECK DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS DR AGEN 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE C8310 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LYMPHOMA UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 20 F TH ESE 3 KEY C0M PO N E NTS: A SITE DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C8311 MANTLE CELL PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LYMPHOMA, LYMPH INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON NODES OF HEAD, FACE, DIOXIDE (BICARBONATE) (92374), CHLORIDE (92435), AND NECK CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 83735 MAGNESIUM C8311 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH INPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 84550 URIC ACID; BLOOD C8311 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH INPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C8311 MANTLE CELL PROFESSIONAL HCT,RBC, WBC AND PLATELET COUNT) AND AUTOMATED LYMPHOMA, LYMPH INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT NODES OF HEAD, FACE, AND NECK $0.00 $0.00 MALE SUBSCRIBER 1050 $81.33 $299.00 MALE SUBSCRIBER 1 050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $783.00 MALE SUBSCRIBER 1 OSO $111.40 $399.00 MALE SUBSCRIBER 1 050 $0.00 $26.00 MALE SUBSCRIBER 1 050 $0.00 $10.80 MALE SUBSCRIBER 1 OSO $0.00 $4.30 MALE SUBSCRIBER 1050 $0.00 $10.40 MALE SUBSCRIBER 1 050 C.7.f 3559 w Z N 3559 III 3559 3559 3559 3559 III. IM ELifi1 3559 3559 2/13/2017 2/3/2017 2/7/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C8311 MANTLE CELL PROFESSIONAL SUBSCRIBER 1050 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, $10.40 MALE LYMPHOMA, LYMPH INPATIENT /HOSPITAL $20,267.60 $50,669.00 MALE TOTAL (82247), CALCIUM, TOTAL (82310), CARBON 1050 NODES OF HEAD, FACE, $50,669,00) MALE SUBSCRIBER 1 EGO DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), $10.80 MALE AND NECK 1 CEO $0.00 $11.30 MALE CREATININE( 82565(, GLUCOSE (82947), PH0SPHATASE, 1 OSO $0.00 $9.20 MALE SUBSCRIBER 1050 ALKALINE (84075), POTASSIUM (84132(, PROTEIN, $3.20 MALE SUBSCRIBER 1050 2/13/2017 2/3/2017 2/7/2017 83735 MAGNESIUM C8311 MANTLE CELL PROFESSIONAL SUBSCRIBER 1 DISC $158.02 $530.00 MALE LYMPHOMA, LYMPH INPATIENT / HDSPITAL NODES OF HEAD, FACE, AND NECK 2/13/2017 2/3/2017 2/7/2017 84550 URIC ACID; BLOOD C8311 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH INPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 2/13/2017 2/3/2017 2/7/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, C9311 MANTLE CELL PROFESSIONAL HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED LYMPHOMA, LYMPH INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT NODES OF HEAD, FACE, AND NECK 2/13/2017 10/19/2016 11/9/2016 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 2/13/2017 10/19/2016 11/9/2016 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 2/16/2017 1/27/2017 1/31/2017 82375 CARBOXYHEMOGLOBIN; QUANTITATIVE 08311 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 2/16/2017 1/27/2017 1131/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, P02, C8311 MANTLE CELL PROFESSIONAL CO2, HCO3 (INCLUDING CALCULATED 02 SATURATION); LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 2/16/2017 1/27/2017 1/31/2017 83050 HEMOGLOBIN; METHEMOGLOBIN, QUANTITATIVE C9311 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 2116/2017 1/27/2017 1/31/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) C8311 MANTLE CELL PROFESSIONAL LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 2/16/2017 1/27/2017 21112017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, C9311 MANTLE CELL PROFESSIONAL FRONTAL AND LATERAL; LYMPHOMA, LYMPH OUTPATIENT/HOSPITAL NODES OF HEAD, FACE, AND NECK 2/16/2017 1/29/2017 2/1/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 C8310 MANTLE CELL PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 2/16/2017 1/30/2017 2/1/2017 99222 INITIAL HOSPITALCARE, PER DAY, FORTIES EVALUATION C9310 MANTLE CELL OTHER MEDICAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LYMPHOMA, UNSPECIFIED THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; SITE ACOMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 2/17/2017 112712017 2/1/2017 93306 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH T451X5D ADVERSE EFFECT OF PROFESSIONAL IMAGE DOCUMENTATION (2D), INCLUDES M-MODE ANTINEOPLASTIC AND OUTPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH IMMUNOSUPPRESSIVE SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH DRUGS, SUBSEQUENT COLOR FLOW DOPPLER ECHOCARDIOGRAPHY ENCOUNTER $0.00 $26.00 MALE SUBSCRIBER 1 050 $0.00 $10.80 MALE SUBSCRIBER 1 OSO $0.00 $4.30 MALE SUBSCRIBER 1050 $0.00 $10.40 MALE SUBSCRIBER 1 EGO $20,267.60 $50,669.00 MALE SUBSCRIBER 1050 ($5.131, Wi $50,669,00) MALE SUBSCRIBER 1 EGO $0.00 $10.80 MALE SUBSCRIBER 1 CEO $0.00 $11.30 MALE SUBSCRIBER 1 OSO $0.00 $9.20 MALE SUBSCRIBER 1050 $0.00 $3.20 MALE SUBSCRIBER 1050 $0.00 $41.00 MALE SUBSCRIBER 1 EGO $10.92 $32.00 MALE SUBSCRIBER 1 DISC $158.02 $530.00 MALE SUBSCRIBER 1 OSO $0.00 $235.00 MALE SUBSCRIBER 1 OSO C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 I= C.7.f 2/17/2017 2/3/2017 2/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C8310 MANTLE CELL PROFESSIONAL $111.40 $399.00 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL REQUIRESAT LEAST 20FTHESE 3 KEY COMPONENTS:A SITE Z DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; N MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM t 2/17/2017 2/3/2017 2/7/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE C8310 MANTLE CELL PROFESSIONAL $11335 $408.00 MALE SUBSCRIBER 1050 3559 7 THAN 30 MINUTES LYMPHOMA, UNSPECIFIED INPATIENT / HDSPITAL SITE 2/20/2017 2/1/2017 2/4/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C8310 MANTLE CELL PROFESSIONAL $148.53 $399.00 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A SITE } DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. CL COUNSELING AND /OR COORDINATION OF CARE WITH Q, OTHER PROVI 2/24/2017 12/19/2016 1/25/2017- - C8310 MANTLE CELL HOSPITAL OUTPATIENT $0.00 $1,356.00 MALE SUBSCRIBER 1050 3559 LYMPHOMA, UNSPECIFIED SITE 2/24/2017 12/19/2016 1/25/2017- - 08310 MANTLE CELL HOSPITAL OUTPATIENT ($557,001 $0.00 MALE SUBSCRIBER 1050 3559 F LYMPHOMA, UNSPECIFIED {JJ ~ SITE D 212712017 2/17/2017 212112017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9310 MANTLE CELL PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 OSO 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SITE _ DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE 184025), POTASSIUM (84132), PROTEIN, IL 2/27/2017 2/17/2017 2/21/2017 83615 LACTATE DEHYDROGENASE(ED), BEDE); 08310 MANTLE CELL PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 050 3559 {Ji LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE UJ 2/27/2017 2/17/2017 2/21/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C8310 MANTLE CELL PR0FE55IONAL $0.00 $10.40 MALE SUBSCRIBER 1050 3559 HUT RBC,WBCAND PLATELET COUNT) AND AUTOMATED LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT SITE 2/27/2017 2/17/2017 212112017 85610 PROTHROMBIN TIME; C8310 MANTLE CELL PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 LLJ LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL e SITE q 2/27/2017 2/17/2017 2/21/2017 85730 THROMBOPLASTIN TIME, PARTIAL(PTT); PLASMA OR C8310 MANTLE CELL PROFESSIONAL $0.00 $6.50 MALE SUBSCRIBER 1050 3559 J WHOLE BLOOD LYMPHOMA, UNSPECIFIED OUTPATIENT/HOSPITAL SITE v 2/27/2017 2/17/2017 2/21/2017 1036E CURRENT TOBACCO NON -USER (CAD, CAP, COPD, PV) 08310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER 1 OSO 3559 f— (DM) BED) LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE llJ 2/27/2017 2/17/2017 2/21/2017 1126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C8310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER 1 OSO 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OFTUBED OR LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, SITE U 2/27/2017 2/17/2017 2121/2017 1220F PATIENTSCREENED FOR DEPRESSION(SUD) C8310 MANTLE CELL PROFESSIONAL $0.00 $0.00 MALE SUBSCRIBER 1 050 3559 F LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 2/27/2017 2/17/2017 2/21/2017 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C9310 MANTLE CELL PROFESSIONAL $15514 $429.00 MALE SUBSCRIBER 1050 3559 {FJ EVALUATION AND MANAGEMENTOFAN ESTABLISHED LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL hl PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY SITE COMPONENTS: A COMPREHENSIVE HISTORY; A = COMPREHENSIVE EXAMINATION; MEDICAL DECISION y MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH L 2/27/2017 2/17/2017 212112017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C8310 MANTLE CELL PROFESSIONAL $0.01 MALE THE MEDIC AL RECORD THEY OBTAINED, UPDATED, OR 1050 LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SUBSCRIBER REVIEWED THE PATIENT'S CURRENT MEDICATIONS $0RD SITE SUBSCRIBER 2/27/2017 2/17/2017 2/21/2017 G8484 INFLUENZA IMMUNIZATIDN WAS NOT ADMINISTERED, C8310 MANTLE CELL PROFESSIONAL $234.09 REASON NOT GIVEN SUBSCRIBER LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL $1,15100 MALE SUBSCRIBER 1050 SITE $59.00 MALE 2/27/2017 2/17/2017 2/21/2017 G8731 PAIN ASSESSMENT USING A STANDARDIZED TOOL IS C8310 MANTLE CELL PROFESSIONAL 1 OSO DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL REQUIRED SITE 2/27/2017 2/17/2017 2/21/2017 68938 EMI IS DOCUMENTED AS BEING OUTSIDE OF NORMAL C9310 MANTLE CELL PROFESSIONAL LIMITS, FOLLOW -UP PLAN IS NOT DOCUMENTED, LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DOCUMENTATION THE PATIENT IS MDT ELIGIBLE SITE 2/27/2017 2/17/2017 2/22/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET)WITH C8311 MANTLE CELL PROFESSIONAL CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL )CT) FOR ATTENUATION CORRECTION AND ANATOMICAL NODES OF HEAD, FACE, LOCALIZATION IMAGING; SKULL BASE TO MID -THIGH AND NECK 3/6/2017 1/27/2017 3/1/2017 .... ..... ..... ..... 3/6/2017 2/27/2017 3/1/2017 36558 INSERTION OFTUNNELED CENTRALLY INSERTED CENTRAL C8311 MANTLE CELL PROFESSIONAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL PUMP; AGE 5 YEARS OR OLDER NODES OF HEAD, FACE, AND NECK 3/6/2017 2/27/2017 3/1/2017 76937 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS C8311 MANTLE CELL PROFESSIONAL REQUIRING ULTRASOUND EVALUATION OF POTENTIAL LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL NODES OF HEAD, FACE, PATENCY, CONCURRENT REALTIME ULTRASOUND AND NECK VISUALIZATION OF VASCULAR NEEDLE ENTRY, 3/6/2017 2/27/2017 3/1/2017 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS C8311 MANTLE CELL PROFESSIONAL DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC NODES OF HEAD, FACE, GUIDANCE FOR VASCULAR ACCESS AND CATHETER AND NECK MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER W ITH RELATED VENOGRAPHYR 3/9/2017 2128/2017 3/3/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST Z52011 AUTOLOGOUS DONOR, PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, STEM CELLS OUTPATIENT/HOSPITAL TOTAL (82247), CALCIUM, TOTAL )82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 3/9/2017 2/28/2017 3/3/2017 82330 CALCIUM; IONIZED Z52011 AUTOLOGOUS DONOR, PROFESSIONAL STEM CELLS OUTPATIENT /HOSPITAL 3/9/2017 2/28/2017 3/3/2017 83735 MAGNESIUM Z52011 AUTOLOGOUS DONOR, PROFESSIONAL STEM CELLS OUTPATIENT /HOSPITAL 3/9/2017 2/28/2017 3/3/2017 84132 POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD Z52011 AUTOLOGOUS DONOR, PROFESSIONAL STEM CELLS OUTPATIENT /HOSPITAL 3/9/2017 2/28/2017 3/3/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC Z52011 AUTOLOGOUS DONOR, PROFESSIONAL EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT STEM CELLS OUTPATIENT /HOSPITAL 3/13/2017 1/9/2017 211012017 - - Z5111 ENCOUNTER FOR HOSPITA L OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0RD $0.01 MALE SUBSCRIBER 1050 $198.62 $485.00 MALE SUBSCRIBER 1 EGO $234.09 $483.05 MALE SUBSCRIBER 1 050 $489.63 $1,15100 MALE SUBSCRIBER 1050 $26.99 $59.00 MALE SUBSCRIBER 1 OSO $29.56 $71.00 MALE SUBSCRIBER 1 OSO $0.00 $26.00 MALE SUBSCRIBER 1 OSO $0.00 $21.60 MALE SUBSCRIBER 1 OSO $0.00 $10.80 MALE SUBSCRIBER 1 050 $0.00 $4.30 MALE SUBSCRIBER 1050 $0.00 $13.20 MALE SUBSCRIBER 1 OSO $25,524.39 $78,350.00 MALE SUBSCRIBER 1050 C.7.f 3/13/2017 1/9/2017 211012017 3/13/2017 1/13/2017 2/10/2017 3/13/2017 1/27/2017 2/20/2017 3/13/2017 1/30/2017 2/10/2017 3/13/2017 2/17/2017 2124/2017 3/13/2017 314/2017 3/6/2017 3/15/2017 1/30 /2017 211012017 3/17/2017 3/8/2017 3114/2017 3/17/2017 3/9/2017 3/11/2017 3/17/2017 3/9/2017 3/11/2017 3/17/2017 3/9/2017 3/11/2017 3/17/2017 3/9/2017 3/14/2017 1036F 3/17/2017 31 3/14/2017 1126F 3/17/2017 3/9/2017 3114/2017 1220F 3/17/2017 3/9/2017 3/14/2017 - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $0.00 $78,350.00 MALE SUBSCRIBER 1 O50 3559 ANTINEOPLASTIC W CHEMOTHERAPY - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $417.75 $1,234.00 MALE SUBSCRIBER 1RISC 3559 N ANTINEOPLASTIC CHEMOTHERAPY - C8311 MANTLE CELL HOSPITAL OUTPATIENT $2,924.22 $7,842.00 MALE SUBSCRIBER 1 ESE) 3559 A LYMPHOMA, LYMPH NODES OF HEAD, FACE, } AND NECK a - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $41734 $1,255.00 MALE SUBSCRIBER 1(50 3559 m ANTINEOPLASTIC w CHEMOTHERAPY - C8311 MANTLE CELL HOSPITAL OUTPATIENT $10,066.00 $23,446.00 MALE SUBSCRIBER 1050 lu 3559 } LYMPHOMA, LYMPH NODES OF HEAD, FACE, L CL AND NECK Q, 99203 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 1069 ACUTE UPPER PROFESSIONAL OFFICE $119.33 $160.00 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOF A NEW PATIENT, RESPIRATORY INFECTION, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED UNSPECIFIED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE P F - Z5111 ENCOUNTER FOR HOSPITAL INPATIENT 1/30/2017 2/3/2017 $13,232.03 $93,373.00 MALE SUBSCRIBER 1 ESE) 3559 ANTINEOPLASTIC CHEMOTHERAPY 93971 DUPLEXSCAN OF EXTREMEYVEINS INCLUDING M7989 OTHER SPECIFIED SOFT PROFESSIONAL $37.71 $89.00 MALE SUBSCRIBER 1050 _ 3559 RESPONSESTO COMPRESSION AND OTHER MANEUVERS; TISSUE DISORDERS OUTPATIENT /HOSPITAL x U N I L A TERAL OR LIMITED STUDY 0 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9310 MANTLE CELL PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1050 3559 Q. INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL uj TOTAL (82247), CALCIUM, TOTAL (8231D), CARBON SITE DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435(, U;! CREATININE( 82565(, 13LUCOSE(82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132(, PROTEIN, Q 83615 LACTATE DEHYDROGENASE (ED), (LDH); C8310 MANTLE CELL PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 OSO 3559 W LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE q 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C8310 MANTLE CELL PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1050 3559 J HOT, BBC, WBCAND PLATELETCOUNT ) ANDAUTOMATED LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT SITE v CURRENTTOBACCO NON-USER (CAD, CAP, CORD, PV) C8310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER 1050 3559 (DM) (IBD) LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE LLJ INTERMEDIATE " DELAY" OF ANY FLAP, PRIMARY "DELAY" C8310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER 1050 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OFTUBED OR LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, SITE U PATIENTSCREENED FOR DEPRESSION (SUD) C8310 MANTLE CELL PROFESSIONAL $0.00 $0.00 MALE SUBSCRIBER 1 OSO 3559 F LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C9310 MANTLE CELL PROFESSIONAL $15514 $429.00 MALE SUBSCRIBER 1050 3559 N EVALUATION AND MANAGEMENTOFAN ESTABLISHED LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL hl PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY SITE COMPONENTS: A COMPREHENSIVE HISTORY; A = COMPREHENSIVE EXAMINATION; MEDICAL DECISION y MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH m 3/17/2017 3/9/2017 3/14/2017 G8428 CURRENTLISTOF MEDICATIONS NOTDOCUMENTEDAS C8310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER 1050 OBTAINED, UPDATED, DR REVIEWED BYTHE ELIGIBLE LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL PROFESSIONAL, REASON NOTGIVEN SITE 3/17/2017 3/9/2017 3/14/201768484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C8310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER 1050 REASON NOT GIVEN LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 3/17/2017 3/9/2017 3/14/2017 G8732 NO DOCUMENTATION OF PAIN ASSESSMENT C8310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER 1050 LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 3/17/2017 3/9/2017 3/14/2017 68938 BMI IS DOCUMENTED AS BEING OUTSIDE OF NORMAL C9310 MANTLE CELL PROFESSIONAL SURD $0.01 MALE SUBSCRIBER 1050 LIMITS, FOLLOW -UP PLAN IS NOT DOCUMENTED, LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DOCUMENTATION THE PATIENT IS MDT ELIGIBLE SITE 3/24/2017 1/30/2017 2/10/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $0.00 $1,255.00 MALE SUBSCRIBER 1 OSO ANTINEOPLASTIC CHEMOTHERAPY 3/24/2017 1/30/2017 211012017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT f$,I -) ($1,255.00) MALE SUBSCRIBER 1 050 ANTINEOPLASTIC CHEMOTHERAPY 3/27/2017 3/3/2017 3/21/2017 - - Z7682 AWAITING ORGAN HOSPITAL OUTPATIENT $208.33 $731.00 MALE SUBSCRIBER 1 050 TRANSPLANT STATUS 3/28/2017 2/27/2017 3/10/2017- - Z52011 AUTOLOGOUS DONOR, HOSPITAL OUTPATIENT $0.00 $53,43100 MALE SUBSCRIBER 1050 STEM CELLS 3/30/2017 2/27/2017 3/21/2017- - Z52011 AUTOLOGOUS DONOR, HOSPITAL OUTPATIENT $0.00 $53,433.00 MALE SUBSCRIBER 1050 STEM CELLS 4/11/2017 2/28/2017 3/10/2017- - Z52011 AUTOLOGOUS DONOR, HOSPITAL OUTPATIENT $0.00 $28,716.00 MALE SUBSCRIBER 1050 STEM CELLS 4/18/2017 3/9/2017 4113/2017- - C8310 MANTLE CELL HOSPITAL OUTPATIENT $665.71 $1,841.00 MALE SUBSCRIBER 1050 LYMPHOMA, UNSPECIFIED SITE 4/18/2017 3/13/2017 4/13/2017 - - C9310 MANTLE CELL HOSPITAL OUTPATIENT $27738 $731.00 MALE SUBSCRIBER 1 050 LYMPHOMA, UNSPECIFIED SITE 4/19/2017 3/8/2017 4/13/2017- - C8310 MANTLE CELL HOSPITAL OUTPATIENT $510.72 $1,344.00 MALE SUBSCRIBER 1050 LYMPHOMA, UNSPECIFIED SITE 4/29/2017 12/19/2016 1/25/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT ($557.007 $1,356.00 MALE SUBSCRIBER 1 050 LYMPHOMA, UNSPECIFIED SITE 5/2/2017 2/27/2017 3/10/2017- - Z52011 AUTOLOGOUS DONOR, HOSPITAL OUTPATIENT $0.00 3,433 00) MALE SUBSCRIBER 1050 STEM CELLS 5/2/2017 2/27/2017 3/21/2017- - Z52011 AUTOLOGOUS DONOR, HOSPITAL OUTPATIENT $0.00 $53,433.00 MALE SUBSCRIBER 1050 STEM CELLS 5/4/2017 5/1/2017 5/3/2017 73610 RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, S93492A SPRAIN OFOTHER PROFESSIONAL OFFICE $25.86 $100.00 MALE SUBSCRIBER 1 050 MINIMUM OF THREE VIEWS LIGAMENT OF LEFT ANKLE, INITIAL ENCOUNTER 5/4/2017 5/1/2017 5/3/2017 99204 OFFICE OR OTHER OUTPATIENTVISIT FOR THE S93492A SPRAIN OF OTHER PROFESSIONAL OFFICE $108.33 $446.82 MALE SUBSCRIBER 1050 EVALUATION AND MANAGEMENTOF A NEW PATIENT, LIGAMENT OF LEFT WHICH REQUIRES THESE 3 KEYCOMPONENTS:A ANKLE, INITIAL COMPREHENSIVE HISTORY; A COMPREHENSIVE ENCOUNTER EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 5/4/2017 5/1/2017 5/3/2017 L1971 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL S93492A SPRAIN OF OTHER PROFESSIONAL OFFICE $256.03 $465.00 MALE SUBSCRIBER 1050 WITHANKLEJOINT, PREFABRICATED, INCLUDESFITTING LIGAMENT OF LEFT AND ADJUSTMENT ANKLE, INITIAL ENCOUNTER C.7.f 5/4/2017 5/1/2017 5/3/2017 L3020 FOOT, INSERT, REMOVABLE, MOLDEDTO PATIENT MODEL, 593492A SPRAIN OF OTHER PROFESSIONAL OFFICE $108.37 $376.00 MALE SUBSCRIBER 1050 3559 LONGITUDINAL/ METATARSAL SUPPORT, EACH LIGAMENT OF LEFT ANKLE, INITIAL ENCOUNTER N 5/12/2017 5/8/2017 5/11/2017 99213 OFFICE OR OTHER DUTPATIENTVISIT FOR THE 593492D SPRAIN OF OTHER PROFESSIONAL OFFICE $45.92 $190.25 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED LIGAMENT OF LEFT PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY ANKLE, SUBSEQUENT COMPONENTS: AN EXPANDED PROBLEM FOCUSED ENCOUNTER HISTORY; AN EXPANDED PROBLEM FOCUSED 7 EXAMINATION; MEDICAL DECISION MAKING OF LOW "a COMPLEXITY. COUNSELING AND COORD 5/16/2017 3/6/2017 5/10/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT $261.06 $687.00 MALE SUBSCRIBER 1 050 3559 LYMPHOMA, UNSPECIFIED } SITE 5/19/2017 3/16/2017 5/15/2017 - - C9310 MANTLE CELL HOSPITAL INPATIENT 4/4/2017 $101,000.00 $580,274.00 MALE SUBSCRIBER 1 050 3559 N. CL LYMPHOMA, UNSPECIFIED Q, SITE Q 5/19/2017 3/16/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE E878 OTHER DISORDERS OF PROFESSIONAL $0.00 $399.00 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH ELECTROLYTE AND FLUID INPATIENT /HOSPITAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A BALANCE, NOT rf DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; ELSEWHERE CLASSIFIED MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH Lij OTHER PROM F D 5/19/2017 3/16/2017 5/15/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; Z7682 AWAITING ORGAN TRANSPLANT STATUS PROFESSIONAL INPATIENT /HOSPITAL $0.00 $41.00 MALE SUBSCRIBER 1 OSO 3559 5/19/2017 3/17/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E879 OTHER DISORDERS OF PROFESSIONAL $0.00 $399.00 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH ELECTROLYTE AND FLUID INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A BALANCE, NOT DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; ELSEWHERE CLASSIFIED Q MEDICAL DECISION MAKING OF HIGH COMPLEXITY. ui COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI U`J 5/19/2017 3/18/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E978 OTHER DISORDERS OF PROFESSIONAL $0.00 $399.00 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH ELECTROLYTE AND FLUID INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A BALANCE, NOT LLJ DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; ELSEWHERE CLASSIFIED MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH J OTHER PROVI v 5/19/2017 3/18/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 OSO 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON LLJ DIOXIDE �BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84D75), POTASSIUM (84132), PROTEIN, Q 5/19/2017 3/18/2017 5/15/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT / HDSPITAL „p 5/19/2017 3/18/2017 5115/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 O5O 3559 UNSPECIFIED INPATIENT /HOSPITAL N 5/19/2017 3/18/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1050 N 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/19/2017 3/18/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1050 3559 HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 5/19/2017 3/19/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E878 OTHER DISORDERS OF PROFESSIONAL $0.00 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH SUBSCRIBER ELECTROLYTE AND FLUID INPATIENT /HOSPITAL $0.00 REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A SUBSCRIBER BALANCE, NOT 3559 $0.00 DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; SUBSCRIBER ELSEWHERE CLASSIFIED 3559 $0.00 MEDICAL DECISION MAKING OF HIGH COMPLEXITY. SUBSCRIBER 1 050 3559 $0.00 COUNSELING AND /OR COORDINATION OF CARE WITH SUBSCRIBER 1 OSO 3559 $0.00 OTHER PROVI SUBSCRIBER 1 OSO 3559 5/19/2017 3/19/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HDSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/19/2017 3/19/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL 5119/2017 3/19/2017 5/15/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED I N PATI ENT /HOSPITAL 5/19/2017 3/19/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL 5/19/2017 3/19/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL 5/19/2017 3/19/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL HCT,RBC,WBC AND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT/HOSPITAL DIFFERENTIAL W BC COUNT 5/19/2017 3/19/2017 5/15 /2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL 5/19/2017 3/20/2017 5/15/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 14510 UNSPECIFIED RIGHT PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY BUNDLE - BRANCH BLOCK INPATIENT /HOSPITAL 5/19/2017 3/20/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE E878 OTHER DISORDERS OF PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH ELECTROLYTEAND FLUID INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A BALANCE, NOT DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; ELSEWHERE CLASSIFIED MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/19/2017 3/21/2017 5/18/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E878 OTHER DISORDERS OF PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH ELECTROLYTE AND FLUID INPATIENT /HOSPITAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A BALANCE, NOT DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; ELSEWHERE CLASSIFIED MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/19/2017 3/22/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E878 OTHER DISORDERS OF PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH ELECTROLYTE AND FLUID INPATIENT /HOSPITAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A BALANCE, NOT DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; ELSEWHERE CLASSIFIED MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/19/2017 3/23/2017 5/15/2017 38241 BONE MARROW OR BLOOD - DERIVED PERIPHERAL STEM C8310 MANTLE CELL PROFESSIONAL CELL TRANSPLANTATION; AUTOLOGOUS LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL SITE $0.00 $399.00 MALE SUBSCRIBER 1 050 $0.00 $26.00 MALE SUBSCRIBER 1 050 C.7.f 3559 ®' $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 $0.00 $5.70 MALE SUBSCRIBER 1 OSO 3559 $0.00 $10.80 MALE SUBSCRIBER 1 OSO 3559 $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 $0.00 $10.40 MALE SUBSCRIBER 1 050 3559 $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 $0.00 $32.00 MALE SUBSCRIBER 1 OSO 3559 $0.00 $399.00 MALE SUBSCRIBER 1 OSO 3559 $0.00 $399.00 MALE SUBSCRIBER 1 OSO 3559 $0.00 $399.00 MALE SUBSCRIBER 1 OSO 3559 $0.00 $650.00 MALE SUBSCRIBER 1 O5O 3559 5/19/2017 3/23/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C8310 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL REQUIRESAT LEAST 2 OFTHESE 3 KEY COMPONENTS:A SITE DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/19/2017 3/24/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R110 NAUSEA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 5/19/2017 3/25/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R110 NAUSEA PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT /HOSPITAL REQUIRESAT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/19/2017 3/26/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R110 NAUSEA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/19/2017 3/27/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R109 UNSPECIFIED ABDOMINAL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH PAIN INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 5/19/2017 3/28/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R109 UNSPECIFIED ABDOMINAL PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH PAIN INPATIENT/HOSPITAL REQUIRESAT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/19/2017 3/29/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R109 UNSPECIFIED ABDOMINAL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH PAIN INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $0.00 $399.00 MALE SUBSCRIBER 1 050 $0.00 $399.00 MALE SUBSCRIBER 1 050 $0.00 $399.00 MALE SUBSCRIBER 1 EGO $0.00 $399.00 MALE SUBSCRIBER 1 OSO $0.00 $399.00 MALE SUBSCRIBER 1 OSO $0.00 $399.00 MALE SUBSCRIBER 1 050 $0.00 $399.00 MALE SUBSCRIBER 1 050 C.7.f 3559 ®' WE mm ®' WE ®' C.7.f 5/19/2017 3/30/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R109 UNSPECIFIED ABDOMINAL PROFESSIONAL $0.00 $399.00 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH PAIN INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A Z DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; N MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM t 5/19/2017 3/30/2017 5/15/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 14510 UNSPECIFIED RIGHT PROFESSIONAL $0.00 $32.00 MALE SUBSCRIBER 1050 3559 7 LEADS; INTERPRETATION AND REPORT ONLY BUNDLE - BRANCH BLOCK INPATIENT /HDSPITAL 5/19/2017 3/31/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R110 NAUSEA PROFESSIONAL $0.00 $399.00 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS A } DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. CL COUNSELING AND /OR COORDINATION OF CARE WITH Q, OTHER PROVI 5/19/2017 4/1/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 8110 NAUSEA PROFESSIONAL $0.00 $399.00 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD N ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. h COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 5/19/2017 4/2/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R110 NAUSEA PROFESSIONAL $0.00 $399.00 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. Q COUNSELING AND /OR COORDINATION OF CARE WITH ui OTHER PROVI 5/22/2017 3/16/2017 5/15/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION D709 NEUTROPENIA, PROFESSIONAL $0.00 $54.60 MALE SUBSCRIBER 1050 3559 AND PRESUMPTIVE IDENTIFICATION OF ISOLATES UNSPECIFIED INPATIENT /HOSPITAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) W 5/22/2017 3/16/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 050 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL �p TOTAL (82247), CALCIUM, TOTAL (82310), CARBON J DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, v ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/22/2017 3/16/2017 5/15/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); D709 NEUTROPENIA PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 OSO 3559 llJ UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3/16/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 0 5/22/2017 3/16/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1 OSO 3559 HCF, BBC, WBCAND PLATELETCOUNT) ANDAUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT „p 5/22/2017 3/16/2017 5115/2017 85730 THROMBOPLASTIN TIME, PARTIAL(PTT); PLASMA OR D709 NEUTROPENIA, PROFESSIONAL $0.00 $6.50 MALE SUBSCRIBER 1050 3559 WHOLE BLOOD UNSPECIFIED INPATIENT /HOSPITAL N 5/22/2017 3/16/2017 5/15/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION D709 NEUTROPENIA, PROFESSIONAL $0.00 $18.20 MALE SUBSCRIBER 1050 N 3559 AND PRESUMPTIVE IDENTIFICATION OF ISOLATES UNSPECIFIED INPATIENT /HOSPITAL = (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) E 5/22/2017 3/16/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 ._ UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3/16/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT/HOSPITAL C.7.f 5/22/2017 3/16/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3/16/2017 5/15/2017 85610 PROTHROMBIN TIME; D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 C! UNSPECIFIED INPATIENT /HOSPITAL N 5/22/2017 3/16/2017 5/15/2017 86480 TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN D709 NEUTROPENIA, PROFESSIONAL $0.00 $180.00 MALE SUBSCRIBER 1 050 3559 RESPONSE MEASUREMENT; GAMMA INTERFERON UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3/17/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 050 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HDSPITAL } TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (92947), PH0SPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, W 5/22/2017 3/17/2017 5/15/2017 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR D709 NEUTROPENIA, PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1050 } 3559 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, UNSPECIFIED INPATIENT /HOSPITAL E. CL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, Q, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; v AUTOMATED, WITH MICROSCOPY 5/22/2017 3/17/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT/HOSPITAL ..f 5/22/2017 3/17/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1050 3559 �+ HCE, BBC, WBCAND PLATELETCOUNT) AND AUTOMATED UNSPECIFIED INPATIENT/HOSPITAL DIFFERENTIAL W BC COUNT uj 512212017 3/17/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 h 5/22/2017 3/17/2017 5/15/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); D709 UNSPECIFIED NEUTROPENIA, INPATIENT /HOSPITAL PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HDSPITAL 5/22/2017 3/17/2017 5115/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO _ 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3/17/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFE55IONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL IL 5/22/2017 3/17/2017 5/15/2017 87081 CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.00 MALE SUBSCRIBER 1050 3559 {i SCREENING ONLY; UNSPECIFIED INPATIENT /HOSPITAL S/22/2017 3/18/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 U`J UNSPECIFIED INPATIENT /HOSPITAL 5122/2017 3/18/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3124/2017 5/15/2017 80202 VANCOMYCIN D709 NEUTROPENIA, PROFE55IONAL $0.00 $23.00 MALE SUBSCRIBER 1 OSO 3559 W UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3/26/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 OSO 3559 � INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL J TOTAL (82247), CALCIUM, TOTAL )82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), V CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, r ALKALINE (84075), POTASSIUM (84132), PROTEIN, W 5/22/2017 3/26/2017 5/15/2017 83615 LACTATE DEHYDROGENASE(ED),(LDHR; D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT/HOSPITAL 5/22/2017 3/26/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 050 3559 (' UNSPECIFIED INPATIENT /HDSPITAL 5/22/2017 3/26/2017 5115/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3/26/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PR0FE55IONAL $0.00 $10.40 MALE SUBSCRIBER 1 OSO 3559 HCT,BBC, WBCAND PLATELETCOUNT ) ANDAUTOMATED UNSPECIFIED INPATIENT /HOSPITAL 04 DIFFERENTIAL W BC COUNT C4 C.7.f 5/22/2017 3/27/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 050 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/22/2017 3/27/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HDSPITAL 5/22/2017 3/27/2017 5115/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 05O 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3/27/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 (1 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3/27/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3/27/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1(1 3559 HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 5/22/2017 3/27/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 EGO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/22/2017 3/28/2017 5/15/2017 874931nfectious agent detection by nucleic acid(DNA or RNA); D709 NEUTROPENIA, PROFESSIONAL $0.00 $28.00 MALE SUBSCRIBER 1EGO 3559 Clos[ rid— diffidle, toxin gene(,), a mplified probe UNSPECIFIED INPATIENT /HOSPITAL technique 5/22/2017 4/10/2017 5/19/2017- - C8310 MANTLE CELL HOSPITAL OUTPATIENT $557.00 $1,234.00 MALE SUBSCRIBER 1 0S 3559 LYMPHOMA, UNSPECIFIED SITE 5/22/2017 5/17/2017 5/19/2017 11100 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND /OR D485 NEOPLASM OF PROFESSIONAL OFFICE $110.53 $110.53 MALE SUBSCRIBER 1 EGO 3559 MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNCERTAIN BEHAVIOR OF UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); SKIN SINGLE LESION 5/22/2017 5/17/2017 5/19/2017 88304 LEVELIII- SURGICAL PATHOLOGY, GROSS AND D485 NEOPLASM OF PROFESSIONAL OFFICE $69.25 $69.25 MALE SUBSCRIBER 1 OSO 3559 MICROSCOPIC EXAMINATION ABORTION, INDUCED, UNCERTAIN BEHAVIOR OF ABSCESS, ANEURYSM - ARTERIAL/VENTRICULAR, ANUS, SKIN TAG, APPENDIX, OTHERTHAN INCIDENTAL, ARTERY, ATHEROMATOUS PLAQUE, BARTHOLIN'S GLAND CYST, BONE FRAGMENT(5), OTHERTHAN PATHOLOGIC FRACTURE, BURSA /SYNOVIAL 5/23/2017 3120/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 05O 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/23/2017 3/20/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/23/2017 3/20/2017 5/15/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 0SO 3559 UNSPECIFIED INPATIENT/HOSPITAL 5/23/2017 3/20/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HDSPITAL 5/23/2017 3/20/2017 5115/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/23/2017 3/20/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1(1 3559 HCT, BBC, WBCAND PLATELETCOUNT ) ANDAUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT C.7.f 5/23/2017 3/21/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 050 3559 INCLUDE THE FOLLOWING ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON Z DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), N CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/23/2017 3/21/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HDSPITAL } 5/23/2017 3/21/2017 5115/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 050 3559 "a UNSPECIFIED INPATIENT /HOSPITAL 5/23/2017 3/21/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 EGO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/23/2017 3/21/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1 050 3559 fl } HCT,ReC, WBC AND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT CL 5123/2017 3/21/2017 5/15/2017 87081 CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.00 MALE SUBSCRIBER 1050 3559 Q, SCREENING ONLY; UNSPECIFIED INPATIENT /HOSPITAL 5/23/2017 3/21/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 v UNSPECIFIED INPATIENT /HOSPITAL 5/23/2017 3/21/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 EGO 3559 ® y UNSPECIFIED INPATIENT /HOSPITAL 5/23/2017 3/22/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 OSO 3559 INCLUDE THE FOLLOW ING ALBUMIN (82040 ),BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL uj TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ~ DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, _ 5/23/2017 3/22/2017 5115/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HDSPITAL 5/23/2017 3/22/2017 5/15/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 050 3559 Q UNSPECIFIED INPATIENT /HOSPITAL Lli 5/23/2017 3/22/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL U`J 5/23/2017 3/22/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 0 5123/2017 3/22/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL W 5/23/2017 3/22/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1050 3559 HOT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT J 5/23/2017 3/23/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 OSO 3559 INCLUDE THE FOLLOWING' ALBUMIN (82040 ),BILIRUBIN, UNSPECIFIED INPATIENT/HOSPITAL v TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, LLJ ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/23/2017 3/23/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 OSO 3559 (' UNSPECIFIED INPATIENT /HDSPITAL 5/23/2017 3/23/2017 5115/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/23/2017 3/23/2017 5/15/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 EGO 3559 UNSPECIFIED INPATIENT /HOSPITAL CEJ 5/23/2017 3/23/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 hl 3559 UNSPECIFIED INPATIENT /HOSPITAL = 5/23/2017 3/23/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4,30 MALE SUBSCRIBER 1 EGO 3559 y UNSPECIFIED INPATIENT /HOSPITAL 5/23/2017 3/23/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1 OSO 3559 ._ HOT, PRO, WBC AND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT 5/23/2017 3/24/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 1 OSO 3559 UNSPECIFIED INCLUDE THE FOLLOWING ALBUMIN (82040), BILIRUBIN, TOTAL (82247), CALCIUM, TOTAL (82310), CARBON NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), 1 O5O 3559 UNSPECIFIED INPATIENT /HOSPITAL CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, PROFESSIONAL 5/23/2017 3/24/2017 5/15/2017 83735 MAGNESIUM D709 5/23/2017 3/24/2017 5115/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, HCE, RISC, W BC AND PLATELET COUNT) AND AUTOMATED $0.00 $5.70 MALE SUBSCRIBER 1 OSO DIFFERENTIAL W BC COUNT UNSPECIFIED S/23/2017 3/24/2017 S/1S/2017 82248 BILIRUBIN; DIRECT D709 5/23/2017 3/24/2017 5/15/2017 83615 LACTATE DEHYDROGENASE (LD), (LDH); D709 5123/2017 3/24/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 5/23/2017 3/24/2017 5/15/2017 84550 URIC ACID; BLOOD D709 5/23/2017 3/25/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 1 OSO 3559 UNSPECIFIED INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL (82247), CALCIUM, TOTAL (82310), CARBON NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE DIOXIDE �BICARBONATE) (82374), CHLORIDE (82435), 1 OSO 3559 UNSPECIFIED INPATIENT/HOSPITAL CREATININE( 82565), GLUCOSE (92947), PH0SPHATASE, ALKALINE (84D75), POTASSIUM (84132), PROTEIN, PROFESSIONAL 5/23/2017 3/25/2017 5/15/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); D709 5/23/2017 3/25/2017 5115/2017 83735 MAGNESIUM D709 5/23/2017 3/25/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 $10.80 MALE SUBSCRIBER 1 OSO HCT, BBC, W BC AND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 5/23/2017 3/25/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 5123/2017 3/25/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 5/23/2017 3125/2017 5/15/2017 84550 URIC ACID; BLOOD D709 5/23/2017 3/26/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 5/23/2017 3/26/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 5/24/2017 3/20/2017 5/15/2017 84550 URIC ACID; BLOOD D709 5/24/2017 3/31/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 3559 UNSPECIFIED INPATIENT /HOSPITAL INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, TOTAL (82247), CALCIUM, TOTAL (82310), CARBON PROFE55IONAL $0.00 $4.30 MALE SUBSCRIBER DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), 3559 UNSPECIFIED INPATIENT /HOSPITAL CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, NEUTROPENIA, ALKALINE (84075), POTASSIUM (84132), PROTEIN, $0.00 5/24/2017 3/31/2017 5/15/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION D709 INPATIENT /HOSPITAL AND PRESUMPTIVE IDENTIFICATION OF ISOLATES NEUTROPENIA, PROFESSIONAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) $4.30 MALE 5/24/2017 3/31/2017 5/15/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR D709 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, NEUTROPENIA, PROFESSIONAL $0.00 LEUI(OCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, SUBSCRIBER 1 OSO 3559 UNSPECIFIED UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY NEUTROPENIA, NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL $0.00 $26.00 MALE SUBSCRIBER 1 050 C.7.f 3559 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HDSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1 O5O 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3SS9 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT/HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED I N PATI ENT / H DSP ITAL NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFE55IONAL $0.00 $4.30 MALE SUBSCRIBER 1 ESE, 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED I N PATI ENT /H DSP ITA L NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFE55IONAL $0.00 $26.00 MALE SUBSCRIBER 1 EGO 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PR0FE55IONAL $0.00 $18.20 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL NEUTROPENIA, PROFESSIONAL $0.00 $6,00 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT/HOSPITAL C.7.f 5/24/2017 3/31/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED I N PATI ENT /H OSP ITA L 5/24/2017 3/31/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HER, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1 OSO 3559 HCT, BBC, WBCAND PLATELETCOUNT ) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 5/24/2017 3/31/2017 5/15/2017 87070 CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, D709 NEUTROPENIA, PROFESSIONAL $0.00 $14.00 MALE SUBSCRIBER 1 050 3559 BLOOD ORSTOOL, AEROBIC, WITH ISOLATION AND UNSPECIFIED INPATIENT /HOSPITAL PRESUMPTIVE IDENTIFICATION OF ISOLATES 5/24/2017 3/31/2017 5115/2017 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, D709 NEUTROPENIA, PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1050 3559 URINE UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 3/31/2017 5/15/2017 87205 SMEAR, PRIMARYSOURCE WITH INTERPRETATION; GRAM D709 NEUTROPENIA, PROFESSIONAL $0.00 $9.20 MALE SUBSCRIBER 1 OSO 3559 OR GIENI STAIN FOR BACTERIA, FUNGI, OR CELLTYPES UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 3/31/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5124/2017 3/31/2017 5/15/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 3/31/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 3/31/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 3/31/2017 5/15/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 4/1/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 OSO 3559 INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL )82310), CARBON DIOXIDE (BICARBONATE) (92374), CHLORIDE (92435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/24/2017 4/1/2017 5/15/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 4/1/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 4/1/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1 050 3559 LET, BBC, WBC AND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 5/24/2017 4/1/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFE55IONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 411/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 PAD 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 4/1/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 4/1/2017 5/15/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.40 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 4/2/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 OSO 3559 INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/24/2017 4/212017 5/15/2017 80202 VANCOMYCIN D709 NEUTROPENIA, PROFESSIONAL $0.00 $23.00 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 4/2/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 4/2/2017 5/15/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); D709 NEUTROPENIA, PROFESSIONAL $0.00 $5,70 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 4/2/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 4/2/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1050 3559 LET, BBC, WBCAND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 5/24/2017 4/2/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 RISC 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/24/2017 4/2/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 3/22/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 OSO 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HDSPITAL TOTAL (82247), CALCIUM, TOTAL )82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (92947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 5/25/2017 3/22/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED I N PATI ENT /HOSPITAL 5125/2017 3/22/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1 OSO 3559 HCF,RBC, WBCAND PLATELETCOUNT ) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 5/25/2017 3/22/2017 5/15/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION D709 NEUTROPENIA, PROFESSIONAL $0.00 $72.80 MALE SUBSCRIBER 1050 3559 AND PRESUMPTIVE IDENTIFICATION OF ISOLATES UNSPECIFIED INPATIENT /HOSPITAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) 5/25/2017 3/22/2017 5/15/2017 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, D709 NEUTROPENIA, PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER 1 RISE) 3559 URINE UNSPECIFIED INPATIENT /HOSPITAL 512512017 3/22/2017 5/15/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR D709 NEUTROPENIA, PROFESSIONAL $0.00 $6.00 MALE SUBSCRIBER 1RISC 3559 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, UNSPECIFIED INPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 5/25/2017 3/28/2017 5/15/2017 83615 LACTATE DEHYDROGENASE(ED), RUE); D709 NEUTROPENIA, PROFE55IONAL $0.00 $5.70 MALE SUBSCRIBER 1 EGO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 3/28/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1 EGO 3559 HCF,RBC, WBCAND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 5/25/2017 3/28/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 3128/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 3/28/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 3/29/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 OSO 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040 ),BILIRUBIN, UNSPECIFIED INPATIENT/HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/25/2017 3/29/2017 5/15/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HDSPITAL 5/25/2017 3/29/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 3/29/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE(CBCU AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1 RISE) 3559 HCF,RBC,WBCAND PLATELETCOUNT) ANDAUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL WEE COUNT 5/25/2017 3/29/2017 5115/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.40 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL C.7.f 5/25/2017 3/30/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 050 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON Z DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), N CREATININE (82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/25/2017 3/30/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HDSPITAL } 5/25/2017 3/30/2017 5115/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); D709 NEUTROPENIA, PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 050 3559 "a UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 3/30/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 3/30/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 fl } UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 3/30/2017 5/15/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER 1 050 3559 E. CL HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT/HOSPITAL Q, DIFFERENTIAL W BC COUNT 5/25/2017 3/30/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 3/31/2017 5/15/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION D709 NEUTROPENIA, PROFESSIONAL $0.00 $54.60 MALE SUBSCRIBER 1 OSO 3559 ® y AND PRESUMPTIVE IDENTIFICATION OF ISOLATES UNSPECIFIED INPATIENT /HOSPITAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) W 5/25/2017 3/31/2017 5/15/2017 71020 RADIOLDGIC EXAMINATION, CHEST, TWO VIEWS, D709 NEUTROPENIA, PROFESSIONAL $0.00 $41.00 MALE SUBSCRIBER 1 DISC 3559 h 5/25/2017 4/3/2017 5/15/2017 FRONTALAND LATERAL; 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 8109 UNSPECIFIED INPATIENT /HOSPITAL UNSPECIFIED ABDOMINAL PROFESSIONAL $0.00 $399.00 MALE SUBSCRIBER 1050 3559 D EVALUATION AND MANAGEMENTOFA PATIENT, WHICH PAIN INPATIENT /HOSPITAL _ REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH IL OTHER PROM Lli 5/25/2017 4/3/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER 1 050 3559 UJ INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (92435), Q CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, W ALKALINE (84075), POTASSIUM (84132), PROTEIN, ..I 4 5/25/2017 413/2017 5/15/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); D709 NEUTROPENIA PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 4/3/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER 1 050 3559 v UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 4/3/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT/HOSPITAL LLJ 5/25/2017 4/3/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 UNSPECIFIED INPATIENT /HOSPITAL 512512017 4/3/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED INPATIENT /HOSPITAL 512512017 4/3/2017 5/15/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC D709 NEUTROPENIA, PROFESSIONAL $0.00 $6.60 MALE SUBSCRIBER 1050 3559 EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT UNSPECIFIED INPATIENT /HDSPITAL „p {V 5/25/2017 4/4/2017 5/15/2017 36589 REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, C8311 MANTLE CELL PROFESSIONAL $0.00 $574.00 MALE SUBSCRIBER 1 OSO 3559 N WITHOUT SUBCUTANEOUS PORT OR PUMP LYMPHOMA, LYMPH INPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK C ❑i 5/25/2017 4/4/2017 5/15/2017 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS C8311 MANTLE CELL PROFESSIONAL 3559 DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR $5.70 MALE LYMPHOMA, LYMPH INPATIENT /HOSPITAL 3559 COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC $10.80 MALE NODES OF HEAD, FACE, 1 OSO 3559 GUIDANCE FOR VASCULAR ACCESS AND CATHETER $4.30 MALE AND NECK 1 OSO 3559 MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS $4.30 MALE SUBSCRIBER 1 OSO 3559 THROUGH ACCESS SITE OR CATHETER WITH RELATED $6.60 MALE SUBSCRIBER 1 060 3559 VENOGRAPHYR $1,351.00 MALE SUBSCRIBER 1 OSO 5/25/2017 4/4/2017 5/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D6481 ANEMIA DUE TO PROFESSIONAL 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH ANTINEOPLASTIC INPATIENT /HDSPITAL REQUIRES AT LEAST 20F THESE 3 KEY C0MPONENTS:A CHEMOTHERAPY DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 5/25/2017 4/4/2017 5/15/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT/HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/25/2017 4/4/2017 5/15/2017 82248 BILIRUBIN; DIRECT D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED I N PATI ENT /H OSP ITA L 5/25/2017 4/4/2017 5/15/2017 83615 LACTATE DEHYDRDGENASE(ED),(LDHU D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 4/4/2017 5/15/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 4/4/2017 5/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED I N PATI ENT /HOSPITAL 5/25/2017 4/4/2017 5/15/2017 84550 URIC ACID; BLOOD D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 4/4/2017 5115/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC D709 NEUTROPENIA, PROFESSIONAL EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT UNSPECIFIED INPATIENT /HOSPITAL 5/25/2017 4/27/2017 5/24/2017 - - C9310 MANTLE CELL HOSPITA L OUTPATIENT LYMPHOMA, UNSPECIFIED SITE 5/25/2017 5/15/2017 5/24/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C8330 DIFFUSE LARGE B -CELL PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SITE DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/25/2017 5/15/2017 5/24/2017 83615 LACTATE DEHYDROGENASE(ED), HEDE); C8330 DIFFUSE LARGE B -CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 5/25/2017 5/15/2017 5/24/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C8330 DIFFUSE LARGE B -CELL PROFESSIONAL HU, BBC, WBCAND PLATELETCDUNT) AND AUTOMATED LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT SITE 5/25/2017 5 /15 /2017 5/24/2017 1036F CURRENTTOBACCO NON - USER (CAD, CAP, CORD, PV) C9310 MANTLE CELL PROFESSIONAL (DM) (IBD) LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 5/25/2017 S /1S/2017 5124/2017 1126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C8310 MANTLE CELL PROFESSIONAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, SITE 5/25/2017 5/15/2017 5/24/2017 1220F PATIENTSCREENED FOR DEPRESSION (SUD) C9310 MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE $0.00 $71.00 MALE SUBSCRIBER 1 050 C.7.f 3559 $0.00 $399.00 MALE SUBSCRIBER 1 050 3559 $0.00 $26.00 MALE SUBSCRIBER 1 PSG 3559 $0.00 $4.30 MALE SUBSCRIBER 1 050 3559 $0.00 $5.70 MALE SUBSCRIBER 1 O50 3559 $0.00 $10.80 MALE SUBSCRIBER 1 OSO 3559 $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 $0.00 $4.30 MALE SUBSCRIBER 1 OSO 3559 $0.00 $6.60 MALE SUBSCRIBER 1 060 3559 $557.00 $1,351.00 MALE SUBSCRIBER 1 OSO 3559 $0.00 $26.00 MALE SUBSCRIBER 1 O5O 3559 $0.00 $5.70 MALE SUBSCRIBER 1 OSO 3559 $0.00 $10.40 MALE SUBSCRIBER 1 OSO 3559 $0.00 $0.01 MALE SUBSCRIBER 1 OSO 3559 $0.00 $0.01 MALE SUBSCRIBER 1 OSO 3559 $0.00 $0.01 MALE SUBSCRIBER 1 050 3559 5/25/2017 5/15/2017 5/24/2017 5/25/2017 5/15/2017 5/24/2017 G8427 5/25/2017 5/15/2017 5/24/2017 68731 5/25/2017 5/15/2017 5/24/2017 G8938 5/27/2017 1/30/2017 211012017 - 5/30/2017 1/27/2017 2/1/2017 5/30/2017 1/27/2017 2/1/2017 5/30/2017 1/27/2017 2/1/2017 5/30/2017 1/27/2017 2/1/2017 5/30/2017 1/27/2017 2/1/2017 5/30/2017 1/27/2017 2/1/2017 5/30/2017 1/27/2017 5/24/2017 5/30/2017 1/27/2017 5/24/2017 5/30/2017 1/27/2017 5/24/2017 5/31/2017 2128/2017 4/25/2017 - 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C8310 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED $0.01 MALE LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY $0.01 MALE SITE 1050 COMPONENTS: A COMPREHENSIVE HISTORY; A $1,255.00 MALE SUBSCRIBER 1050 COMPREHENSIVE EXAMINATION; MEDICAL DECISION $32.00 MALE SUBSCRIBER 1 OSO MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR $46.00 MALE SUBSCRIBER 1 OSO COORDINATION OF CARE WITH $35.00 MALE SUBSCRIBER 1 OSO ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C8310 MANTLE CELL PROFESSIONAL THE MEDIC AL RECORD THEY OBTAINED, UPDATED, OR ($46.09 MALE LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS (.5,15.00) MALE SITE 1 OSO PAIN ASSESSMENT USING A STANDARDIZED TOOL IS C8310 MANTLE CELL PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN $46.00 MALE LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL REQUIRED $35,00 MALE SITE 1 050 BMI IS DOCUMENTED AS BEING OUTSIDE OF NORMAL C9310 MANTLE CELL PROFESSIONAL LIMITS, FOLLOW -UP PLAN IS NOT DOCUMENTED, LYMPHOMA UNSPECIFIED OUTPATIENT /HOSPITAL DOCUMENTATION THE PATIENT IS NOT ELIGIBLE SITE - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 94010 SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTALAND C8311 MANTLE CELL PROFESSIONAL TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL MEASUREMENT(S), WITH OR WITHOUT MAXIMAL NODES OF HEAD, FACE, VOLUNTARY VENTILATION AND NECK 94726 PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG C8311 MANTLE CELL PROFESSIONAL VOLUMES AND, WHEN PERFORMED, AIRWAY RESISTANCE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 94729 DIFFUSING CAPACITY(EG, CARBON MONOXIDE, C8311 MANTLE CELL PROFESSIONAL MEMBRANE) (LIST SEPARATELY IN ADDITION TO CODE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL FOR PRIMARY PROCEDURE) NODES OF HEAD, FACE, AND NECK 94010 SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTALAND C9311 MANTLE CELL PROFESSIONAL TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL MEASUREMENT(S), WITH OR WITHOUT MAXIMAL NODES OF HEAD, FACE, VOLUNTARY VENTILATION AND NECK 94726 PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG C9311 MANTLE CELL PROFESSIONAL VOLUMES AND, WHEN PERFORMED, AIRWAY RESISTANCE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 94729 DIFFUSING CAPACITY(EG, CARBON MONOXIDE, C8311 MANTLE CELL PROFESSIONAL MEMBRANE) (LIST SEPARATELY IN ADDITION TO CODE LYMPHOMA LYMPH OUTPATIENT /HOSPITAL FOR PRIMARY PROCEDURE) NODES OF HEAD, FACE, AND NECK 94010 SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTALAND C8311 MANTLE CELL PROFESSIONAL TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL MEASUREMENT(S), WITH OR WITHOUT MAXIMAL NODES OF HEAD, FACE, VOLUNTARY VENTILATION AND NECK 94726 PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG C8311 MANTLE CELL PROFESSIONAL VOLUMES AND, WHEN PERFORMED, AIRWAY RESISTANCE LYMPHOMA LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 94729 DIFFUSING CAPACITY(EG, CARBON MONOXIDE, C8311 MANTLE CELL PROFESSIONAL MEMBRANE) (LIST SEPARATELY IN ADDITION TO CODE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL FOR PRIMARY PROCEDURE) NODES OF HEAD, FACE, AND NECK - Z52011 AUTOLOGOUS DONOR, HOSPITAL OUTPATIENT STEM CELLS $155.24 $429.00 MALE SUBSCRIBER 1 050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 ,$= '.20.211 $1,255.00 MALE SUBSCRIBER 1050 $13.43 $32.00 MALE SUBSCRIBER 1 OSO $9.17 $46.00 MALE SUBSCRIBER 1 OSO $11.14 $35.00 MALE SUBSCRIBER 1 OSO ($10.071 {$32.0M MALE SUBSCRIBER 1 050 $0.00 ($46.09 MALE SUBSCRIBER 1 OSO ($4.64) (.5,15.00) MALE SUBSCRIBER 1 OSO $0.00 $32.00 MALE SUBSCRIBER 1 OSO $0.00 $46.00 MALE SUBSCRIBER 1 OSO $0.00 $35,00 MALE SUBSCRIBER 1 050 $9,214.53 $28,716.00 MALE SUBSCRIBER 1050 C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 6/6/2017 5/30/2017 6/5/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 593492D SPRAIN OF OTHER PROFESSIONAL OFFICE 1 OSO $328.09 $328.09 MALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 EGO LIGAMENT OF LEFT $69.25 MALE SUBSCRIBER 1 OSO $69.57 PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY SUBSCRIBER ANKLE, SUBSEQUENT COMPONENTS: AN EXPANDED PROBLEM FOCUSED ENCOUNTER HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 6/14/2017 4/13/2017 5/31/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED SITE 6/16/2017 6/13/2017 6/15/2017 11402 EXCISION, BENIGN LESION, EXCEPTSKIN TAG (UNLESS D225 MELANOCYTIC NEVI OF PROFESSIONAL OFFICE LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; LESION TRUNK DIAMETER 1.1 TO 2.0 CM 6/16/2017 6/13/2017 6/15/2017 12032 REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILIAE, D225 MELANOCYTIC NEVI OF PROFESSIONAL OFFICE TRUNK AND /OR EXTREMITIES (EXCLUDING HANDS AND TRUNK FEET); 2.6 CM TO 7.5 CM 6/16/2017 6/13/2017 6/15/2017 88304 LEVELIII- SURGICAL PATHOLOGY, GROSS AND D225 MELANOCYTIC NEVI OF PROFESSIONAL OFFICE MICROSCOPIC EXAMINATION ABORTION, INDUCED, TRUNK ABSCESS, ANEURYSM - ARTERIAL/VENTRICULAR, ANUS, TAG, APPENDIX, OTHER THAN INCIDENTAL, ARTERY, ATHEROMATOUS PLAQUE, BARTHOLIN'S GLAND CYST, BONE FRAGMENT(SE OTHER THAN PATHOLOGIC FRACTURE, BURSA /SYNOVIAL 6/19/2017 4/10/2017 5/19/2017 - - C9310 MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED SITE 6/19/2017 4/10/2017 5119/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED SITE 6/19/2017 4/10/2017 6/6/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED SITE 6/26/2017 5/25/2017 6/21/2017 - - 25111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 6/28/2017 6/23/2017 6/27/2017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE L989 DISORDER OF THE SKIN PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED AND SUBCUTANEOUS PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY TISSUE, UNSPECIFIED COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 6/28/2017 6/26/2017 6/27/2017 92004 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H169 UNSPECIFIED KERATITIS PROFESSIONAL OFFICE AND EVALUATION WITH INITIATION OF DIAGNOSTIC AND TREATMENT PROGRAM; COMPREHENSIVE, NEW PATIENT, 1 OR MORE VISITS 6/30/2017 6/27/2017 6/29/2017 20605 ARTHROCENTESIS, ASPIRATION AND /OR INJECTION, M19072 PRIMARY PROFESSIONAL OFFICE INTERMEDIATE JOINT OR BURSA (EG, OSTEOARTHRITIS, LEFT TEMPOROMANDIBUTAR, ACROMIOCIAVICULAR, WRIST, ANKLE AND FOOT ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE 6/30/2017 6/27/2017 6/29/201711030 INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG M19072 PRIMARY PROFESSIONAL OFFICE OSTEOARTHRITIS, LEFT ANKLE AND FOOT 7117/2017 6/29/2017 7/12/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED SITE $45.92 $190.25 MALE SUBSCRIBER 1 050 $0.00 $1,351.00 MALE SUBSCRIBER 1050 $86.74 $173.48 MALE SUBSCRIBER 1 OSO $328.09 $328.09 MALE SUBSCRIBER 1 EGO $69.25 $69.25 MALE SUBSCRIBER 1 OSO $0.00 $1,234.00 MALE SUBSCRIBER 1050 $0.00 $0.00 MALE SUBSCRIBER 1050 $0.00 $1,234.00 MALE SUBSCRIBER 1050 $18,460.78 $48,581.00 MALE SUBSCRIBER 1050 $69.57 $314.00 MALE SUBSCRIBER 1 OSO $158.38 $175.00 MALE SUBSCRIBER 1 OSO $38.91 $163.65 MALE SUBSCRIBER 1 DEC $538 $7.00 MALE SUBSCRIBER 1050 $8,401.80 $24,655.00 MALE SUBSCRIBER 1050 C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 WE 3559 3559 C.7.f 712112017 4/27 /2017 5/24/2017 - 712112017 4/27/2017 5/24/2017 - 7/21/2017 4/27/2017 7/10/2017 - 7/26/2017 7/7/2017 7/18/2017 - 7/26/2017 7/19/2017 7125/2017 1036F 7/26/2017 711912017 7/25/2017 1126F 7/26/2017 7/19/2017 7/25/2017 1220F 7/26/2017 7/19/2017 7/25/2017 C8310 C8310 C8310 C9310 MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED 1050 SITE (5557.00) MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED 3559 SITE $1,351.00 MALE MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED $5,466.38 SITE SUBSCRIBER MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED $0.01 MALE SITE 1 OSO MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 3559 MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE $155.24 MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE C8310 MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE $0.00 $1,351.00 MALE SUBSCRIBER 1050 3559 (5557.00) ($1,351.00) MALE SUBSCRIBER 1 RISC 3559 $0.00 $1,351.00 MALE SUBSCRIBER 1050 3559 $5,466.38 $14,774.00 MALE SUBSCRIBER 1050 3559 $0.00 $0.01 MALE SUBSCRIBER 1 OSO 3559 $0.00 $0.01 MALE SUBSCRIBER 1 050 3559 $0.00 $0.01 MALE SUBSCRIBER 1 OSO 3559 $155.24 $429.00 MALE SUBSCRIBER 1 050 3559 7/26/2017 7/19/2017 7/25/2017 G8427 7/26/2017 7/19/2017 7/25/2017 68732 7/26/2017 7/19/2017 7/25/2017 G8938 7/31/2017 4/27/2017 5/24/2017 8/2/2017 7/28/2017 81 8/2/2017 7/28/2017 8/1/2017 8/2/2017 7/28/2017 8/1/2017 6/7/2017 7/26/2017 8/5/2017 1036F 8/7 /2017 7 /28/2017 8/5/2017 1126F CURRENTTOBACCO NON - USER(CAD, CAP,CDPD, PV) C8310 (DM) (IBD) OUTPATIENT /HOSPITAL INTERMEDIATE " DELAY" OF ANY FLAP, PRIMARY "DELAY" C9310 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR PROFESSIONAL DIRECT FLAP, AT EYELIDS NOSE, OUTPATIENT /HOSPITAL PATIENT SCREENED FOR DEPRESSION (SUD) C8310 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C8310 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SUBSCRIBER COMPONENTS: A COMPREHENSIVE HISTORY; A PROFESSIONAL COMPREHENSIVE EXAMINATION; MEDICAL DECISION OUTPATIENT /HOSPITAL MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C8310 THE MEDICAL RECORD THEY OBTAINED, UPDATED, DR REVIEWED THE PATIENT'S CURRENT MEDICATIONS NO DOCUMENTATION OF PAIN ASSESSMENT C8310 BMI IS DOCUMENTED AS BEING OUTSIDE OF NORMAL C9310 LIMITS, FOLLOW -UP PLAN IS NOT DOCUMENTED, DOCUMENTATION THE PATIENT IS NOT ELIGIBLE C8310 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C8330 INCLUDE THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 83615 LACTATE DEHYDROGENASE (ED), (LDH); C8330 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C9330 HCT, BBC, W BC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL W BC COUNT CURRENTTOBACCO NON - USER (CAD, CAP, CORD, PV) C8310 (DM) (IBD) INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" 08310 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR DIRECT FLAP, AT EYELIDS NOSE, MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE MANTLE CELL PROFESSIONAL LYMPHOMA UNSPECIFIED OUTPATIENT /HOSPITAL SITE MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED SITE DIFFUSE LARGE B -CELL PROFESSIONAL LYMPHOMA UNSPECIFIED OUTPATIENT /HOSPITAL SITE DIFFUSE LARGE B -CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE $0.00 DIFFUSE LARGE B -CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE $0.01 MALE MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE SUBSCRIBER MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE $0.00 $0.01 MALE SUBSCRIBER 1 050 3559 $0.00 $0.01 MALE SUBSCRIBER 1 RISC 3559 $0.00 $0.01 MALE SUBSCRIBER 1 RISC 3559 $557.00 $1,351.00 MALE SUBSCRIBER 1 OSO 3559 $0.00 $26.00 MALE SUBSCRIBER 1 OSO 3559 $0.00 $5.70 MALE SUBSCRIBER 1 OSO 3559 $0.00 $10.40 MALE SUBSCRIBER 1 OSO 3559 $0.00 $0.01 MALE SUBSCRIBER 1 OSO 3559 $0.00 $0.01 MALE SUBSCRIBER 1 RISC) 3559 81712017 7/28/2017 8/5/2017 1220F 8/7/2017 7/28/2017 8/5/2017 8/7/2017 7/28/2017 8/5/2017 G8427 8/7/2017 7/28/2017 8/5/2017 G8731 8/7/2017 7/28/2017 8/5/2017 G8938 8/8/2017 7/28/2017 81 8/8/2017 7/28/2017 8/1/2017 1036F 8/8/2017 7/28/2017 8/1/2017 81812017 712812017 81112017 G8427 8/8/2017 7/28/2017 8/1/2017 G8731 81812017 7 /28/2017 81112017 G8938 8/11/2017 8/8/2017 8110/2017 8/11/2017 8/8/2017 8/10/2017 8/11/2017 818/2017 8/10/2017 PATIENTSCREENED FOR DEPRESSION (SUD) C8310 MANTLE CELL PROFESSIONAL 1050 $0.00 LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SUBSCRIBER 1050 SITE 99215 OFFICE OR OTHER 0UTPATIENTVISIT FOR THE C8310 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED $102.00 MALE LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY $0.00 SITE COMPONENTS: A COMPREHENSIVE HISTORY; A OSO $0.00 COMPREHENSIVE EXAMINATION; MEDICAL DECISION SUBSCRIBER RO1 050 MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C8310 MANTLE CELL PR0FE55IONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS SITE PAIN ASSESSMENT USING ASTANDARDIZED T00L 15 C9310 MANTLE CELL PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN LYMPHOMA UNSPECIFIED OUTPATIENT /HOSPITAL REQUIRED SITE EMI IS DOCUMENTED AS BEING 0UT5IDE OF NORMAL C8310 MANTLE CELL PROFESSIONAL LIMITS, FOLLOW -UP PLAN IS NOT DOCUMENTED, LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DOCUMENTATION THE PATIENT IS NOT ELIGIBLE SITE 92083 VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, H547 UNSPECIFIED VISUAL LOSS PROFESSIONAL WITH INTERPRETATION AND REPORT; EXTENDED OUTPATIENT /HOSPITAL EXAMINATION (EG, GOLDMANN VISUAL FIELDS WITH AT LEAST 3 (SORTERS PLOTTED AND STATIC DETERMINATION WITHIN THE CENTRAL 30 DEGREES, OR QUANTITATIVE, AUTOMATED THRESHOLD PERIMETRY, OCTOPUS PROGRAM G -1 CURRENTT08ACC0 N0N- USER (CAD, CAP, CORD, PV) H547 UNSPECIFIED VISUAL LOSS PROFESSIONAL (DM) (IED) OUTPATIENT /HOSPITAL 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H547 UNSPECIFIED VISUAL LOSS PROFESSIONAL EVALUATION AND MANAGEMENT OF A NEW PATIENT, OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN H547 UNSPECIFIED VISUAL LOSS PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS PAIN ASSESSMENT USING A STANDARDIZED TOOL IS H547 UNSPECIFIED VISUAL LOSS PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW -UP PLAN OUTPATIENT /HOSPITAL REQUIRED BMI IS DOCUMENTED AS BEING OUTSIDE OF NORMAL H547 UNSPECIFIED VISUAL LOSS PROFESSIONAL LIMITS, FOLLOW -UP PLAN IS NOT DOCUMENTED, OUTPATIENT /HOSPITAL DOCUMENTATION THE PATIENT IS NOT ELIGIBLE 82945 GLU COSE, BODY FLUID, OTHER THAN BLOOD C8310 MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 84155 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, C8310 MANTLE CELL PROFESSIONAL PLASMA OR WHOLE BLOOD LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 87015 CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS C8310 MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE $0.00 $0.01 MALE SUBSCRIBER 1050 $155.24 $429.00 MALE SUBSCRIBER 1 OSO $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $38.69 $102.00 MALE SUBSCRIBER 1 OSO $0.00 $0.01 MALE SUBSCRIBER 1050 $18238 $507.00 MALE SUBSCRIBER 1 050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $0.01 MALE SUBSCRIBER 1050 $0.00 $2.00 MALE SUBSCRIBER RO1 ESE, $0.00 $16.00 MALE SUBSCRIBER RO1 OSO $0.00 $10.00 MALE SUBSCRIBER RO1 050 C.7.f 3559 w Z 3559 N 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 rl C.7.f 811112017 8/8/2017 811012017 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, C8310 MANTLE CELL PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER R01 OSO 3559 URINE LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 811112017 8/8/2017 8/10/2017 87205 SMEAR, PRIMARYSOURCE WITH INTERPRETATION; GRAM C8310 MANTLE CELL PROFESSIONAL $0.00 $9.20 MALE SUBSCRIBER R01 EGO 3559 N OR GI EMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 8/11/2017 8/8/2017 8/1012017 89051 CELL COUNT, MISCELLANEOUS BODY FLUIDS C8310 MANTLE CELL PROFESSIONAL $0.00 $12.00 MALE SUBSCRIBER R01 OSO 3559 A CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL WITH DIFFERENTIAL COUNT SITE 8/19/2017 4/10/2017 5/19/2017 - - C9310 MANTLE CELL HOSPITAL OUTPATIENT j$557. CHI $1,234.00 MALE SUBSCRIBER 1 OSO 3559 LYMPHOMA, UNSPECIFIED m SITE 8/21/2017 8/8/2017 8118/2017 88108 CYTOPATHOLOGY, CONCENTRATION TECHNIQUE, SMEARS R838 OTHER ABNORMAL PROFESSIONAL $42.96 $86.00 MALE SUBSCRIBER R01 OSO 3559 AND INTERPRETATION (EG, SACCOMANNO TECHNIQUE) FINDINGS IN OUTPATIENT /HOSPITAL fl } CEREBROSPINAL FLUID 812112017 8/8/2017 8/19/2017 88189 FLOWCYTOMETRY /READ, 16 &> R997 ABNORMAL PROFESSIONAL $150.05 $421.00 MALE SUBSCRIBER R01 050 3559 N. CL HISTOLOGICAL FINDINGS OUTPATIENT /HOSPITAL Q, IN SPECIMENS FROM OTHER ORGANS, SYSTEMS AND TISSUES 812212017 ]/28/201] 8/10/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT $2,681.00 $12,547.00 MALE SUBSCRIBER 1 EGO 3559 LYMPHOMA, UNSPECIFIED SITE F 9/22/2017 4/27/2017 5/24/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT (5557.CO) $1,351.00 MALE SUBSCRIBER 1 050 3559 LYMPHOMA, UNSPECIFIED Z 10/5/2017 712812017 10/3/2017 70543 MAGNETIC RESONANCE(EG, PROTON) IMAGING, ORBIT, C9310 SITE MANTLE CELL PROFESSIONAL $173.80 $407.00 MALE SUBSCRIBER 1050 3559 _ FACE, AND /OR NECK; WITHOUTCONTRAST MATERIAL(S), LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL FOLLOWED BY CONTRAST MATERIALS) AND FURTHER SITE SEQUENCES 10/5/2017 7/28/2017 10/3/2017 70553 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN C8310 MANTLE CELL PROFESSIONAL $189.92 $436.00 MALE SUBSCRIBER 1050 3559 Q (INCLUDING BRAIN STEM); WITHOUTCONTRAST LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL ui MATERIAL, FOLLOWED BYCONTRAST MATERIALS ) AND SITE FURTHER SEQUENCES UJ 10/9/2017 9/26/2017 10/5/2017 Y ° "` '• * *• •<••' ••'** ' --- $40521 $3,584.00 MALE SUBSCRIBER RUT OSO 3559 10/10/2017 9/28/2017 10/9/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $593.00 $1,325.00 MALE SUBSCRIBER R01 ORO 3559 ANTINEOPLASTIC CHEMOTHERAPY LLJ 1011212017 ]/ /201] 10/10/2017 810 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC C8310 MANTLE CELL PROFESSIONAL $538.67 $945.00 MALE SUBSCRIBER 1 EGO e 3559 PROCEDURES, ENDOSCOPE INTRODUCED DISTAL TO LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DUODENUM SITE J 10/12/2017 9/19/2017 10/9/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $19,104.00 $47,760.00 MALE SUBSCRIBER R01 OSO 3559 ANTINEOPLASTIC v CHEMOTHERAPY 10/13/2017 7 12812017 101912017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $557.00 $1,234.00 MALE SUBSCRIBER 1 050 3559 ANTINEOPLASTIC uj CHEMOTHERAPY 10/17/2017 7/19/2017 101 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $18,340.70 $48,265.00 MALE SUBSCRIBER 1 OSO 3559 ANTINEOPLASTIC �..� CHEMOTHERAPY 10/18/2017 9/28/2017 10/16/2017 * * * *x * * *w« + +•* wt * ** * * * ** $0.00 $3,584.00 MALE SUBSCRIBER R01 OSO 3559 10/18/2017 10/9/2017 10117/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT $593.00 $1,599.00 MALE SUBSCRIBER R01 050 3559 LYMPHOMA, UNSPECIFIED {j SIT hl 1011812017 10/9/2017 10/1]/201]- - C8310 MANTLE CELL HOSPITAL OUTPATIENT $0.00 $1,599.00 MALE SUBSCRIBER RO1 050 3559 LYMPHOMA, UNSPECIFIED C SITE {� 10119/2017 7/7/2017 10/17/2017 883421MMUNOHISTOC HEMISTRY OR IMMUNO CYTOCHEMISTRY, C8319 MANTLE CELL PROFESSIONAL $128.80 $262.00 MALE SUBSCRIBER 1050 3559 PER SPECIMEN; INITIALSINGLE ANTIBODYSTAIN LYMPHOMA, OUTPATIENT /HOSPITAL PROCEDURE EXTRANODALAND SOLID ORGAN SITES �, C.7.f 10/19/2017 7/7/2017 10/17/2017 88305 LEVEL IV- SURD ICA L PATH OLOGY, GROSS AND C8319 MANTLE CELL PROFESSIONAL $292.85 $700.00 MALE SUBSCRIBER 1 OSO 3559 MICROSCOPIC EXAMINATION ABORTION- LYMPHOMA, OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE EXTRANODALANO SOLID Z MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, ORGAN SITES N OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION 11/6/2017 9/28/2017 11/3/2017 1036F CURRENTTOBACCO NON- USER(CAD, CAP,COPD, PV) N644 MASTODYNIA PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 050 3559 7 (DM) (IBM OUTPATIENT /HOSPITAL 11/6/2017 9/28/2017 11/3/2017 1126F INTERMEDIATE "DELAY" OFANY FLAP, PRIMARY "DELAY" N644 MASTODYNIA PROFE55IONAL $0.00 $0.01 MALE SUBSCRIBER RD1 OSO 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, 11/6/2017 9/28/2017 11/3/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N644 MASTODYNIA PROFESSIONAL $170.75 $429.00 MALE SUBSCRIBER ROE OSO 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OUTPATIENT /HOSPITAL CL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY Q, COMPONENTS: A COMPREHENSIVE HISTORY; A v COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 11/6/2017 9/28/2017 11/3/2017 68427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN N644 MASTODYNIA PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 EGO 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OUTPATIENT /HOSPITAL uj REVIEWED THE PATIENT'S CURRENT MEDICATIONS 11/6/2017 9/28/2017 11/3/2017 68732 NO DOCUMENTATION OF PAIN ASSESSMENT N644 MASTODYNIA PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 OSO 3559 OUTPATIENT /HOSPITAL _ 11/6/2017 9/28/2017 11/3/2017 68938 BMI IS DOCUMENTEDAS BEING OUTSIDEOF NORMAL N644 MASTODYNIA PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 OSO 3559 LIMITS, FOLLOW -UP PLAN IS NOT DOCUMENTED, OUTPATIENT /HOSPITAL DOCUMENTATION THE PATIENT IS NOT ELIGIBLE IL W 11/6/2017 10/9/2017 11/3/2017 1036F CURRENTTOBACCO NON - USER (CAD, CAP, CORD, PV) 08310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER RUT O50 3559 ()M) (IBD) LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL Uy SITE 11/6/2017 10/9/2017 11/3/20171125F INTERMEDIATE " DEWY" OFANY FLAP, PRIMARY "DELAY" C9310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 050 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DIRECT FLAP, AT FOREHEAD, CHEE SITE 11/6/2017 10/9/2017 11/3/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C9310 MANTLE CELL PROFESSIONAL $120.11 $299.00 MALE SUBSCRIBER R01 OSO eW 3559 °✓ EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY SITE J COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF v MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER W 11/6/2017 10/9/2017 11/3/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C9310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 OSO 3559 THE MEDIC AL RECORD THEY OBTAINED, UPDATED, OR LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS SITE (' Q 11/6/2017 10/9/2017 11/3/2017 68484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C8310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 OSO 3559 REASON NOT GIVEN LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 11/6/2017 10/9/2017 11/3/2017 08730 PAIN ASSESSMENT DOCUMENTED AS POSITIVE USING A C8310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 OSO 3559 N STANDARDIZED TOOL AND A FDLLOW-UP PLAN IS LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DOCUMENTED SITE _ 11/6/2017 10/9/2017 11/3/2017 68938 BMI IS DOCUMENTEDAS BEING OUTSIDEOF NORMAL C8310 MANTLE CELL PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 O50 3559 y LIMITS, FOLLOW -UP PLAN IS NOT DOCUMENTED, LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DOCUMENTATION THE PATIENT IS NOT ELIGIBLE SITE C.7.f 11/17/2017 5/15/2017 5/24/2017 1036F CURRENT TOBACCO NON - USER(CAD, CAP, CORD, PV) C8310 MANTLE CELL PROFESSIONAL $0.00 ($0.0].1 MALE SUBSCRIBER 1 OSO 3559 (DM) HER) LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 11/17/2017 5/15/2017 5/24/2017 1126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C8310 MANTLE CELL PROFESSIONAL $0.00 ;$0.911 MALE SUBSCRIBER 1 RISC 3559 OFSMALL FLAP, ORSECTIONING PEDICLE OFTUBEDOR LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, SITE 11/17/2017 5/15/2017 5/24/2017 1220F PATIENTSCREENED FOR DEPRESSION(SUD) C8310 MANTLE CELL PROFESSIONAL $0.00 ($0.01) MALE SUBSCRIBER 1 OSO 3559 LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 11/17/2017 5/15/2017 5/24/2017 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 06310 MANTLE CELL PROFESSIONAL $]5i 241 (;429.001 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY SITE COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 11/17/2017 5/15/2017 5/24/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C8310 MANTLE CELL PROFESSIONAL $0.00 {$0.911 MALE SUBSCRIBER 1 ONO 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS SITE 11/17/2017 5/15/2017 5/24/2017 G8731 PAIN ASSESSMENT USING A STANDARDIZED TOOL IS C8310 MANTLE CELL PROFESSIONAL $0.00 157,911 MALE SUBSCRIBER 1 ESE) 3559 DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL REQUIRED SITE 11/17/2017 5/15/2017 5/24/2017 G8938 BMI IS DOCUMENTED AS BEING OUTSIDE OF NORMAL C8310 MANTLE CELL PROFESSIONAL $0.00 ($0.01i MALE SUBSCRIBER 1050 3559 LIMITS, FOLLOW -UP PLAN IS NOT DOCUMENTED, LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DOCUMENTATION THE PATIENT IS NOT ELIGIBLE SITE 11/17/2017 10/26/2017 11116/2017 36415 COLLECTION OF VENOUS BLOOD BYVENIPUNCTURE E785 HYPERLIPIDEMIA, PROFESSIONAL OFFICE $1.80 $12.00 MALE SUBSCRIBER RO1 050 3559 UNSPECIFIED 11/17/2017 11/14/2017 11/16/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C8310 MANTLE CELL PROFE55IONAL $0.00 $26.00 MALE SUBSCRIBER R01 ONO 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SITE DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 11/17/2017 11/14/2017 11/16/2017 83615 LACTATE DEHYDROGENASE(LD),(LDH); C8310 MANTLE CELL PROFESSIONAL $0.00 $5.70 MALE SUBSCRIBER R01 OSO 3559 LYMPHOMA, UNSPECIFIED OUTPATIENT/HOSPITAL SITE 11/17/2017 11/14/2017 11/16/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C8310 MANTLE CELL PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER R01 OSO 3559 HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT SITE 1112012017 5/15/2017 5/24/2017 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C8310 MANTLE CELL PROFESSIONAL $429.00 MALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY SITE COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 1112012017 11/6/2017 11/17/2017 xxxxx w..ww xxxxx w...a w...* $10531 $473.00 MALE SUBSCRIBER R01 050 3559 11/22/2017 11/14/2017 11/21/2017 G0204 DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT2D N644 MASTODYNIA PROFESSIONAL $59.30 $167.00 MALE SUBSCRIBER RO1 OSO 3559 DIGITAL IMAGE, BILATERAL, ALL VIEWS OUTPATIENT /HOSPITAL 11/22/2017 11/14/2017 11/21/2017 G0279 TOMOSYNTHESIS, MAMMO SCREEN N644 MASTODYNIA PROFESSIONAL $O.OD $117.00 MALE SUBSCRIBER RDl 050 3559 OUTPATIENT /HOSPITAL 1112712017 5/15/2017 5/24/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C8310 MANTLE CELL PROFESSIONAL SUBSCRIBER RO1 050 $0.00 EVALUATION AND MANAGEMENT OF AN ESTABLISHED SUBSCRIBER RO1 OSD LYMPHOMA UNSPECIFIED OUTPATIENT /HOSPITAL $10.40 MALE SUBSCRIBER R01 050 PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY $0.01 MALE SITE $170.75 $429.00 MALE COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 11/27/2017 8/8/2017 11/22/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED SITE 11/27/2017 11/15/2017 11/21/2017 11100 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND /OR D485 NEOPLASM OF PROFESSIONAL OFFICE MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNCERTAIN BEHAVIOR OF UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); SKIN SINGLE LESION 11/27/2017 11/15/2017 11/21/2017 88304 LEVEL III- SURGICAL PATHOLOGY, GROSS AND D485 NEOPLASM OF PROFESSIONAL OFFICE MICROSCOPIC EXAMINATION ABORTION, INDUCED, UNCERTAIN BEHAVIOR OF ABSCESS, ANEURYSM ARTERIAL/VENTRICULAR, ANUS, SKIN TAG, APPENDIX, OTHER THAN INCIDENTAL, ARTERY, ATHERDMATDUS PLAQUE, BARTHOLIN'S GLAND CYST, BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE, BURSA /SYNOVIAL 11/29/2017 11/23/2016 11/27/2017 - - C8310 MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED SITE 12/7/2017 12/1/2017 12/5/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C8310 MANTLE CELL PROFESSIONAL INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, LYMPHOMA UNSPECIFIED OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (8231D), CARBON SITE DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 12/7/2017 12/1/2017 12/5/2017 82306 CALCIFEDIOL(25 -OH VITAMIN D-3) C9310 MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 12/7/2017 12/1/2017 12/5/2017 83615 LACTATE DEHYDROGENASE(LD),(LDH); 08310 MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 121712017 121112017 12/5/2017 83735 MAGNESIUM C9310 MANTLE CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL SITE 12/7/2017 12/1/2017 12/5/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C8310 MANTLE CELL PROFESSIONAL HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED LYMPHOMA UNSPECIFIED OUTPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT SITE 12/8/2017 12/1/2017 12/6/2017 1126F INTERMEDIATE "DELAY" OFANY FLAP, PRIMARY "DELAY" C8310 MANTLE CELL PROFESSIONAL OF SMALL FLAP, DR SECTIONING PEDICLE OF TUBED OR LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, SITE 12/8/2017 12/1/2017 12/6/2017 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C8310 MANTLE CELL PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY SITE COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 12/13/2017 11/28/2017 1211212017 12/21/2017 121112017 1211912017 - - C9310 MANTLE CELL HOSPITA L OUTPATIENT LYMPHOMA, UNSPECIFIED SITE $155.24 $429.00 MALE SUBSCRIBER 1 OSO $3,166.54 $8,741.00 MALE SUBSCRIBER R01 050 $110.53 $340.26 MALE SUBSCRIBER BUT OSO $69.25 $131.25 MALE SUBSCRIBER R01 OSO $0.00 $27,142.00 MALE SUBSCRIBER 1050 $0.00 $26.00 MALE SUBSCRIBER R01 OSO $0.00 $28.00 MALE SUBSCRIBER RD1 OSO $0.00 $5.70 MALE SUBSCRIBER RO1 050 $0.00 $10.80 MALE SUBSCRIBER RO1 OSD $0.00 $10.40 MALE SUBSCRIBER R01 050 $0.00 $0.01 MALE SUBSCRIBER R01 OSO $170.75 $429.00 MALE SUBSCRIBER R01 OSO $103.91 $461.00 MALE SUBSCRIBER RO1 OSO $1,343.20 $3,502.00 MALE SUBSCRIBER RO1 OSO C.7.f 3559 3559 3559 im 3559 3559 3559 3559 3559 3559 3559 3559 12/22/2017 11/14/2017 12/19/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT SUBSCRIBER R01 OSO $315,587.60 $1,514,077.07 $35.00 MALE ANTINEOPLASTIC $42.50 $102.00 MALE SUBSCRIBER R01 BCC $45.92 $190.25 MALE CHEMOTHERAPY 1 BCC 12/29/2017 12/19/2017 12/27/2017- - C8310 MANTLE CELL HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED SITE Sub Total 1.875E +10 1/6/2017 12/S/2016 1/5/2017 74230 SWALLOWING FUNCTION, W ITH Z8521 PERSONAL HISTORY OF PROFESSIONAL CINERADIOGRAPHY /VIDEORADIOGRAPHY MALIGNANT NEOPLASM OUTPATIENT /HOSPITAL OFLARYNX 111012017 10/18/2016 1/9/2017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE L600 INGROWING NAIL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 1/30/2017 1/9/2017 1/14/20171126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" 0329 MALIGNANT NEOPLASM PROFESSIONAL OF SMALL FLAP, OR SECTIONING P ELATE OF TUBED OR OF LARYNX, UNSPECIFIED OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, 1/30/2017 1/9/2017 1/14/2017 31575 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC C329 MALIGNANT NEOPLASM PROFESSIONAL OF LARYNX, UNSPECIFIED OUTPATIENT /HOSPITAL 1/30/2017 1/12/2017 1/13/2017 92012 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMI NATION H538 OTHER VISUAL PROFESSIONAL OFFICE AND EVALUATION, W ITH INITIATION OR CONTINUATION DISTURBANCES OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT 1/30/2017 1/12/2017 1/17/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE R1319 OTHER DYSPHAGIA PROFESSIONAL OFFICE 1/30/2017 1/12/2017 1/17/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R1319 OTHER DYSPHAGIA PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 1/30/2017 1/13/2017 1/20/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, R1319 OTHER DYSPHAGIA OTHER MEDICAL FRONTAL AND LATERAL; 1/30/2017 1/13/2017 1/20/2017 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R1319 OTHER DYSPHAGIA OTHER MEDICAL LEADS; WITH INTERPRETATION AND REPORT 1/30/2017 1/23/2017 1/24/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R1319 OTHER DYSPHAGIA PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 2/13/2017 1/26/2017 1/31/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1329 CHRONIC SINUSITIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 2/17/2017 2/1/2017 2/10/2017 74220 RADIOLOGIC EXAMINATION; ESOPHAGUS K222 ESOPHAGEAL PROFESSIONAL OBSTRUCTION INPATIENT /HOSPITAL $21,317.60 $53,452.00 MALE SUBSCRIBER R01 OSO $10,725.00 $17,223.00 MALE SUBSCRIBER R01 OSO $315,587.60 $1,514,077.07 $35.00 MALE SUBSCRIBER R01 BCC $42.50 $102.00 MALE SUBSCRIBER R01 BCC $45.92 $190.25 MALE SUBSCRIBER 1 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $0.00 $312.00 MALE SUBSCRIBER R01 BCC $64.13 $115.00 MALE SUBSCRIBER R01 BCC $0.00 $35.00 MALE SUBSCRIBER R01 BCC $61.79 $190.00 MALE SUBSCRIBER RO1 BCC $0.00 $164.00 MALE SUBSCRIBER RO1 BCC $0.00 $120.00 MALE SUBSCRIBER R01 BCC $61.79 $190.00 MALE SUBSCRIBER R01 BCC $61.79 $190.00 MALE SUBSCRIBER R01 FCC $1183 $89.00 MALE SUBSCRIBER R01 BCC C.7.f 3559 w 3559 N 3559 3559 3559 3559 3559 ®' 3559 3559 3559 III gm rl C.7.f 2/17/2017 2/5/2017 211112017 74000 RADIOLOGIC EXAM I NATION, ABDOMEN; SINGLE R109 UNSPECIFIED ABDOMINAL PROFESSIONAL $10.89 $35.00 MALE SUBSCRIBER R01 BCC 3559 ANTEROPOSTERIOR VIEW PAIN INPATIENT /HOSPITAL 2/17/2017 2/6/2017 2/9/2017 49465 CONTRAST INIECTIDN(S) FOR RADIOLOGICAL EVALUATION K9423 GASTROSTOMY PROFESSIONAL $0.00 $124.00 MALE SUBSCRIBER RO1 BCC 3559 C! OF EXISTING GASTROSTOMY, DUODENOSTOMY, MALFUNCTION INPATIENT /HOSPITAL N JEJUNOSTOMY, GASTRO- JEJUNOSTOMY, OR CECOSTOMY OR (OR OTHER COLONIC) TUBE, FROM A PERCUTANEDUS APPROACH INCLUDING IMAGE DOCUMENTATION AND BID REPORT 2/20/2017 1/31/2017 2111/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC K222 ESOPHAGEAL PROFESSIONAL $442.94 $1,050.00 MALE SUBSCRIBER ROl BCC 3559 "a PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO OBSTRUCTION INPATIENT /HOSPITAL DUODENUM 2/20/2017 1/31/2017 2/11/2017 43200 ESO P HAGOSCOPY, FLEXI B LE, TRANSORAL; D I AG N OSTIC, K222 ESOPHAGEAL PROFESSIONAL $122.11 $394.00 MALE SUBSCRIBER R01 BCC 3SS9 INCLUDING COLLECTION OF SPECIMENS) BY BRUSHING OBSTRUCTION INPATIENT /HOSPITAL } OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) L CL 2120/2017 2/6/2017 2/16/2017 74176 Computed tomography, a bdomen and pelvis; without K222 ESOPHAGEAL PROFESSIONAL $101.76 $335.00 MALE SUBSCRIBER Rol BCC 3559 Q, contrast material OBSTRUCTION INPATIENT /HOSPITAL 212012017 21712017 2/14/2017 99253 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED 81010 UPPER ABDOMINAL PAIN, PROFESSIONAL $137.18 $430.00 MALE SUBSCRIBER R01 BCC 3559 PATIENT,WHICH REQUIRES THESE 3 KEY COMPONENTS: A UNSPECIFIED INPATIENT /HOSPITAL DETAILED HISTORY; A DETAILED EXAMINATION; AND rf MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED Uj F CONSISTENT WITH D 2/20/2017 2/11/2017 2/15/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 1517 CARDIOMEGALY PROFESSIONAL $10.89 $35.00 MALE SUBSCRIBER RO1 BCC 3559 FRONTAL INPATIENT /HOSPITAL 3/1/2017 2/3/2017 2/17/2017 49440 INSERTION OF GASTROSTOMY TUBE, PERCUTANEDUS, K222 ESOPHAGEAL PROFESSIONAL $307.00 $907.00 MALE SUBSCRIBER R01 BCC 3559 UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST OBSTRUCTION INPATIENT /HOSPITAL INJECTIONS), IMAGE DOCUMENTATION AND REPORT d 3/1/2017 2/3/2017 2117/2017 99152 Moderate sedation services provided by the same K222 ESOPHAGEAL PROFESSIONAL $15.05 $49.00 MALE SUBSCRIBER Rol BCC 3559 {i Physician or other qualified healthcare professional OBSTRUCTION INPATIENT /HOSPITAL performing the diagnostic or therapeutic service that (fJ � 3/1/2017 2/3/2017 2/17/2017 99153 Moderate sedation services provided by the same K222 ESOPHAGEAL PROFESSIONAL $13.15 $43.00 MALE SUBSCRIBER R01 BCC 3559 MfY physician or other qualified health care professional OBSTRUCTION INPATIENT /HOSPITAL Performing the diagnostic or therapeutic service that IELJ 0 3/1/2017 2/7/2017 2/18/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC R1319 OTHER DYSPHAGIA PROFESSIONAL $394.27 $945.00 MALE SUBSCRIBER Rol BCC 3559 PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO INPATIENT /HOSPITAL J DUODENUM 3/1/2017 2/10/2017 212112017 43235 ESOPHAGOGASTRODUODENOS COPY, FLEXIBLE, R1319 OTHER DYSPHAGIA PROFESSIONAL $230.71 $548.00 MALE SUBSCRIBER R01 BCC 3559 v TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF INPATIENT /HOSPITAL SPECIMENS) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) uj 3/1/2017 2/14/2017 2/15/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R1319 OTHER DYSPHAGIA PROFESSIONAL OFFICE $102.40 $265.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED 0 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR N " COORDINATION OF CARE WITH OTHER N 3/2/2017 21712017 2/15/2017 43235 ESOPHAGOGASTRODUODENOSCOPY ,FLEXIBLE, R1319 OTHER DYSPHAGIA PROFESSIONAL $173.03 $548.00 MALE SUBSCRIBER R01 BCC 3559 TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF INPATIENT /HOSPITAL SPECIMENS) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) 3/2/2017 2/8/2017 2/15/2017 74176 Computed tomography, a bdomen and pelvis; without K222 ESOPHAGEAL PROFESSIONAL $101.76 $335.00 MALE SUBSCRIBER R01 BCC 3559 contrast material OBSTRUCTION INPATIENT /HOSPITAL 3/2/2017 2/8/2017 2/15/2017 74220 RADIOLOGIC EXAMINATION; ESOPHAGUS K222 ESOPHAGEAL PROFESSIONAL $27.85 $89.00 MALE SUBSCRIBER R01 BCC OBSTRUCTION INPATIENT /HOSPITAL 3/3/2017 2/17/2017 2/23/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L600 INGROWING NAIL PROFESSIONAL OFFICE $45.92 $190.25 MALE SUBSCRIBER R01 BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 3/6/2017 2/10/2017 2123/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC R1319 OTHER DYSPHAGIA PROFESSIONAL $473.77 $840.00 MALE SUBSCRIBER R01 BCC PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO INPATIENT /HOSPITAL DUODENUM 3/6/2017 2/27/2017 3/2/2017 74000 RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE Z431 ENCOUNTERFOR PROFESSIONAL $14.52 $35.00 MALE SUBSCRIBER R01 BCE ANTEROPOSTERIOR VIEW ATTENTION TO OUTPATIENT /HOSPITAL GASTROSTOMY 3/8/2017 3/2/2017 3/3/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R1319 OTHER DYSPHAGIA PROFESSIONAL OFFICE $86.79 $190.00 MALE SUBSCRIBER R01 BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 3/9/2017 2/24/2017 2/28/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L600 INGROWING NAIL PROFESSIONAL OFFICE $45.92 $190.25 MALE SUBSCRIBER R01 BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 3/13/2017 1/9/2017 2/7/2017 - - C329 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $0.00 $538.00 MALE SUBSCRIBER R01 BCC OF LARYNX, UNSPECIFIED 3/13/2017 1/31/2017 2/20/2017 - - 19589 OTHER POSTPROCEDURAL HOSPITAL INPATIENT 1/31/2017 4##449#4 $30,822.33 $131,497.53 MALE SUBSCRIBER R01 BCC COMPLICATIONS AND DISORDERS OF RESPIRATORY SYSTEM, NOT ELSEWHERE CLASSIFIED 3/13/2017 2/27/2017 3/9/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC R1319 OTHER DYSPHAGIA PROFESSIONAL $532.18 $1,050.00 MALE SUBSCRIBER R01 BCC PROCEDURES, ENDDSCOPE INTRODUCED PROXIMAL TO OUTPATIENT /HOSPITAL DUODENUM 3/14/2017 2/27/2017 3/6 /2017 - - K222 ESOPHAGEAL HOSPITAL OUTPATIENT $2,822.00 $5,074.08 MALE SUBSCRIBER R01 BCC OBSTRUCTION 3/15/2017 2/27/2017 3/6/2017 - - Z431 ENCOUNTER FOR HOSPITAL OUTPATIENT $192.52 $2,256.55 MALE SUBSCRIBER R01 BCC ATTENTION TO GASTROSTOMY 3/17/2017 2/11/2017 3/11/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $9.23 $60.00 MALE SUBSCRIBER R01 BCC LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL 3/17/2017 2/27/2017 3/7/2017 43226 ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH R1319 OTHER DYSPHAGIA PROFESSIONAL $224.70 $583.00 MALE SUBSCRIBER R01 BCC INSERTION OF GUIDE WIRE FOLLOW ED BY PASSAGE OF OUTPATIENT /HOSPITAL DILATOR(S) OVER GUIDE WIRE C.7.f 3559 w 3559 3559 3559 3559 09 3559 3559 3559 3559 3559 3559 3559 C.7.f 3/17/2017 3/7/2017 3/9/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L600 INGROWING NAIL PROFESSIONAL OFFICE $45.92 $190.25 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED N HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 3/21/2017 3/14/2017 3/20/2017 - - K222 ESOPHAGEAL HOSPITAL OUTPATIENT $1,709.00 $5,271.66 MALE SUBSCRIBER R01 BCC 3559 7 OBSTRUCTION 3/21/2017 3/14/2017 3120/2017 43235 ESOPHAGOGASTRODUODENOS COPY, FLEXIBLE, R1319 OTHER DYSPHAGIA PROFESSIONAL $230.71 $548.00 MALE SUBSCRIBER R01 BCC 3559 TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF OUTPATIENT /HOSPITAL SPECIMENS) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) W } 0 3/23/2017 3/14/2017 3/20/2017 - - K222 ESOPHAGEAL HOSPITAL OUTPATIENT 151.709.00) {55,271.06) MALE SUBSCRIBER R01 BCC 3559 G. CL OBSTRUCTION Q, 3123/2017 3/14/2017 3/22/2017 - - K222 ESOPHAGEAL HOSPITAL OUTPATIENT $1,709.00 $5,445.26 MALE SUBSCRIBER R01 BCC 3559 OBSTRUCTION v 3/23/2017 3/14/2017 3/22/2017 - - K222 ESOPHAGEAL HOSPITAL OUTPATIENT $0.00 $5,445.26 MALE SUBSCRIBER R01 BCC 3559 OBSTRUCTION 3/23/2017 3/20/2017 312212017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L600 INGROWING NAIL PROFESSIONAL OFFICE $45.92 $190.25 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY Lij COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY, COUNSELING AND COORD _ 3/29/2017 3/24/2017 3/28/2017 70490 COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT M542 CERVICALGIA PROFESSIONAL $104.43 $242.00 MALE SUBSCRIBER R01 BCC 3559 CONTRAST MATERIAL OUTPATIENT /HOSPITAL IL 3/31/2017 3/14/2017 3129/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC R1319 OTHER DYSPHAGIA PROFESSIONAL $460.79 $840.00 MALE SUBSCRIBER R01 BCC 3559 {j PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO OUTPATIENT /HOSPITAL DUODENUM U`J 3/31/2017 3/24/2017 3/30/2017 74220 R.ADIOLOGIC EXAMINATION; ESOPHAGUS K228 OTHER SPECIFIED PROFESSIONAL $37.13 $89.00 MALE SUBSCRIBER R01 BCC 3559 DISEASES OF ESOPHAGUS OUTPATIENT /HOSPITAL 0 3/31/2017 3124/2017 3/30/2017 43226 ESOPHAG05COPY, FLEXIBLE, TRANSORAL; WITH 81319 OTHER DYSPHAGIA PROFE55IONAL $224.70 $583.00 MALE SUBSCRIBER R01 BCC 3559 LLJ INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF OUTPATIENT/HOSPITAL DILATORS) OVER GUIDE WIRE 4/4/2017 3/31/2017 4/3/2017 43226 ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH R1319 OTHER DYSPHAGIA PROFESSIONAL $224.70 $583.00 MALE SUBSCRIBER R01 BCC 3559 J INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF OUTPATIENT /HOSPITAL DILATOR(S) OVER GUIDE WIRE v 4/6/2017 3/24/2017 3/30/2017- - K219 CASTRO- ESOPHAGEAL HOSPITAL OUTPATIENT $1,709.00 $9,891.18 MALE SUBSCRIBER R01 BCC 3559 r REFLUX DISEASE Z WITHOUT ESOPHAGITIS LLJ 4/10/2017 3/31/2017 4/6/2017 - - K222 ESOPHAGEAL HOSPITAL OUTPATIENT $0.00 $5,436.33 MALE SUBSCRIBER R01 BCC 3559 OBSTRUCTION U 4/10/2017 4/5/2017 4/6/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL T819XXD UNSPECIFIED PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER R01 BCC 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL COMPLICATION OF OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) PROCEDURE, CREATININE(8256S) GLUCOSE (S2947) POTASSIUM SUBSEQUENT ENCOUNTER N (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) N 4/10/2017 4/5/2017 4/6/2017 83605 LACTATE (LACTIC ACID) T819XXD UNSPECIFIED PROFESSIONAL $0.00 $7.60 MALE SUBSCRIBER R01 BCC 3559 = COMPLICATION OF OUTPATIENT /HOSPITAL PROCEDURE, SUBSEQUENT ENCOUNTER C.7.f 4/10/2017 4/5/2017 4/6/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, T819XXD UNSPECIFIED PROFESSIONAL A HCT,REG,WBC AND PLATELET COUNT) AND AUTOMATED COMPLICATION OF OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT PROCEDURE, i' SUBSEQUENT ENCOUNTER 4/10/2017 4/5/2017 4/6/2017 85610 PROTHROMBIN TIME; T919XXD UNSPECIFIED PROFESSIONAL COMPLICATION OF OUTPATIENT /HOSPITAL fl PROCEDURE, } SUBSEQUENT ENCOUNTER $0.00 4/10/2017 4/5/2017 4/6/2017 85730 THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR T919XXD UNSPECIFIED PROFESSIONAL CL WHOLE BLOOD COMPLICATION OF OUTPATIENT /HOSPITAL PROCEDURE, $0.00 $10.40 MALE SUBSEQUENT ENCOUNTER BCC 4/10/2017 415/2017 4/7/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR T819XXD UNSPECIFIED PROFESSIONAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, COMPLICATION OF INPATIENT /HOSPITAL h LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, PROCEDURE, D UROBILINDGEN, ANY NUMBER OF THESE CONSTITUENTS; SUBSEQUENT ENCOUNTER $0.01 MALE SUBSCRIBER R01 BCC 3559 AUTOMATED, WITHOUT MICROSCOPY 4/10/2017 4/7/2017 4/8/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HER, T819XXD UNSPECIFIED PROFESSIONAL HCT,REG,NBC AND PLATELET COUNT) AND AUTOMATED COMPLICATION OF INPATIENT /HOSPITAL d $111.38 DIFFERENTIAL W BC COUNT SUBSCRIBER R01 PROCEDURE, 3559 ui SUBSEQUENT ENCOUNTER 4/12/2017 4/5/2017 4/11/20171125F INTERMEDIATE "DELAY" OFANY FLAP, PRIMARY "DELAY" C329 MALIGNANT NEOPLASM PROFESSIONAL 3559 OFSMALL FLAP, DRSECTIONING PEDICLE OF TUBED OR OF LARYNX, UNSPECIFIED OUTPATIENT /HOSPITAL DIRECT FLAP, AT FOREHEAD, CHEE $454.30 $840.00 MALE SUBSCRIBER R01 4/12/2017 4/5/2017 4/11/2017 31575 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC C329 MALIGNANT NEOPLASM PROFESSIONAL OF LARYNX, UNSPECIFIED OUTPATIENT /HOSPITAL 4/12/2017 4/5/2017 4/11/2017 70491 COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH R221 LOCALIZED SWELLING, PROFESSIONAL 3559 $2,248.12 $6,076.00 MALE CONTRAST MATERIALS) BCC MASS AND LUMP, NECK OUTPATIENT /HOSPITAL 4/14/2017 3/24/2017 411212017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC 18500 ESOPHAGEAL VARICES PROFESSIONAL $104.43 PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO SUBSCRIBER R01 WITHOUT BLEEDING OUTPATIENT /HOSPITAL DUODENUM 4/5/2017 # # # # # # ## $10,169.32 $55,730.07 MALE 4/14/2017 3/31/2017 4/13/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC R1319 OTHER OYSPHAGIA PROFESSIONAL 3559 (' PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO OUTPATIENT /HOSPITAL DUODENUM 4/14/2017 4/5/2017 4/13/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, L0211 CUTANEOUS ABSCESS OF PROFESSIONAL FRONTAL NECK INPATIENT /HOSPITAL 4/17/2017 4/5/2017 4/13/2017 - - C329 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF LARYNX, UNSPECIFIED 4/17/2017 4/11/2017 4/15/2017 70490 COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT Z930 TRACHEOSTOMY STATUS PROFESSIONAL CONTRAST MATERIAL INPATIENT /HOSPITAL 4/24/2017 4/5/2017 4/20/2017 * " * ** * *' ** " * * ** ' * * ** * * * ** 4/24/2017 4/5/2017 4121/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 19589 OTHER POSTPROCEDURAL PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES COMPLICATIONS AND OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS DISORDERS OF IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL RESPIRATORY SYSTEM, CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE NOT ELSEWHERE HISTORY; A COMPREHENSIVE EXAMINATION; AND CLASSIFIED MEDICAL DECIS 4124/2017 4/19/2017 4/21/20171036F CURRENTTOBACCO NON- USER(CAD, CAP,COPD, PV) C329 MALIGNANT NEOPLASM PROFESSIONAL (DM) (IBD) OF LARYNX, UNSPECIFIED OUTPATIENT /HOSPITAL $0.00 $10.40 MALE SUBSCRIBER R01 BCC 3559 NIP $0.00 $4.30 MALE SUBSCRIBER R01 BCC 3559 A i' $0.00 $6.50 MALE SUBSCRIBER R01 BCC 3559 OR fl } fl $0.00 $4.00 MALE SUBSCRIBER R01 BCC 3559 G. CL CL Q $0.00 $10.40 MALE SUBSCRIBER R01 BCC 3559 F W h D $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 $11833 $312.00 MALE SUBSCRIBER 301 BCC 3559 O d $111.38 $263.00 MALE SUBSCRIBER R01 BCC 3559 ui $48026 $840.00 MALE SUBSCRIBER R01 BCC 3559 J $454.30 $840.00 MALE SUBSCRIBER R01 BCC 3559 LLJ . $14.52 $35.00 MALE SUBSCRIBER R01 BCC 3559 $2,248.12 $6,076.00 MALE SUBSCRIBER R01 BCC 3559 v $104.43 $242.00 MALE SUBSCRIBER R01 BCC 3559 LLJ 4/5/2017 # # # # # # ## $10,169.32 $55,730.07 MALE SUBSCRIBER R01 SCC 3559 $410.78 $1,714.00 MALE SUBSCRIBER R01 BCC 3559 (' $0.00 $001 MALE SUBSCRIBER R01 BCC 3559 C.7.f 4/24/2017 4/19/2017 4121120171125F INTERMEDIATE" DELAY" OFANY FLAP, PRIMARY "DELAY" C329 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF LARYNX, UNSPECIFIED OUTPATIENT /HOSPITAL DIRECT FLAP, AT FOREHEAD, CHEF 4/24/2017 4/19/2017 4/21/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C329 MALIGNANT NEOPLASM PROFESSIONAL $69.77 $193.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF LARYNX, UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 4/24/2017 4/19/2017 4/21/201768419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C329 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN OF LARYNX, UNSPECIFIED OUTPATIENT /HOSPITAL 4/24/2017 4/19/2017 4/21/2017 08427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C329 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER ROE BCC 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF LARYNX, UNSPECIFIED OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS 4/24/2017 4/19/2017 4/21/201768509 PAIN ASSESSMENT DOCUMENTEDAS POSITIVE USING C329 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 STANDARDIZED TOOL, FOLLOW -UP PLAN NOT OF LARYNX, UNSPECIFIED OUTPATIENT /HOSPITAL DOCUMENTED, REASON NOT GIVEN 4/24/2017 4/20/2017 4/21/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R1319 OTHER DYSPHAGIA PROFESSIONAL OFFICE $127.40 $265.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5/25/2017 5/17/2017 5124/2017 1036F CURRENTTOBACCO NON - USER (CAD, CAP, COBO PV) R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER RO1 BCC 3559 (DM) BED) PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL PHASE 5/25/2017 5/17/2017 5/24/2017 1126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR PHARYNGOESOPHA6EAL OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, PHASE 5/25/2017 5/17/2017 5/24/2017 1220F PATIENT SCREENED FOR DEPRESSION)SUD) R1314 DYSPHAGIA, PROFE55IONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL PHASE 5/25/2017 5/17 /2017 5/24/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R1314 DYSPHAGIA, PROFESSIONAL $69.77 $193.00 MALE SUBSCRIBER RO1 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY PHASE COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 5/25/2017 5/17/2017 5/24/2017 G8419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL PHASE 5/25/2017 5/17/2017 5/24/2017 138427 ELIGIBLE PROFESSIDNALATTESTSTO DOCUMENTING IN R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS PHASE 5/25/2017 5/17/2017 5/24/201768731 PAIN ASSESSMENT USING ASTANDARDIZED TOOL IS R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL REQUIRED PHASE C.7.f 5/30/2017 5/24/2017 5/26/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C139 MALIGNANT NEOPLASM PROFESSIONAL $182.78 $507.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF ANEW PATIENT, OF HYPOPHARYNX, OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS:A UNSPECIFIED COMPREHENSIVE HISTORY; A COMPREHENSIVE N EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR t 5/30/2017 5/24/2017 5/26/2017 68732 NO DOCUMENTATION OF PAIN ASSESSMENT C139 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 7 OF HYPOPHARYNX, OUTPATIENT /HOSPITAL UNSPECIFIED 6/2/2017 5/25/2017 6/1/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC R1314 DYSPHAGIA, PROFESSIONAL $51910 $945.00 MALE SUBSCRIBER R01 BCC 3559 PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO PHARYNGOESOPHAGEAL INPATIENT /HOSPITAL } DUODENUM PHASE 6/2/2017 5/25/2017 6/1/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 19811 ATELECTASIS PROFESSIONAL $14.52 $35.00 MALE SUBSCRIBER RO1 BCC 3559 ' CL FRONTAL INPATIENT /HOSPITAL Q, 6/2/2017 5/25/2017 6/1/2017 43220 ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH R1314 DYSPHAGIA PROFESSIONAL $201.41 $527.00 MALE SUBSCRIBER RO1 BCC 3559 Q TRANSENDOSCOPIC BALLOON DILATION (LESS THAN 30 PHARYNGOESOPHAGEAL INPATIENT /HOSPITAL v MM DIAMETER) PHASE 6/5/2017 5/24/2017 6/1/2017 - - 19589 OTHER POSTPROCEDURAL HOSPITAL INPATIENT 5/25/2017 # # # # # # ## $6,941.56 $22,048.08 MALE SUBSCRIBER RO1 BCC 3559 ® y COMPLICATIONS AND DISORDERS OF RESPIRATORY SYSTEM, h NOT ELSEWHERE CLASSIFIED 6/6/2017 6/2/2017 6/5/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R1319 OTHER DYSPHAGIA PROFESSIONAL OFFICE $8639 $190.00 MALE SUBSCRIBER RO1 BCC 3559 _ EVALUATION AND MANAGEMENTOFAN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED IL EXAMINATION; MEDICAL DECISION MAKING OF LOW ui COMPLEXITY. COUNSELING AND COORD 6/21/2017 6/14/2017 6/20/2017 1036F CURRENTTOBACCO NON- USER(CAD, CAP,COPQ PV) R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 (DM) (1131)) PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL 0 PHASE 6/21/2017 6114/2017 612012017 1126F INTERMEDIATE" DELAY" OF ANY FLAP, PRIMARY "DELAY" 81314 DYSPHAGIA PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER RO1 BCC 3559 LLJ OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, PHASE � 6/21/2017 6/14/2017 6/20/2017 1220F PATIENT SCREENED FOR DEPRESSION(SUD) R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER RO1 BCC 3559 J PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL PHASE v 6/21/2017 6/14/2017 6/20/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 81314 DYSPHAGIA, PROFESSIONAL $69.]] $193.00 MALE SUBSCRIBER RO1 BCC 3559 r EVALUATION AND MANAGEMENT OF AN ESTABLISHED PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL Z PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY PHASE LLJ COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW (' COMPLEXITY. COUNSELING AND COORD 6/21/2017 6/14/2017 6/20/201]68419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN PHARYNGOESOPHA6EAL OUTPATIENT /HOSPITAL CFJ PHASE N 6/21/2017 6/14/2017 6120/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER RO1 BCC 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL = REVIEWED THE PATIENT'S CURRENT MEDICATIONS PHASE y E 6/21/2017 6/14/2017 6/20/2017 G8731 PAIN ASSESSMENT USING ASTANDARDIZED TOOL IS 81314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 ._ DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN REQUIRED PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL PHASE �, C.7.f 7/17/2017 71712017 7/13/2017 7/20/2017 7/17/2017 7/19/2017 7/20/2017 7/18/2017 7119/2017 7/27/2017 7/6/2017 7/26/2017 7/27/2017 7/6/2017 7/26/2017 7/31/2017 7/6/2017 7/28/2017 8/23/2017 8/16/2017 8/22/2017 1126F 8/23/2017 8/16/2017 8122/2017 8/24/2017 8/16/2017 8/23/2017 - 9/21/2017 9/14/2017 9/20/2017 - 9/25/2017 9/18/2017 9/24/2017 9/25/2017 9/18/2017 9/24/2017 9/29/2017 9/26/2017 9/28/2017 9/29/2017 9/26/2017 9/28/2017 9/29/2017 9/26/2017 9/28/2017 - K222 ESOPHAGEAL HOSPITAL OUTPATIENT $1,260.00 MALE SUBSCRIBER R01 BCC OBSTRUCTION $527.00 MALE 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L609 NAIL DISORDER, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED $312.00 MALE UNSPECIFIED $214.23 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SUBSCRIBER R01 BCC $10,725.00 $17,22100 MALE COMPONENTS: AN EXPANDED PROBLEM FOCUSED $49.65 $70.08 MALE SUBSCRIBER R01 BUT HISTORY; AN EXPANDED PROBLEM FOCUSED $27.06 MALE SUBSCRIBER R01 BCC $62.01 EXAMINATION; MEDICAL DECISION MAKING OF LOW SUBSCRIBER R01 BCC $25.86 $100.00 MALE COMPLEXITY. COUNSELING AND COORD $45.92 $190.25 MALE SUBSCRIBER RO1 BCC 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R1319 OTHER DYSPHAGIA PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 19811 ATELECTASIS PROFESSIONAL FRONTAL INPATIENT /HOSPITAL 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC R1314 DYSPHAGIA PROFESSIONAL PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL DUODENUM PHASE 43220 ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH R1314 DYSPHAGIA, PROFESSIONAL TRANSENDOSCDPIC BALLOON MUTATION (LESS THAN 30 PHARYNGOESOPHAGEAL INPATIENT /HOSPITAL MM DIAMETER) PHASE INTERMEDIATE " DELAY" OF ANY FLAP, PRIMARY "DELAY" R1314 DYSPHAGIA, PROFESSIONAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, PHASE 31575 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC R1314 DYSPHAGIA, PROFESSIONAL PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL PHASE - C329 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF LARYNX, UNSPECIFIED - C329 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF LARYNX, UNSPECIFIED 93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING N179605 PAIN IN LEFT LEG PROFESSIONAL RESPONSES TO COMPRESSION AND OTHER MANEUVERS; OUTPATIENT /HOSPITAL UNILATERAL OR LIMITED STUDY 73590 RADIOLOGIC EXAMINATIDN; TIBIA AND FIBULA, TWO M79662 PAIN IN LEFT LOWER LEG OTHER MEDICAL VIEWS 11730 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, L609 NAIL DISORDER, PROFESSIONAL OFFICE SIMPLE; SINGLE UNSPECIFIED 73610 RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, L609 NAILDISORDER, PROFESSIONAL OFFICE MINIMUM OF THREE VIEWS UNSPECIFIED 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L609 NAIL DISORDER, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL L609 NAIL DISORDER, PROFESSIONAL OFFICE WITH ANKLE JOINT, PREFABRICATED, INCLUDES FITTING UNSPECIFIED ANDADIUSTMENT $3,033.00 $18,867.98 MALE SUBSCRIBER R01 BCC $45.92 $190.25 MALE SUBSCRIBER RO1 BCC $86.79 $190.00 MALE SUBSCRIBER RO1 BCC $14.52 $35.00 MALE SUBSCRIBER RO1 BCC $700.92 $1,260.00 MALE SUBSCRIBER R01 BCC $201.41 $527.00 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $118.53 $312.00 MALE SUBSCRIBER R01 BCC $214.23 $579.00 MALE SUBSCRIBER R01 BCC $10,725.00 $17,22100 MALE SUBSCRIBER R01 BCC $49.65 $70.08 MALE SUBSCRIBER R01 BUT $18.55 $27.06 MALE SUBSCRIBER R01 BCC $62.01 $263.00 MALE SUBSCRIBER R01 BCC $25.86 $100.00 MALE SUBSCRIBER R01 BCC $45.92 $190.25 MALE SUBSCRIBER RO1 BCC ®' ®' 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 9/29/2017 9/26/2017 9128/2017 L1971 101212017 9/18/2017 9/29/2017 -- $256.03 $465.00 MALE SUBSCRIBER RO1 BCC $1,935.80 $4,363.85 MALE SUBSCRIBER R01 BCC 3559 3559 C.7.f 10/6/2017 9/18/2017 10/5/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION M79605 PAIN IN LEFT LEG OTHER MEDICAL Ql AND MANAGEMENT OF A PATIENT, WHICH REQUIRES N THESE 3 KEYCOMPONENTS: A DETAILED HISTORY; A m DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING $3,151.00 $24,381.40 MALE SUBSCRIBER R01 AND /OR COORDINATION OF CARE WITH OTHER 3559 7 $0.00 $11.00 MALE SUBSCRIBER RO1 BCC 3559 "a PROVIDERS OR.AGENCIES ARE PR 10/24/2017 9/22/2017 10/2/2017 *kA *" $817 11/6/2017 9/14/2017 11/3/2017 36415 COLLECTION OF VENOUS BLOOD BYVENIPUNCTURE Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL 2 6L PREPROCEDURAL QZ LZ EXAMINATION 11/6/2017 9/14/2017 11/3/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL $6.08 $37.00 MALE INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, BCC PREPROCEDURAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON EXAMINATION F DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), W $3.07 $19.00 MALE SUBSCRIBER RO1 CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, 3559 h D ALKALINE (84075), POTASSIUM (84132), PROTEIN, 11/6/2017 9/14/2017 11/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED BEGS, 201818 ENCOUNTER FOR OTHER OTHER MEDICAL $29.00 MALE SUBSCRIBER R01 BCC HCT, BBC, WBCAND PLATELETCOUNT) ANDAUTOMATED PREPROCEDURAL DIFFERENTIAL W BC COUNT EXAMINATION O 11/6/2017 9/14/2017 11/3/2017 85610 PROTHRDMBIN TIME; Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL SUBSCRIBER RO1 BCC 3559 {i PREPROCEDURAL EXAMINATION 11/6/2017 9/14/2017 11/3/2017 85730 THROMBOPLASTIN TIME, PARTIAL(PTT); PLASMA OR ZO1818 ENCOUNTER FOR OTHER OTHER MEDICAL BCC 3559 0 WHOLE BLOOD PREPROCEDURAL $11.96 $37.00 MALE SUBSCRIBER RO1 BCC 3559 LLJ EXAMINATION 11/6/2017 9/14/2017 11/3/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 Z01810 ENCOUNTER FOR OTHER MEDICAL $12.41 $35.00 MALE LEADS; INTERPRETATION AND REPORT ONLY BCC PREPROCEDURAL $780.05 $1,365.00 MALE SUBSCRIBER ROl BCC J 3559 CARDIOVASCULAR v EXAMINATION 11/6/2017 9/21/2017 11/3/2017 73560 RADIOLOGIC EXAMINATION, KNEE; ONE ORTWOVIEWS M7732 CALCANEAL SPUR, LEFT PROFESSIONAL W FOOT INPATIENT /HOSPITAL 11/6/2017 9/21/2017 11/3/2017 73610 RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, M7732 CALCANEAL SPUR, LEFT PROFESSIONAL MINIMUM OF THREE VIEWS FOOT INPATIENT /HOSPITAL 11/6/2017 9/21/2017 11/3/2017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, 19811 ATELECTASIS PROFESSIONAL FRONTAL INPATIENT /HOSPITAL 11/6/2017 9/21/2017 11/3/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC R1314 DYSPHAGIA, PROFESSIONAL N $0.00 $0.01 MALE PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO BCC PHARYNGOESOPHAGEAL INPATIENT /HOSPITAL DUODENUM $0.00 PHASE SUBSCRIBER ROl 11/6/2017 9/21/2017 11/3/2017 4255F DURATION OF GENERAL DR NEURAXIAL ANESTHESIA 60 R1314 DYSPHAGIA, PROFESSIONAL MINUTES OR LONGER, AS DOCUMENTED IN THE PHARYNGOESOPHAGEAL INPATIENT /HOSPITAL ANESTHESIA RECORD (CRIT) PHASE 11/6/2017 9/21/2017 11/3/2017 43220 ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH R1314 DYSPHAGIA, PROFESSIONAL TRANSENDOSCOPIC BALLOON DILATION (LESS THAN 30 PHARYNGOESOPHAGEAL INPATIENT /HOSPITAL MM DIAMETER) PHASE 11/6/2017 10/25/2017 11/3/2017 1036F CURRENTTDBACCO NON - USER (CAD, CAP, CORD, PV) R1314 DYSPHAGIA, PROFESSIONAL (DM)(IBD) PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL PHASE 11/6/2017 10/25/2017 11/3/2017 1126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" R1314 DYSPHAGIA, PROFESSIONAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, PHASE 11/6/2017 10125/2017 11/3/2017 1220F PATIENTSCREENED FOR DEPRESSION(SUD) R1314 DYSPHAGIA, PROFESSIONAL PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL PHASE $239.54 $964.00 MALE SUBSCRIBER R01 BCC 3559 W Ql N m Q! $3,151.00 $24,381.40 MALE SUBSCRIBER R01 BCC 3559 7 $0.00 $11.00 MALE SUBSCRIBER RO1 BCC 3559 "a QS $817 $50.00 MALE SUBSCRIBER RD1 BCC 3559 > } 2 6L QZ LZ Q $6.08 $37.00 MALE SUBSCRIBER R01 BCC 3559 F W $3.07 $19.00 MALE SUBSCRIBER RO1 BCC 3559 h D $4.69 $29.00 MALE SUBSCRIBER R01 BCC 3559 O IL $12.97 $32.00 MALE SUBSCRIBER RO1 BCC 3559 {i $11.51 $38.00 MALE SUBSCRIBER RO1 BCC 3559 0 $11.96 $37.00 MALE SUBSCRIBER RO1 BCC 3559 LLJ $12.41 $35.00 MALE SUBSCRIBER RO1 BCC 3559 $780.05 $1,365.00 MALE SUBSCRIBER ROl BCC J 3559 v $0.00 $0.01 MALE SUBSCRIBER RO1 BCC 3559 W $207.35 $527.00 MALE SUBSCRIBER R01 BCC 3559 U Q $0.00 $0.01 MALE SUBSCRIBER RO1 BCC 3559 Q N $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 N $0.00 $0.01 MALE SUBSCRIBER ROl BCC 3559 C.7.f 11/6/2017 10/25/2017 11/3/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R1314 DYSPHAGIA, PROFESSIONAL $78.63 $193.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PHARYNGOE50PHAGEAL OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY PHASE Z COMPONENTS: AN EXPANDED PROBLEM FOCUSED N HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 11/6/2017 10/25/2017 11/3/2017 G8419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 7 FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL PHASE 11/6/2017 10/25/2017 11/3/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER RD1 BCC 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS PHASE } fl 11/6/2017 10/25/2017 11/3/2017 G8494 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, R1314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 CL REASON NOT GIVEN PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL Q, PHASE 11/6/2017 10/25/2017 11/3/2017 68731 PAIN ASSESSMENT USING ASTANDARDIZED TOOL IS 81314 DYSPHAGIA, PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 DOCUMENTED AS NEGATIVE, NOFOLLOW- UPPLAN PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL REQUIRED PHASE rf 11/7/2017 11/2/2017 11/6/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L600 INGROWING NAIL PROFESSIONAL OFFICE $45.92 $190.25 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY h COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD _ 11/13/2017 11/9/2017 11/11/2017 43220 ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; WITH R1314 DYSPHAGIA, PROFESSIONAL $207.35 $527.00 MALE SUBSCRIBER R01 BCC 3559 TRANSENDOSCOPIC BALLOON DIIATION(LESS THAN 30 PHARYNGOESOPHAGEAL OUTPATIENT /HOSPITAL MM DIAMETER) PHASE Q 11/17/2017 9/22/2017 11 /15 /2017 * * * ** * * *w* xx*sx e..*x. w...* $0.00 $25,84636 MALE SUBSCRIBER RD1 BCC 3559 {i 11/27/2017 3/31/2017 4/6/2017 - - K222 ESOPHAGEAL HOSPITAL OUTPATIENT $1,709.00 $5,436.33 MALE SUBSCRIBER R01 BCC 3559 OBSTRUCTION UJ 11/27/2017 3/31/2017 4/6/2017 - - K222 ESOPHAGEAL HOSPITAL OUTPATIENT $0.00 ($5,43633] MALE SUBSCRIBER R01 BCC 3559 ) �(f OBSTRUCTION Y 121112017 9/22/2017 10/2/2017 * * *'* ` * * "* * " ** ` * * *" " * * *" I$3, 1.51.COI ($ - - - MALE SUBSCRIBER 801 BCC 3559 J 121112017 9/22/2017 11/16/2017 * * ° *' * * * ** * " ** * * * ** * * * ** $3,151.00 $25,846.36 MALE SUBSCRIBER R01 BCC 3559 W 12/27/2017 12/20/2017 12/25/20171036F CURRENTTOBACCO NON- USER (CAD, CAP, CORD, PV) C139 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 (DM) (IBD) OF HYPOPHARYNX, OUTPATIENT /HOSPITAL �q UNSPECIFIED w• J 1212712017 12/20/2017 12/25/20171126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C139 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 v OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF HYPOPHARYNX, OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, UNSPECIFIED W 12/27/2017 12/20/2017 12/25/20171220F PATIENTSCREENED FOR DEPRESSION (SUD) C139 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF HYPOPHARYNX, OUTPATIENT /HOSPITAL UNSPECIFIED (' 12/27/2017 12/20/2017 12/25/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C139 MALIGNANT NEOPLASM PROFESSIONAL $78.63 $193.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF HYPOPHARYNX, OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY UNSPECIFIED CN! COMPONENTS: AN EXPANDED PROBLEM FOCUSED N HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW = COMPLEXITY. COUNSELING AND COORD 12/27/2017 12/20/2017 12/25/2017 68419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C139 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC FDLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN OF HYPOPHARYNX, OUTPATIENT /HOSPITAL UNSPECIFIED 12/27/2017 12/20/2017 12/25/201768427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C139 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF HYPOPHARYNX, OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS UNSPECIFIED 12/27/2017 12/20/2017 12/25/2017 G8434 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C139 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC REASON MDT GIVEN OF HYPOPHARYNX, OUTPATIENT /HOSPITAL UNSPECIFIED 12/27/2017 12/20/2017 12/25/2017 68731 PAIN ASSESSMENT USING A STANDARDIZED TOOL IS C139 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC DOCUMENTED AS NEGATIVE, NOFOLLOW- UPPLAN OF HYPOPHARYNX, OUTPATIENT /HOSPITAL REQUIRED UNSPECIFIED Sub TOtal $89,102.10 $371,530.59 1.875E +10 1/26/2017 11/28/2016 11/29/2016 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $2.34 $10.00 MALE SUBSCRIBER 1 BCC OF PROSTATE 1/26/2017 11/28/2016 11/29/2016 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $157.99 $250.00 MALE SUBSCRIBER 1 BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 1/26/2017 11/28/2016 11/29/201619217 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $57735 $1,500.00 MALE SUBSCRIBER 1 BCC OF PROSTATE 1/26/2017 11/28/2016 11/29/2016 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE I1 =31) ($1OAOU MALE SUBSCRIBER 1 BCC OF PROSTATE 1/26/2017 11/28/2016 11/29/2016 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE (<l 57 991 11250.00I MALE SUBSCRIBER 1 SCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 1/26/2017 11/28/2016 11/29/2016 J9217 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 M6 C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 i$1,500, OO) MALE SUBSCRIBER 1 BCC OF PROSTATE 1/30/2017 1/3/2017 1/6/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $229.19 $705.59 MALE SUBSCRIBER RO1 BCC OF PROSTATE 1/30/2017 1/5/2017 1/9/2017 963651ntravenous infusion, for th era py, prophylaxis, or diagnosis C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $73.09 $240.24 MALE SUBSCRIBER R01 BCC (specify substance or drug); initial, up to 1 hour NEOPLASM OF BONE 1/30/2017 1/5/2017 1/9/201713489 INJECTION, ZOLEDRONIC ACID, I MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $17030 $1,285.20 MALE SUBSCRIBER R01 BCC NEOPLASM OF BONE 1/30/2017 1/11/2017 1/12/2017 99213 OFFICE DR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $113.52 $193.00 MALE SUBSCRIBER R01 BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD C.7.f 1/30/2017 1/19/2017 1/23/2017 77263 THE RAP EUTIC RADIO LOGY TREATMENT PLAN N ING; C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $172.06 $565.54 MALE SUBSCRIBER R01 BCC 3559 COMPLEX NEOPLASM OF BONE 1/30/2017 1/19/2017 1/23/2017 77290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $536.74 $1,764.24 MALE SUBSCRIBER R01 BCC 3559 N SETTING; COMPLEX NEOPLASM OF BONE OR Q! 1/30/2017 1/19/2017 1/23/2017 77334 TREATMENT DEVICES, DESIGN AND CONSTRUCTION; C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $155.95 $512.61 MALE SUBSCRIBER R01 BCC 3559 COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, NEOPLASM OF BONE COMPENSATORS, WEDGES, MOLDS OR CASTS) } 1/30/2017 1/19/2017 1/24/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $32.62 $154.85 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED NEOPLASM OF BONE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A > } PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR A. CL COORDINATION OF CARE WIT Q, Q 2/2/2017 11/28/2016 1/31/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $10.00 MALE SUBSCRIBER 1 BCC 3559 v OF PROSTATE 2/2/2017 11/28/2016 1/31/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $250.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY h COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH _ 2/2/2017 11/28/2016 1/31/201719217 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $1,500.00 MALE SUBSCRIBER 1 BCC 3559 OF PROSTATE IL 2/10/2017 1/26/2017 2/2/2017 72146 MAGNETIC RESONANCE(EG, PROTON( IMAGING, SPINAL C7949 SECONDARY MALIGNANT PROFESSIONAL $91.84 $310.00 MALE SUBSCRIBER R01 BCC 3559 {li CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST NEOPLASM OF OTHER OUTPATIENT /HOSPITAL MATERIAL PARTS OF NERVOUS UJ SYSTEM 2/10/2017 1126/2017 2/2/2017 72148 MAGNETIC RESONANCE(EG, PROTON( IMAGING, SPINAL C7949 SECONDARY MALIGNANT PROFESSIONAL $92.25 $288.00 MALE SUBSCRIBER R01 BCC 3559 CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST NEOPLASM OF OTHER OUTPATIENT /HOSPITAL LLJ MATERIAL PARTS OF NERVOUS SYSTEM 4 J 2/10/2017 1/27/2017 2/3/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE 07951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $191.02 $627.87 MALE SUBSCRIBER ROl BCC 3559 TREATMENTS NEOPLASM OF BONE v 2/10/2017 1/30/2017 2/2/2017 G6013 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $285.55 $872.97 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE 2/10/2017 1/31/2017 2/3/2017 G6013 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $285.55 $872.97 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE (' 2/13/2017 1/26/2017 2/1/2017 772953 - DIMENSIONAL RADIOTHERAPY PLAN, INCLUDING DOSE- C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $577.07 $1,896.85 MALE SUBSCRIBER R01 BCC 3559 VOLUME HISTOGRAMS NEOPLASM OF BONE N 2/13/2017 1/26/2017 2/1/2017 77300 BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL 07951 SECONDARY MALIGNANT PROFESSIONAL OFFICE 5215.17 $707.25 MALE SUBSCRIBER R01 BCC 3559 N AXIS DEPTH DOSE CALCULATION, TDF, NSD, CAP NEOPLASM OF BONE CALCULATION, OFF AXIS FACTOR, TISSUE C INHOMOGENEITY FgCTORS, CALCULATION OF NOW y IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN PRESCRIBED BY THE TREATING 2 C.7.f 2/13/2017 1/26/2017 2/1/2017 77334 TREATMENT DEVICES, DESIGN AND CONSTRUCTION; C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $467.86 $1,537.83 MALE SUBSCRIBER R01 BCC 3559 COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, NEOPLASM OF BONE COMPENSATORS, WEDGES, MOLDS OR CASTS) N 2/13/2017 1/27/2017 2/1/2017 66013 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $285.55 $872.97 MALE SUBSCRIBER RO1 BCC 3559 NEOPLASM OF BONE OR 2/13/2017 2/1/2017 2/6/2017 G6013 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $285.55 $872.97 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE } 2/13/2017 2/3/2017 2/8/2017 G6013 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $28535 $872.97 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE 2/13/2017 2/3/2017 2110/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $191.02 $627.87 MALE SUBSCRIBER R01 BCC 3559 } TREATMENTS NEOPLASM OF BONE CL i® 2/13/2017 213/2017 211012017 ]]300 BASIC RADIATION DOSIMETRV CALCULATION, CENTRAL C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $215.17 $682.53 MALE SUBSCRIBER RO1 BCC 3559 Q, AXIS DEPTH DOSE CALCULATION, TDF, NED, GAP NEOPLASM OF BONE CALCULATIDN, OFF AXIS FACTOR, TISSUE INHOMOGENEITY FACTORS, CALCULATION OF NON - IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN PRESCRIBED BY THE TREATING 2/13/2017 2/6/2017 2/9/2017 G6013 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $285.55 $872.97 MALE SUBSCRIBER RO1 BCC 3559 Lij NEOPLASM OF BONE D 2/13/2017 2/7/2017 2/10/2017 G6013 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $285.55 $872.97 MALE SUBSCRIBER RO1 BCC 3559 NEOPLASM OF BONE _ 2/13/2017 2/8/2017 2/9/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E119 TYPE 2 DIABETES PROFESSIONAL OFFICE $234 $22.00 MALE SUBSCRIBER R01 BCC 3559 MELLITUS WITHOUT COMPLICATIONS 0. 2/20/2017 2/212017 2/6/2017 963651 ntravenous infusion, for therapy, prophylaxis, or diagnosis C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $73.09 $240.24 MALE SUBSCRIBER R01 BCC 3559 ui (specify substance ordrug); initial, up to 1 hour NEOPLASM OF BONE 2/20/2017 2/2/2017 2/6/2017 13489 INJECTION, ZOLEDRONIC ACID,1 MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $170.30 $1,285.20 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE 0 212012017 21212017 2/6/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $70.63 $235.75 MALE SUBSCRIBER RO1 BCC 3559 LLj EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY .A COMPONENTS: AN EXPANDED PROBLEM FOCUSED J HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW v COMPLEXITY, COUNSELING AND COORD 212012017 2/2/2017 2/6/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $53.47 $175.75 MALE SUBSCRIBER RO1 BCC 3559 LLJ INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, NEOPLASM OF BONE QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF U THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY 2/20/2017 2/2/2017 2/6/2017 66013 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $285.55 $872.97 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE N N 2/20/2017 2/8/2017 2/13/2017 G6013 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $285.55 $872.97 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE n 2/20/2017 2/9/2017 2/14/2017 77336 CONTINUING ME DICALPHYSICSCONSULTATION, C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $705.59 MALE INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, $73.09 NEOPLASM OF BONE SUBSCRIBER RO1 BCC QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF $1,285.20 MALE SUBSCRIBER R01 BCC $70.63 PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF SUBSCRIBER R01 BCC THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY 212012017 2/9/2017 2/14/2017 G6013 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE NEOPLASM OF BONE 2/20/2017 2/10/2017 2114/2017 77300 BASIC RADIATION D0SIMETRY CALCULATION, CENTRAL C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE AXIS DEPTH DOSE CALCULATION, TDF, NED, GAP NEOPLASM OF BONE CALCULATION, OFF AXIS FACTOR, TISSUE INHOMOGENEITY FACTORS, CALCULATION OF NON - IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN PRESCRIBED BY THE TREATING 2127/2017 2/17/2017 2/21/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE G9520 UNSPECIFIED CORD PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, COMPRESSION WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE 3/1/2017 2/15/2017 2/17/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E119 TYPE 2 DIABETES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MELLITUS WITHOUT PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY COMPLICATIONS COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 3/9/2017 3/1/2017 3/2/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 3/9/2017 3/1/2017 3/2/201719217 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF PROSTATE 3/13/2017 1/30/2017 2/2/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 3/13/2017 3/2/2017 3/7/2017 963651ntc— ousinfuslon, for therapy, p,ophylaas, or diagnosis C7951 SECONDARY MALIGNANT PROFE55IONAL OFFICE (specify substance or drug); initial, up to 1 hour NEOPLASM OF BONE 3/13/2017 3/2/2017 3/7/201713489 INJECTION, ZOLEDRONIC ACID, I MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE NEOPLASM OF BONE 3/13/2017 3/2/2017 3/7/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED NEOPLASM OF BONE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD $53.47 $175.75 MALE SUBSCRIBER R01 BCC $285.55 $872.97 MALE SUBSCRIBER R01 BCC $215.17 $682.53 MALE SUBSCRIBER RO1 BCC $221.20 $912.00 MALE SUBSCRIBER RO1 BCC $179.68 $285.00 MALE SUBSCRIBER RO1 BCC $132.99 $250.00 MALE SUBSCRIBER RO1 BCC $0.00 $1,500.00 MALE SUBSCRIBER R01 BCC $529.18 $705.59 MALE SUBSCRIBER R01 BCC $73.09 $240.24 MALE SUBSCRIBER RO1 BCC $170.30 $1,285.20 MALE SUBSCRIBER R01 BCC $70.63 $235.75 MALE SUBSCRIBER R01 BCC C.7.f 3559 3559 3559 Ft}Y] ®' mw 3559 3559 3559 3559 3559 C.7.f 3/15/2017 2/28/2017 3/6/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $529.18 $705.59 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE W 3/17/2017 3/7/2017 3/9/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE G9520 UNSPECIFIED CORD PROFESSIONAL OFFICE $143.64 $627.00 MALE SUBSCRIBER RO1 BCC 3559 N EVALUATION AND MANAGEMENT OF AN ESTABLISHED COMPRESSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR 7 COORDINATION OF CARE WITH "a 3/17/2017 3/8/2017 3/12/2017- - 69520 UNSPECIFIED CORD HOSPITAL OUTPATIENT $2,774.25 $6,493.55 MALE SUBSCRIBER R01 BCC 3559 COMPRESSION 3/17/2017 3/8/2017 3/12/2017- - G9520 UNSPECIFIED CORD HOSPITAL OUTPATIENT $aUD $6,493.55 MALE SUBSCRIBER R01 BCC lu 3559 > } COMPRESSION 3/17/2017 3/8/2017 3/15/2017 72146 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL C61 MALIGNANT NEOPLASM PROFESSIONAL $91.84 $310.00 MALE SUBSCRIBER R01 BCC 3559 iL CL CANALAND CONTENTS, THORACIC; WITHOUT CONTRAST OF PROSTATE OUTPATIENT /HOSPITAL Q, MATERIAL < 3/20/2017 1/26/2017 1/30/2017- - Z8546 PERSONAL HISTORY OF HOSPITAL OUTPATIENT $2,774.25 $12,450.66 MALE SUBSCRIBER R01 BCC 3559 MALIGNANT NEOPLASM OF PROSTATE 4 3/31/2017 3/27/2017 3/30/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $640.50 $1,051.06 MALE SUBSCRIBER RO1 BCC 3559 OF PROSTATE W 4/3/2017 3/9/2017 3/31/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $32.62 $142.05 MALE SUBSCRIBER RO1 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED NEOPLASM OF BONE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT Q W 4/5/2017 3/27/2017 3/30/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,814.14 $8,489.53 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE a) 4/5/2017 3/31/2017 4/4/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 69520 UNSPECIFIED CORD PROFESSIONAL OFFICE $168.64 $627.00 MALE SUBSCRIBER RO1 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED COMPRESSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY e LLJ COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH v 4/7/2017 4/3/2017 4/5/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $141.30 $348.35 MALE SUBSCRIBER ROl BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LLJ COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR (' COORDINATION OF CARE WITH OTHER 4/10/2017 3/22/2017 4/6/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $57.62 $136.10 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED NEOPLASM OF BONE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY Cy COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD = MEDICAL DECISION MAKING. COUNSELING AND /OR y COORDINATION OF CARE WIT 4/10/2017 3/27/2017 4/6/2017 4/10/2017 3/27/2017 4/6/2017 4/17/2017 4/3/2017 4/12/2017 4/17/2017 4/3/2017 4/12/2017 4/17/2017 4/3/2017 4/12/2017 13489 5/4/2017 4/26/2017 5/3/2017 - 5/8/2017 4/27/2017 5/3/2017 - 5/8/2017 5/4/2017 5/5 /2017 5/11/2017 4/27/2017 5/10/2017 5/11/2017 4/27/2017 5/10/2017 5/11/2017 4/27 /2017 5/10/2017 5/16/2017 5/11/2017 5/15/2017 5/17/2017 5/11/2017 5/15/2017 5/17/2017 5/11/2017 5/15/2017 10897 6/14/2017 6/2/2017 6/13/2017 - 6115/2017 6/13/2017 6/14/2017 72197 MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; C7951 SECONDARY MALIGNANT PROFESSIONAL WITHOUT CONTRAST MATERIAL(SE FOLLOWED BY $18.20 NEOPLASM OF BONE OUTPATIENT /HOSPITAL CONTRAST MATERIAL(S) AND FURTHER SEQUENCES $97.45 $240.24 MALE 73502 Radiologic examination, hip, unilateral, with pelvis when C7951 SECONDARY MALIGNANT PROFESSIONAL performed; 2 -3 views $207.16 NEOPLASM OF BONE OUTPATIENT /HOSPITAL 963651 ntravenous infusion, for therapy, prophylaxis, or diagnos is C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE (specify substance or drug); initial, Lip to 1 hour $5,692.00 NEOPLASM OF BONE 963661 ntravenous infusion, for therapy, prophylaxis, or diagnosis C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE (specify substance or drug); each additional hour (List NEOPLASM OF BONE separately m addition to code for primary procedure) INJECTION, ZOLEDRONIC ACID, I MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE NEOPLASM OF BONE - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST C7951 SECONDARY MALIGNANT PROFESSIONAL MATERIALS) NEOPLASM OF BONE OUTPATIENT /HOSPITAL 74177 Cor puled tomography, abdomen and pelvis; with C7951 SECONDARY MALIGNANT PROFESSIONAL contrast material(s) NEOPLASM OF BONE OUTPATIENT /HOSPITAL 78306 BONE AND/OR JOINT IMAGING; WHOLE BODY C7951 SECONDARY MALIGNANT PROFESSIONAL NEOPLASM OF BONE OUTPATIENT /HOSPITAL 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 96401 CHEMOTHERAPY ADMINISTRATION , SUBCUTANEOUS OR C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE INTRAMUSCULAR; NON - HORMONAL ANTI- NEOPLASTIC NEOPLASM OF BONE INJECTION, DENOSUMAB, 1 MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE NEOPLASM OF BONE - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 772953 - DIMENSIONAL RADIOTHERAPY PLAN, INCLUDING DOSE- C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE VOLUME HISTOGRAMS NEOPLASM OF BONE $185.98 $438.00 MALE SUBSCRIBER R01 BCC $18.20 $43.00 MALE SUBSCRIBER R01 BCC $97.45 $240.24 MALE SUBSCRIBER R01 BCC $59.10 $145.70 MALE SUBSCRIBER R01 BCC $207.16 $1,285.20 MALE SUBSCRIBER ROE BCC $854.00 $1,051.06 MALE SUBSCRIBER R01 BCC $5,692.00 $18,390.68 MALE SUBSCRIBER RO1 BCC $141.30 $348.35 MALE SUBSCRIBER R01 BCC $10237 $239.00 MALE SUBSCRIBER R01 BCC $14933 $360.00 MALE SUBSCRIBER R01 BCC $68.39 $169.00 MALE SUBSCRIBER R01 BCC $141.30 $348.35 MALE SUBSCRIBER R01 BCC $100.55 $247.89 MALE SUBSCRIBER R01 BCC $1,982.40 $5,364.00 MALE SUBSCRIBER R01 BCC $680.00 $680.00 MALE SUBSCRIBER R01 BCC $769.43 $2,107.64 MALE SUBSCRIBER RO1 BCC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 C.7.f 6/15/2017 6/13/2017 6/14/2017 77300 BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL C7951 SUBSCRIBER R01 AXIS DEPTH DOSE CALCULATION, TIDE, NSD, GAP 3559 NEOPLASM OF BONE CALCULATION, OFF AXIS FACTOR, TISSUE INHOMOGENEITY FACTORS, CALCULATION OF NON - W IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN O1 PRESCRIBED BY THE TREATING 6/15/2017 6/13/2017 6/14/2017 77334 TREATMENT DEVICES, DESIGN AND CONSTRUCTION; C7951 COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, COMPENSATORS, WEDGES, MOLDS OR CASTS) m 6/15/2017 6/13/2017 6/14/2017 77470 SPECIAL TREATMENT PROCEDURE(EG, TOTAL BODY C7951 IRRADIATION, HEMIBODY RADIATION, PER ORAL OR Q! ENDOCAVITARY IRRADIATION( 6/16/2017 6/12/2017 6/15/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 SECONDARY MALIGNANT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED $1,713.33 MALE SUBSCRIBER R01 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY 3559 NEOPLASM OF BONE COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF } MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/19/2017 6/5/2017 6/14/2017 96402 CHEMOTHERAPY ADMINISTRATION , SUBCUTANEOUS OR C61 INTRAMUSCULAR; HORMONAL ANTI - NEOPLASTIC 6/19/2017 6/5/2017 6/14/2017 J9217 LEUPROUDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG C61 6/19/2017 6/12/2017 6115/2017 96401 CHEMOTHERAPY ADMINISTRATION , SUBCUTANEOUS OR C7951 NEOPLASM OF BONE INTRAMUSCULAR; NON- HORMONAL ANTI - NEOPLASTIC 6/19/2017 6/12/2017 6/15/2017 J0897 INJECTION, DENOSUMAB, 1 MG C7951 6/19/2017 6/13/2017 6/16/2017 77263 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; C79S1 COMPLEX W 6/19/2017 6/13/2017 6/16/2017 G6012 RADIATION TREATMENT DELIVERY C7951 6/19/2017 6/14/2017 6/16/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 OF PROSTATE OF RADIATION THERAPY FIELDS 6/19/2017 6/14/2017 6/16/2017 G6012 RADIATION TREATMENT DELIVERY C7951 6/19/2017 6/16/2017 6/17/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E119 6/20/2017 6/12/2017 6119/2017 - - C61 6/21/2017 6/12/2017 6/20/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION C7951 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES Q THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER Q PROVIDERS OR AGENCIES ARE PR SECONDARY MALIGNANT PROFESSIONAL OFFICE $191.26 $523.28 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE W O1 N m Q! OR SECONDARY MALIGNANT PROFESSIONAL OFFICE $623.82 $1,713.33 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE } SECONDARY MALIGNANT PROFESSIONAL OFFICE $274.85 $1,179.49 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE W MALIGNANT NEOPLASM PROFESSIONAL OFFICE $141.30 $348.35 MALE SUBSCRIBER ROl BCC } 3559 OF PROSTATE L CL CL Q Q MALIGNANT NEOPLASM PROFESSIONAL OFFICE $47.37 $116.78 MALE SUBSCRIBER ROl BCC 3559 OF PROSTATE W MALIGNANT NEOPLASM PROFESSIONAL OFFICE $573.48 $3,176.61 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE SECONDARY MALIGNANT PROFESSIONAL OFFICE $100.55 $247.89 MALE SUBSCRIBER RO1 BCC 3559 NEOPLASM OF BONE O SECONDARY MALIGNANT PROFESSIONAL OFFICE $1,982.40 $5,364.00 MALE SUBSCRIBER R01 BCC 3559 Q NEOPLASM OF BONE Lli SECONDARY MALIGNANT PROFESSIONAL OFFICE $22931 $617.85 MALE SUBSCRIBER R01 BCC 3559 UJ NEOPLASM OF BONE SECONDARY MALIGNANT PROFESSIONAL OFFICE $340.39 $870.62 MALE SUBSCRIBER R01 BCC 3559 LLj NEOPLASM OF BONE V SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER R01 BCC 3559 � NEOPLASM OF BONE w• J SECONDARY MALIGNANT PROFESSIONAL OFFICE $340.39 $870.62 MALE SUBSCRIBER RO1 BCC 3559 v NEOPLASM OF BONE TYPE DIABETES PROFESSIONAL OFFICE $2.34 $22.00 MALE SUBSCRIBER R01 BCC 3559 LLj MELLITUS WITHOUT COMPUCATIO NS MALIGNANTNEOPLASM HOSPITAL OUTPATIENT $7,679.00 $13,553.05 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE Q Q SECONDARY MALIGNANT PROFESSIONAL $21136 $994.00 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE OUTPATIENT /HOSPITAL n,e C.7.f 6/21/2017 6/13/2017 6/20/2017 ]]427 RADIATION TREATMENT MANAGEMENT, FIVE C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $254.69 $687.27 MALE SUBSCRIBER R01 BCC 3559 TREATMENTS NEOPLASM OF BONE 6/21/2017 6/15/2017 6/20/2017 ]]014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER RO1 BCC 3559 N OF RADIATION THERAPY FIELDS NEOPLASM OF BONE Q! 6/21/2017 6/15/2017 6/20/2017 G6012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $340.39 $870.62 MALE SUBSCRIBER RO1 BCC 3559 A NEOPLASM OF BONE i 6/21/2017 6/16/2017 612012017 ]]014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER R01 BCC 3559 "a OF RADIATION THERAPY FIELDS NEOPLASM OF BONE m c) 6/21/2017 6/16/2017 6120/2017 G6012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $34039 $870.62 MALE SUBSCRIBER RO1 BCC 3559 NEOPLASM OF BONE } fl 6/23/2017 6/16/2017 6/22/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 A419 SEPSIS, UNSPECIFIED PROFESSIONAL $0.00 $69.00 MALE SUBSCRIBER R01 BCC 3559 N. CL LEADS; INTERPRETATION AND REPORT ONLY ORGANISM OUTPATIENT /HOSPITAL Q, Q 6/23/2017 6/16/2017 6/22/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE A419 SEPSIS, UNSPECIFIED PROFESSIONAL $399.67 $1,870.00 MALE SUBSCRIBER R01 BCC 3559 v CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- ORGANISM OUTPATIENT/HOSPITAL 74 MIN UTES 6/23/2017 6/19/2017 6/22/2017 ]]014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER RO1 BCC 3559 OF RADIATION THERAPY FIELDS NEOPLASM OF BONE W 6/23/2017 6/19/2017 6/22/2017 G6012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $340.39 $870.62 MALE SUBSCRIBER RO1 BCC 3559 NEOPLASM OF BONE 6/23/2017 6/20/2017 6/22/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER RO1 BCC 3559 _ OF RADIATION THERAPY FIELDS NEOPLASM OF BONE 6/23/2017 6/20/2017 612212017 66012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $341139 $870.62 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE 0. W 6/26/2017 6/16/2017 6123/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R509 FEVER, UNSPECIFIED PROFESSIONAL $14.94 $36.00 MALE SUBSCRIBER RO1 BCC 3559 FRONTAL OUTPATIENT /HOSPITAL UJ 6/26/2017 6/16/2017 6/23/2017 - - T66XXXA RADIATION SICKNESS, HOSPITAL INPATIENT 6/15/2017 # # # # # # ## $10,104.97 $12,978.82 MALE SUBSCRIBER R01 BCC 3559 0 UNSPECIFIED, INITIAL ENCOUNTER LLJ 6/26/2017 6/22/2017 6/24/2017 . * "* * * * ** " "' F..' * * "* $204.68 $285.00 MALE SUBSCRIBER RO1 BCC 3559 6/27/2017 6/12/2017 6/26/2017 70553 MAGNETIC RESONANCE(EG, PROTON) IMAGING, BRAIN C61 MALIGNANT NEOPLASM PROFESSIONAL $188.15 $457.00 MALE SUBSCRIBER RO1 BCC 3559 (INCLUDING BRAIN STEM); WITHOUTCONTRAST OF PROSTATE OUTPATIENT /HOSPITAL J MATERIAL, FOLLOWED BY CONTRAST MATERIALS) AND FU THER SEQUENCES (, 6/27/2017 6/21/2017 6/26/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER RO1 BCC 3559 OF RADIATION THERAPY FIELDS NEOPLASM OF BONE W 6/2]/201] 6/21/2017 6/26/2017 G6012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $340.39 $870.62 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE U 6/27/2017 6/22/2017 6/26/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER RO1 BCC 3559 OF RADIATION THERAPY FIELDS NEOPLASM OF BONE Q 6/27/2017 6/22/2017 6/26/2017 66012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $34039 $870.62 MALE SUBSCRIBER ROl BCC 3559 CN! NEOPLASM OF BONE f'V 6/28/2017 6/12/2017 6/27/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT C7982 SECONDARY MALIGNANT PROFESSIONAL $70.32 $166.00 MALE SUBSCRIBER R01 BCC 3559 = CONTRAST MATERIAL NEOPLASM OF GENITAL OUTPATIENT /HOSPITAL y ORGANS C.7.f 6/30/2017 6/20/2017 6/29/2017 ]]427 RADIATION TREATMENT MANAGEMENT, FIVE C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $254.69 $687.27 MALE SUBSCRIBER R01 BCC 3559 TREATMENTS NEOPLASM OF BONE 6/30/2017 6/23/2017 6/29/2017 ]]014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER R01 BCC 3559 N OF RADIATION THERAPY FIELDS NEOPLASM OF BONE Q! 6/30/2017 6/23/2017 6/29/2017 G6012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $340.39 $870.62 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE 6/30/2017 6/26/2017 6/29/2017 ]]014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER R01 BCC 3559 "a OF RADIATION THERAPY FIELDS NEOPLASM OF BONE 6/30/2017 6/26/2017 6129/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $7129 $195.32 MALE SUBSCRIBER R01 BCC 3559 INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, NEOPLASM OF BONE } QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF {j PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF CL THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF Q, THERAPY 6/30/2017 6/26/2017 6/29/2017 G6012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $34039 $870.62 MALE SUBSCRIBER R01 BCC v 3559 NEOPLASM OF BONE 7/3/2017 6/16/2017 6/30/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 8509 FEVER, UNSPECIFIED PROFESSIONAL $189.81 $893.00 MALE SUBSCRIBER R01 BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; IJU F A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN _ 7/3/2017 6/17/2017 6/30/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE R509 FEVER, UNSPECIFIED PROFESSIONAL $9919 $467.00 MALE SUBSCRIBER R01 BCC 3559 THAN 30 MINUTES INPATIENT /HOSPITAL 0 71512017 6/27/2017 ]/3/201] ]]014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER R01 BCC 3559 Q. OF RADIATION THERAPY FIELDS NEOPLASM OF BONE uj 7/5/2017 6/27/2017 7/3/201766012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $34039 $870.62 MALE SUBSCRIBER R01 BCC 3559 UJ NEOPLASM OF BONE 7/5/2017 6/28/2017 71312017 ]]014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER R01 BCC 3559 LLJ OF RADIATION THERAPY FIELDS NEOPLASM OF BONE W 7 /5/2017 6/28/2017 7/3/2017 G6012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $340.39 $870.62 MALE SUBSCRIBER R01 BCC 3559 �q NEOPLASM OF BONE w• J 7/10/2017 6/29/2017 7/7/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER R01 BCC 3559 v OF RADIATION THERAPY FIELDS NEOPLASM OF BONE 711012017 6/29/2017 7/7/2017 G6012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $340.39 $870.62 MALE SUBSCRIBER R01 BCC 3559 LLJ NEOPLASM OF BONE 7/10/2017 6/30/2017 7/7/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER RO1 BCC 3559 (' OF RADIATION THERAPY FIELDS NEOPLASM OF BONE 7/10/2017 6/30/2017 7/7/2017 66012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $34039 $870.62 MALE SUBSCRIBER R01 BCC 3559 Q NEOPLASM OF BONE {hj Cy 7/10/2017 7/3/2017 7/7/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $260.03 $714.10 MALE SUBSCRIBER RO1 BCC 3559 OF RADIATION THERAPY FIELDS NEOPLASM OF BONE n 7/10/2017 7/3/2017 7/7/2017 77336 CONTINUING ME DICALPHYSICSCONSULTATION, C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE LEE 67q,01) ($13,553.051 MALE SUBSCRIBER R01 DEC INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, $13,553.05 MALE NEOPLASM OF BONE $0.00 $13,55105 MALE SUBSCRIBER RO1 BCC QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF $70.00 MALE SUBSCRIBER RO1 BCC $57.62 $156.52 MALE SUBSCRIBER R01 BCC PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY 7/10/2017 7/3/2017 7/7/2017 G6012 RADIATION TREATMENT DELIVERY C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE NEOPLASM OF BONE 7/11/2017 6/12/2017 7110/2017 99212 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENTOFAN ESTABLISHED NEOPLASM OF BONE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 7113/2017 7/6/2017 7/12/2017 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 7/13/2017 7/6/2017 7/12/2017 96401 CHEMOTHERAPY ADMINISTRATION , SUBCUTANEOUS OR C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE INTRAMUSCULAR; NON- HORMONALANTI- NEOPLASTIC NEOPLASM OF BONE 7/13/2017 7/6/2017 7/12/2017 J0897 INJECTION, DENOSUMAB, 1 MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE NEOPLASM OF BONE 7/18/2017 6/12/2017 6/19/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 7/18/2017 6/12/2017 7/17/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 7/18/2017 6112/2017 7/17/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 7/20/2017 6/16/2017 7/18/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL 713112017 7/13/2017 712812017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED NEOPLASM OF BONE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 8/2/2017 7/27/2017 81112017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 8/9/2017 7/29/2017 8/8/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET)WITH C61 MALIGNANT NEOPLASM PROFESSIONAL CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY OF PROSTATE OUTPATIENT /HOSPITAL (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID THIGH 8/18/2017 7/29/2017 8/8/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE $71.29 $195.32 MALE SUBSCRIBER R01 BCC $340.39 $870.62 MALE SUBSCRIBER R01 BCC $57.62 $156.52 MALE SUBSCRIBER RO1 BCC $190.28 $469.12 MALE SUBSCRIBER RO1 BCC $100.55 $247.89 MALE SUBSCRIBER RO1 BCC $0.00 $5,364.00 MALE SUBSCRIBER R01 BCC LEE 67q,01) ($13,553.051 MALE SUBSCRIBER R01 DEC $7,679.00 $13,553.05 MALE SUBSCRIBER R01 BCC $0.00 $13,55105 MALE SUBSCRIBER RO1 BCC $11.07 $70.00 MALE SUBSCRIBER RO1 BCC $57.62 $156.52 MALE SUBSCRIBER R01 BCC $657.00 $657.00 MALE SUBSCRIBER R01 BCC $194.31 $477.00 MALE SUBSCRIBER RO1 BCC $1,864.25 $16,993.00 MALE SUBSCRIBER R01 BCC C.7.f 3559 3559 3559 KEW 3559 3559 3559 3559 3559 3559 3559 3559 3559 III 812112017 8/3/2017 811812017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $348.35 MALE SUBSCRIBER ROE BCC $15.49 EVALUATION AND MANAGEMENT OF AN ESTABLISHED SUBSCRIBER RO1 BCC OF PROSTATE $22.00 MALE SUBSCRIBER RD1 BCC $204.68 $285.00 MALE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 8/21/2017 8/7/2017 8/18 /2017 96401 CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE INTRAMUSCULAR; NON - HORMONALANTI - NEOPLASTIC NEOPLASM OF BONE 8/21/2017 81712017 8/18/2017 J0897 INJECTION, DENOSUMAB, 1 MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE NEOPLASM OF BONE 8/21/2017 8/7/2017 8/18/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 8/29/2017 8/21/2017 8/28/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 9/15/2017 8/21/2017 9/14/2017 36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL Z452 ENCOUNTER FOR PROFESSIONAL VENOUSACCESS DEVICE, WITH SUBCUTANEOUS PORT; ADIUSTMENTAND OUTPATIENT /HOSPITAL AGE 5 YEARS DR OLDER MANAGEMENT OF VASCULAR ACCESS DEVICE 9/15/2017 8/21/2017 9/14/2017 76937 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS Z452 ENCOUNTER FOR PROFESSIONAL REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ADIUSTMENTAND OUTPATIENT /HOSPITAL ACCESS SITES, DOCUMENTATION OF SELECTEDVESSEL MANAGEMENT OF PATENCY, CONCURRENT REALTIME ULTRASOUND VASCULAR ACCESS DEVICE VISUALIZATION OF VASCULAR NEEDLE ENTRY, 9115/2017 8/21/2017 9/14/2017 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS Z452 ENCOUNTERFOR PROFESSIONAL DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR ADIUSTMENTAND OUTPATIENT /HOSPITAL COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC MANAGEMENT OF GUIDANCE FOR VASCULAR ACCESS AND CATHETER VASCULAR ACCESS DEVICE MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHYR 9/15/2017 8/21/2017 9/14/2017 99152 Moderate sedation services provided by the same Z452 ENCOUNTER FOR PROFESSIONAL physician or other qualified health care professional ADJUSTMENTAND OUTPATIENT /HOSPITAL performingthe diagnostic or therapeutic service that MANAGEMENT OF VASCULAR ACCESS DEVICE 9/29/2017 9/22/2017 9/28/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 10/10/2017 10/212017 10/9/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 10/12/2017 10/2/2017 10111/2017 73552 Radiologia examination, fe mu r; minimum 2 views C7951 SECONDARY MALIGNANT PROFESSIONAL NEOPLASM OF BONE OUTPATIENT /HOSPITAL 10/25/2017 10/23/2017 1012412017 36415 COLLECTION OFVENOUS BLOOD BYVENIPUNCTURE E119 TYPE 2 DIABETES PROFESSIONAL OFFICE MELLITUS WITHOUT COMPLICATIONS 11/2/2017 10/30/2017 11/1/2017 . *' "* " "" ' "• ** ' * " "' " "'* $141.30 $348.35 MALE SUBSCRIBER R01 BCC $100.55 $247.89 MALE SUBSCRIBER R01 BCC $1,995.60 $5,364.00 MALE SUBSCRIBER R01 BCC $141.30 $348.35 MALE SUBSCRIBER ROE BCC $0.00 $15,634.55 MALE SUBSCRIBER R01 BCC $0.00 $1,399.00 MALE SUBSCRIBER R01 BCC $0.00 $64.00 MALE SUBSCRIBER R01 BCC $0.00 $71.00 MALE SUBSCRIBER RO1 BCC $0.00 $48.00 MALE SUBSCRIBER RO1 BCC $473.95 $473.95 MALE SUBSCRIBER R01 BCC $979.00 $1,166.00 MALE SUBSCRIBER R01 BCC $15.49 $36.00 MALE SUBSCRIBER RO1 BCC $2.34 $22.00 MALE SUBSCRIBER RD1 BCC $204.68 $285.00 MALE SUBSCRIBER R01 BCC C.7.f 3559 3559 3559 3559 3559 3559 Im IIJIM 99liz 3559 3559 3559 3559 3559 C.7.f 11/3/2017 9/22/2017 111212017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $57.62 $156.52 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED NEOPLASM OF BONE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A N PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 11/8/2017 10/31/2017 11/7/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $854.00 $1,326.95 MALE SUBSCRIBER R01 BCC 3559 7 OF PROSTATE 11/16/2017 8/21/2017 11/15/2017 60103 PROSTATE CANCER SCREENING; PROSTATE SPECIFIC C61 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $25.00 MALE SUBSCRIBER RD1 BCC 3559 ANTIGEN TEST(PSA) OF PROSTATE OUTPATIENT /HOSPITAL W 12/4/2017 11/24/2017 11/30/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $473.95 $473.95 MALE SUBSCRIBER RO1 BCC } 3559 OF PROSTATE L CL 12/5/2017 8/21/2017 8/28/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $0.00 ($15,6.34.55) MALE SUBSCRIBER R01 BCC ` CL 3559 `it OF PROSTATE v 12/5/2017 8/21/2017 9/14/2017 36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL Z452 ENCOUNTER FOR PROFESSIONAL $0.00 151.399.00) MALE SUBSCRIBER RO1 BCC 3559 VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; ADIUSTMENTAND OUTPATIENT /HOSPITAL AGE 5 YEARS OR OLDER MANAGEMENT OF VASCULAR ACCESS DEVICE F 12/5/2017 8/21/2017 9/14/2017 76937 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND EVALUATION OF POTENTIAL Z452 ENCOUNTER FOR ADJUSTMENT AND PROFESSIONAL OUTPATIENT /HOSPITAL $0.00 ($64.00) MALE SUBSCRIBER R01 BCC 3559 ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL MANAGEMENT OF _ PATENCY, CONCURRENT REALTIME ULTRASOUND VASCULAR ACCESS DEVICE VISUALIZATION OF VASCULAR NEEDLE ENTRY, O 12/5/2017 8/21/2017 9/14/2017 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS Z452 ENCOUNTERFOR PROFESSIONAL $0.00 ($7:!..00) MALE SUBSCRIBER R01 BCC 3559 Q DEVICE PLACEM ENT, REPLACEMENT (CATHETER ONLY OR ADIUSTMENTAND OUTPATIENT /HOSPITAL ILLI COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC MANAGEMENT OF GUIDANCE FOR VASCULAR ACCESS AND CATHETER VASCULAR ACCESS DEVICE U;! MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS 0 THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHYR LLj n `✓ 12/5/2017 8/21/2017 9/14/2017 99152 Moderate sedation services provided by the same Z452 ENCOUNTER FOR PROFESSIONAL $0.00 ($48.00) MALE SUBSCRIBER R01 BCC 3559 physician or other qualified health care professional ADJUSTMENT AND OUTPATIENT /HOSPITAL 4 performing the diagnostic or therapeutic service that MANAGEMENT OF J VASCULAR ACCESS DEVICE v 12/5/2017 8/21/2017 12/4/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $13,901.55 $15,634.55 MALE SUBSCRIBER ROl BCC 3559 r OF PROSTATE Z W 12/5/2017 8/21/2017 12/4/2017 36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL Z452 ENCOUNTER FOR PROFESSIONAL $616.81 $1,399.00 MALE SUBSCRIBER RO1 BCC 3559 VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; ADJUSTMENT AND OUTPATIENT /HOSPITAL AGE 5 YEARS OR OLDER MANAGEMENT OF (' VASCULAR ACCESS DEVICE 12/5/2017 8/21/2017 12/4/2017 76937 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS Z452 ENCOUNTER FOR PROFESSIONAL $23.87 $64.00 MALE SUBSCRIBER R01 BCC 3559 REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ADJUSTMENT AND OUTPATIENT /HOSPITAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL MANAGEMENT OF N PATENCY, CONCURRENT REACTIVE ULTRASOUND VASCULAR ACCESS DEVICE VISUALIZATION OF VASCULAR NEEDLE ENTRY, r- C.7.f 12/5/2017 8/21/2017 12/4/2017 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS Z452 ENCOUNTERFOR PROFESSIONAL $31.75 $71.00 MALE SUBSCRIBER R01 BCC 3559 DEVICE PIACEM ENT, REPLACEMENT (CATHETER ONLY OR ADIUSTMENTAND OUTPATIENT /HOSPITAL COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC MANAGEMENT OF GUIDANCE FOR VASCULAR ACCESS AND CATHETER VASCULAR ACCESS DEVICE MANIPULATION, ANY NECESSARY CONTRAST INIECFIONS THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHYR 12/5/2017 8/21/2017 12/4/2017 99152 Moderate sedation services provided by the same Z452 ENCOUNTER FOR PROFESSIONAL $20.62 $48.00 MALE SUBSCRIBER R01 BCC 3559 physician or other qualified health care professional ADJUSTMENT AND OUTPATIENT /HOSPITAL performing the diagnostic or therapeutic service that MANAGEMENT OF VASCULAR ACCESS DEVICE 12/6/2017 8/21/2017 11/15/2017 G0103 PROSTATE CANCER SCREENING; PROSTATE SPECIFIC C61 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $25.00 MALE SUBSCRIBER RD1 BCC 3559 ANTIGEN TEST(PSA) OF PROSTATE OUTPATIENT /HOSPITAL 12/6/2017 8/21/2017 11/15/2017 G0103 PROSTATE CANCER SCREENING; PROSTATE SPECIFIC C61 MALIGNANT NEOPLASM PROFESSIONAL $0.00 ($25,001 MALE SUBSCRIBER RO1 DEC 3559 ANTIGEN TEST(PSA) OF PROSTATE OUTPATIENT /HOSPITAL 121812017 11/27/2017 12/5/201719171 INJECTION, DOCETAXEL, I MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $358.75 $8,706.25 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE 12/8/2017 1112712017 12/5/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $89.24 $219.98 MALE SUBSCRIBER RO1 BCC 3559 OR DIAGNOSIS ISPECIFY SUBSTANCE OR DRUG); NEOPLASM OF BONE ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 12/8/2017 11/27/2017 12/5/2017 963681rtravenou s infusion, for th era py, prophylaxis, or diagnos i, C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $26.38 $65.02 MALE SUBSCRIBER R01 BCC 3559 (specify substance or drug); concurrent infusion (List NEOPLASM OF BONE separately in addition to code for primary procedure) 12/8/2017 11/27/2017 12/5/2017 96401 CHEMOTHERAPY ADMINISTRATION , SUBCUTANEOUS OR C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $10035 $247.89 MALE SUBSCRIBER RD1 BCC 3559 INTRAMUSCULAR; NON- HORMONALANTI- NEOPLASTIC NEOPLASM OF BONE 12/8/2017 11/27/2017 12/5/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $20046 $494.20 MALE SUBSCRIBER R01 BCC 3559 INFUSION TECHNIQUE; UP TO I HOUR, SINGLE OR INITIAL NEOPLASM OF BONE SUBSTANCE /DRUG 121812017 11/27/2017 12/5/2017 10897 INJECTION, DENOSUMAB, 1 MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $2,044.80 $5,364.00 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE 12/8/2017 11/27/2017 12/5/201711100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $1.30 $3.20 MALE SUBSCRIBER RO1 BCC 3559 NEOPLASM OF BONE 12/8/2017 11/27/2017 12/5/201711200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $0.63 $3.35 MALE SUBSCRIBER RO1 BCC 3559 NEOPLASM OF BONE 12/8/2017 11/27/2017 12/5/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCC C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $14.90 $27.00 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE 12/18/2017 11/2/2017 12115/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $89.24 $219.98 MALE SUBSCRIBER RO1 BCC 3559 OR DIAGN05I5(SPECIFY SUBSTANCE OR DRUG); OF PROSTATE ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 12/18/2017 11/2/2017 12/15/2017 963681rtravenous infusion, for therapy, prophylaxis, or diagnos is C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $2638 $65.02 MALE SUBSCRIBER R01 BCC 3559 (specify substance or drug); concurrent infusion (List OF PROSTATE separately in addition to code for primary procedure) C.7.f 12/18/2017 11/2/2017 12/15/2017 96372 Thera peutic, pro phylactic, or diagnostic Injection (specify C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $31.41 $77.44 MALE SUBSCRIBER R01 BCC 3559 substance or drug); s,bcutaneousor'mtramuscular OF PROSTATE 12/18/2017 11/2/2017 12/15/2017 96375 Therapeutic, prophylactic, or diagnostic Injection (specify C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $31.17 $76.85 MALE SUBSCRIBER R01 BCC 3559 substance or drug); each additional sequential intravenous OF PROSTATE push of anew substance /drug (List separately In addition to code for primary procedure) 12/18/2017 11/2/2017 12115/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $200.46 $494.20 MALE SUBSCRIBER R01 BCC 3559 INFUSION TECHNIQUE; UPTO I HOUR, SINGLE OR INITIAL OF PROSTATE SUBSTANCE /DRUG 12/18/2017 11/2/2017 12/15/201711100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.30 $3.20 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE 1211812017 111212017 1211512017 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG C61 MALIGNANT NEOPLASM PR0FE55IONAL OFFICE $0.63 $3.35 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE 12/18/2017 11/2/2017 12/15/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCC C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $14.90 $27.00 MALE SUBSCRIBER RO1 BCC 3559 OF PROSTATE 12/18/2017 11/2/2017 12/15/201713420 INJECTION, VITAMIN B- 12 CYANOCOBAIAMIN, UP TO C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $2.65 $5.75 MALE SUBSCRIBER R01 BCC 3559 1000 MCG OF PROSTATE 12/18/2017 11/2/2017 12/15/201719171 INJECTION, DDCETAXEL, I MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $358.75 $8,706.25 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE 12/20/2017 12/15/2017 1211912017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $473.95 $473.95 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE 12/27/2017 9/22/2017 12122/2017 J9171 INJECTION, DDCETAXEL, I MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $428.80 $7,960.00 MALE SUBSCRIBER RO1 BCC 3559 OF PROSTATE 12/27/2017 9/22/2017 12/22/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $13186 $329.97 MALE SUBSCRIBER R01 BCC 3559 OR DIAGNOSIS (SPECIFY SUBSTANCE DR DRUG); OF PROSTATE ADDITIONAL SEQUENTIAL INFUSION OF NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 1212712017 9/22/2017 1212212017 96368 Intravenous infusion, for therapy, prophylaxis, or diagnosis C61 MALIGNANT N EOPLASM PROFESSIONAL OFFICE $26.38 $65.02 MALE SUBSCRIBER R01 BCC 3559 (specify substance or drug); concurrent infusion (List OF PROSTATE separately in addition to code for primary procedure) 12/27/2017 9/22/2017 12/22/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $200.46 $494.20 MALE SUBSCRIBER R01 BCC 3559 INFUSION TEC HNIQUE ; UPTO I HOUR, SINGLE OR INITIAL OF PROSTATE SUBSTANCE /DRUG 1212712017 9/22/2017 1212212017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.10 $3.20 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE 12/27/2017 9/22/2017 12/22/201711200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.76 $3.35 MALE SUBSCRIBER RO1 BCC 3559 OF PROSTATE 12/27/2017 9/22/2017 12/22/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCC C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $14.90 $27.00 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE 12/27/2017 9/22/2017 12/22/2017 J3490 UNCLASSIFIED DRUGS C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.43 $2.79 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE 12/27/2017 9/22/2017 1212212017 96372 Therapeutic, prophylactic, or diagnostic Injection(sp -Ty E538 DEFICIENCY OF OTHER PROFESSIONAL OFFICE $31.41 $77.44 MALE SUBSCRIBER R01 BCC 3559 substance or drug); s,bcutaneousor'mtramuscular SPECIFIED B GROUP VITAMINS C.7.f 12/27/2017 9/22/2017 1212212017 J3420 INJECTION, VITAMIN B- 12CYAN000BALAMIN, UPTO E538 DEFICIENCY OF OTHER PROFESSIONAL OFFICE $3.54 $5.75 MALE SUBSCRIBER R01 BCC 3559 1000 MCG SPECIFIED B GROUP VITAMINS 12/27/2017 9/22/2017 12/22/2017 96401 CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $100.55 $247.89 MALE SUBSCRIBER R01 BCC 3559 INTRAMUSCULAR; NON HORMONAL ANTI- NEOPLASTIC NEOPLASM OF BONE 12/27/2017 9/22/2017 12/22/2017 10897 INJECTION, DENOSUMAB, 1 MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $1,995.60 $5,364.00 MALE SUBSCRIBER R01 BCC 3559 NEOPLASM OF BONE 12/27/2017 10/12/2017 12/22/201719171 INJECTION, DOCETAXEL, I MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $358.75 $8,706.25 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE 12/27/2017 10/12/2017 12122/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $133.86 $329.97 MALE SUBSCRIBER RO1 BCC 3559 OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); OF PROSTATE ADDITIONAL SEQUENTIAL INFUSION OF NEW DRUG /SUBSTANCE, UP TO HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 12/27/2017 10/12/2017 1212212017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $200.46 $494.20 MALE SUBSCRIBER R01 BCC 3559 INFUSION TEC HNIQUE ; UPTO I HOUR, SINGLE OR INITIAL OF PROSTATE SUBSTANCE /DRUG 12/27/2017 10/12/2017 1212212017 J1100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, I MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.30 $3.20 MALE SUBSCRIBER RO1 BCE 3559 OF PROSTATE 12/27/2017 10/12/2017 12/22/201711200 INJECTION, DIPHENHYDRAMINE HOT, UP TO 50 MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.63 $3.35 MALE SUBSCRIBER RO1 BCC 3559 OF PROSTATE 1212712017 1011212017 1212212017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $14.90 $27.00 MALE SUBSCRIBER RO1 BCC 3559 OF PROSTATE 12/27/2017 10/12/2017 12/22/201713490 UNCLASSIFIED DRUGS C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.43 $2.79 MALE SUBSCRIBER RO1 BCC 3559 OF PROSTATE 12/27/2017 10/12/2017 12/22/2017 96372 Therapeutic, prophylactic, or diagnostic njection(specify E538 DEFICIENCY OF OTHER PROFESSIONAL OFFICE $3141 $77.44 MALE SUBSCRIBER RO1 BCC 3SS9 substance or drug); s ubcuta neouso. intramuscu la, SPECIFIED B GROUP VITAMINS 12/27/2017 10112/2017 12/22/2017 13420 INJECTION, VITAMIN B- 12 CYANOCOBALAMIN, UP TO E538 DEFICIENCY OF OTHER PROFESSIONAL OFFICE $2.65 $5.75 MALE SUBSCRIBER RO1 BCC 3559 1000 MCG SPECIFIED B GROUP VITAMINS 12/27/2017 10/23/2017 1212212017 96401 CHEMOTHERAPY ADMINISTRATION , SUBCUTANEOUS OR C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $100.55 $247.89 MALE SUBSCRIBER R01 BCC 3559 INTRAMUSCULAR; NON-HORMONALANTI- NEOPLASTIC NEOPLASM OF BONE 12/27/2017 10/23/2017 1212212017 J0897 INJECTION, DENOSUMAB, 1 MG C7951 SECONDARY MALIGNANT PROFESSIONAL OFFICE $2,044.80 $5,364.00 MALE SUBSCRIBER R01 BCE 3559 NEOPLASM OF BONE 12/27/2017 12/16/2017 12/22/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET)WITH C61 MALIGNANT NEOPLASM PROFESSIONAL $194.31 $596.00 MALE SUBSCRIBER RO1 BCC 3559 CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY OF PROSTATE OUTPATIENT /HOSPITAL (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID -THIGH 12/28/2017 9/6/2017 12/27/2017 96402 CHEMOTHERAPY ADMINISTRATION , SUBCUTANEOUS OR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $4737 $116.78 MALE SUBSCRIBER R01 BCC 3559 INTRAMUSCULAR; HORMONALANTI- NEOPLASTIC OF PROSTATE 12/28/2017 9/22/2017 12/27/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $141.30 $348.35 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/28/2017 10/12/2017 12/27/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $141.30 $348.35 MALE SUBSCRIBER R01 BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER C.7.f 3559 12/28/2017 12/16/2017 12/20/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $11,379.00 $16,993.00 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE 12/28/2017 12/19/2017 12/27/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $141.30 $348.35 MALE SUBSCRIBER PUT BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/29/2017 8/28/2017 12/27/201719171 INJECTION, DOCETAXEL, I MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $482.40 $8,955.00 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE 12/29/2017 9/6/2017 12/27/201719217 LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $575.19 $3,176.61 MALE SUBSCRIBER R01 BCC 3559 OF PROSTATE Sub T—1 $109,282.43 $321,696.43 1.875E +10 1/6/2017 12/27/2016 1/5/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1069 ACUTE UPPER OTHER MEDICAL $175.00 $200.00 FEMALE SUBSCRIBER 1CCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED RESPIRATORY INFECTION, PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY UNSPECIFIED COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 1/20/2017 11/4/2016 1/19/2017 14060 ADJACENTTISSUE TRANSFER OR REARRANGEMENT, S0120YA UNSPECIFIED OPEN PROFESSIONAL OFFICE $718.05 $950.00 FEMALE SUBSCRIBER 1 CCC 3559 EYELIDS, NOSE, EARSAND /OR LIPS; DEFECT 105QCM OR WOUND OF NOSE, INITIAL LESS ENCOUNTER 1/26/2017 11/4/2016 1/25/2017 14060 ADJACENTTISSUE TRANSFER OR REARRANGEMENT, T814XXA INFECTION FOLLOWING A PROFE55IONAL OFFICE $0.00 $950.00 FEMALE SUBSCRIBER 1CCC 3559 EYELIDS, NOSE, EARSAND /OR LIPS; DEFECT 105QCM OR PROCEDURE, INITIAL LESS ENCOUNTER 3/22/2017 3/20/2017 3/2112017 99396 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z0189 ENCOUNTER FOR OTHER PROFESSIONAL OFFICE $195.97 $250.00 FEMALE SUBSCRIBER 1 CCC 3559 REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL SPECIFIED SPECIAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATIONS EXAMINATION, COUNSELING /ANTICIPATORY GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; 40 -64 YEARS 3/23/2017 3/14/2017 3/22/2017 99212 OFFICE OR OTHER OUTPATIENTVISIT FOR THE L918 OTHER HYPERTROPHIC PROFESSIONAL OFFICE $20.48 $45.48 FEMALE SUBSCRIBER 1CCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISORDERS OF THE SKIN PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 3/27/2017 3/22/2017 3/25/2017 - - Z1231 ENCOUNTER FOR HOSPITAL OUTPATIENT $83100 $832,00 FEMALE SUBSCRIBER 1 CCC 3559 SCREENING MAMMOGRAM FOR MALIGNANT NEOPLASM OF BREAST 3/30/2017 3/22/2017 3/29/2017 77067 Screening mammography, bi late re I(2-v—tudy of each Z1231 ENCOUNTER FOR PROFESSIONAL breast), including computer -aided detection (CAD) when SCREENING OUTPATIENT /HOSPITAL performed MAMMOGRAM FOR MALIGNANT NEOPLASM OF BREAST 3/31/2017 3/21/2017 3/27/2017- - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS DRILLING 4/7/2017 4/3/2017 4/5/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C3490 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF UNSPECIFIED PART OF PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY UNSPECIFIED BRONCHUS COMPONENTS: A DETAILED HISTORY; A DETAILED DRILLING EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5/9/2017 3/21/2017 5/8 /2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST 8918 OTHER NONSPECIFIC PROFESSIONAL MATERIAL(S) ABNORMAL FINDING OF OUTPATIENT /HOSPITAL LUNG FIELD 8/16/2017 8/2/2017 8/15/2017 99204 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, HYPERTENSION WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 8/16/2017 8/7/2017 8115/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E785 HYPERLIPIDEMIA, PROFESSIONAL OFFICE UNSPECIFIED 8/21/2017 8/14/2017 8/19/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 10/31/2017 10/10/2017 10/30/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C3490 MALIGNANT NEOPLASM OTHER MEDICAL OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS ORLUNG 10/31/2017 10/10/2017 10/30/2017 99000 HANDLING AND /OR CONVEYANCE OF SPECIMEN FOR C3490 MALIGNANT NEOPLASM OTHER MEDICAL TRANSFER FROM THE PHYSICIAN S OFFICETOA OF UNSPECIFIED PART OF LABORATORY UNSPECIFIED BRONCHUS DRILLING 10/31/2017 10/11/2017 10/30/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST C3491 MALIGNANT NEOPLASM OTHER MEDICAL MATERIALS) OF UNSPECIFIED PART OF RIGHT BRONCHUS OR LUNG 10/31/2017 10/11/2017 10/30/2017 82565 CREATININE; BLOOD C3491 MALIGNANT NEOPLASM OTHER MEDICAL OF UNSPECIFIED PART OF RIGHT BRONCHUS OR LUNG $60.23 $149.00 FEMALE SUBSCRIBER 1 CCC $633.06 $3,200.23 FEMALE SUBSCRIBER 1 CCC $11630 $348.35 FEMALE SUBSCRIBER 1 CCC $57.58 $186.00 FEMALE SUBSCRIBER 1 CCC $139.14 $722.00 FEMALE SUBSCRIBER 1 CCC $1.80 $12.00 FEMALE SUBSCRIBER 1 CCC $78.91 $461.00 FEMALE SUBSCRIBER 1 CCC $0.00 $32.00 FEMALE SUBSCRIBER 1 CCC $0.00 $41.00 FEMALE SUBSCRIBER 1 CCC $262.50 $1,696.00 FEMALE SUBSCRIBER 1 CCC $0.00 $47.00 FEMALE SUBSCRIBER 1 CCC 10/31/2017 10/11/2017 10/30/2017 84520 UREA NITROGEN; QUANTITATIVE C3491 MALIGNANT NEOPLASM OTHER MEDICAL $10.00 $10.00 FEMALE SUBSCRIBER OF UNSPECIFIED PART OF $20.00 $25.00 FEMALE SUBSCRIBER RIGHT BRONCHUS OR $145.73 $477.00 FEMALE SUBSCRIBER LUNG 11/6/2017 10/12/2017 11/3/2017 90471 IMMUNIZATION ADMINISTRATION (INCLUDES Z23 ENCOUNTER FOR PROFESSIONAL $116.30 PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR SUBSCRIBER IMMUNIZATION OUTPATIENT /HOSPITAL INTRAMUSCULAR INJECTIONS);1 VACCINE (SINGLE OR COMBINATION VACCINE /TOXOID) 11/6/2017 10/12/2017 11/3/2017 90686 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLITVIRUS, Z23 ENCOUNTER FOR PROFESSIONAL PRESERVATIVE FREE, WHEN ADMINISTERED TO IMMUNIZATION OUTPATIENT /HOSPITAL INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR USE 11/8/2017 10/28/2017 11/7/2017 78815 POSITRON EMISSION TOMOGRAPHY(PET)WITH 03491 MALIGNANT NEOPLASM PROFESSIONAL CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY OF UNSPECIFIED PART OF OUTPATIENT /HOSPITAL (CTS FOR ATTENUATION CORRECTION AND ANATOMICAL RIGHT BRONCHUS OR LOCALIZATION IMAGING; SKULL BASE TO MID THIGH LUNG 11/17/2017 11/8/2017 11/14/2017- - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS ORLUNG 11/27/2017 10/301 11/23/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C3490 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF UNSPECIFIED PART OF PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY UNSPECIFIED BRONCHUS COMPONENTS: A DETAILED HISTORY; A DETAILED DRILLING EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 11/27/2017 11/7/2017 11/22/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C3490 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF A NEW PATIENT, OF UNSPECIFIED PART OF OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS :A UNSPECIFIED BRONCHUS COMPREHENSIVE HISTORY; A COMPREHENSIVE ORLUNG EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE 11/27/2017 11/8/2017 11/16/2017 70553 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN C3490 MALIGNANT NEOPLASM PROFESSIONAL (INCLUDING BRAIN STEM); WITHOUTCONTRAST OF UNSPECIFIED PART OF OUTPATIENT/HOSPITAL MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S ) AND UNSPECIFIED BRONCHUS FURTHER SEQUENCES ORLUNG 11/27/2017 11/14/2017 11/21/2017- - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS ORLUNG 11/27/2017 11/14/2017 11/22/2017 94010 SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTALAND C3490 MALIGNANT NEOPLASM PROFESSIONAL TIMED VITALCAPACITY, EXPIRATORY FLOW RATE OF UNSPECIFIED PART OF OUTPATIENT /HOSPITAL MEASUREMENT(S), WITH OR WITHOUT MAXIMAL UNSPECIFIED BRONCHUS VOLUNTARY VENTILATION ORLUNG 11/27/2017 11/14/2017 11/22/2017 94727 GAS DILUTION OR WASHOUT FOR DETERMINATION OF C3490 MALIGNANT N EOPLASM PROFESSIONAL LUNG VOLUMES AND, WHEN PERFORMED, DISTRIBUTION OF UNSPECIFIED PART OF OUTPATIENT /HOSPITAL OF VENTILATION AND CLOSING VOLUMES UNSPECIFIED BRONCHUS DRILLING $0.00 $40.00 FEMALE SUBSCRIBER 1 CCC $10.00 $10.00 FEMALE SUBSCRIBER 1 DEC $20.00 $25.00 FEMALE SUBSCRIBER 1 CCC $145.73 $477.00 FEMALE SUBSCRIBER 1 CCC $2,774.25 $8,202.00 FEMALE SUBSCRIBER 1 CCC $116.30 $348.35 FEMALE SUBSCRIBER 1 COO $119.33 $661.00 FEMALE SUBSCRIBER 1 CCC $141.11 $457.00 FEMALE SUBSCRIBER 1 COO $732.37 $2,002.00 FEMALE SUBSCRIBER 1 CCC $7.54 $30.00 FEMALE SUBSCRIBER 1 COD $10.69 $45.00 FEMALE SUBSCRIBER 1 CCC C.7.f 3559 w N 3559 3559 "a 3559 fl } fl i® CL CL Q 3559 v 3559 3559 3559 3559 3559 3559 C.7.f 1112]1201] 11/14/2017 1112212017 94729 DIFFUSING CAPACITY(EG, CARBON MONOXIDE, C3490 MALIGNANT NEOPLASM PROFESSIONAL $7.21 $45.00 FEMALE SUBSCRIBER 1 CCC 3559 MEMBRANE) HLISTSEPARATELY IN ADDITION TO CODE OF UNSPECIFIED PART OF OUTPATIENT /HOSPITAL FOR PRIMARY PROCEDURE) UNSPECIFIED BRONCHUS Z ORLUNG N m 11/29/2017 11/9/2017 1112812017 99214 OFFICE OR OTHER 0UTPATIENTVISIT FOR THE C3490 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $116.30 $348.35 FEMALE SUBSCRIBER 1CCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF UNSPECIFIED PART OF PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY UNSPECIFIED BRONCHUS COMPONENTS: A DETAILED HISTORY; A DETAILED ORLUNG } EXAMINATION; MEDICAL DECISION MAKING OF "a MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER ate+ 11/30/2017 11/27/2017 11/29/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION C3490 MALIGNANT NEOPLASM PROFESSIONAL $172.03 $500.00 FEMALE SUBSCRIBER 1 CCC 3559 W } AND MANAGEMENT OFA PATIENT, WHICH REQUIRES OF UNSPECIFIED PART OF INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; UNSPECIFIED BRONCHUS iL CL ACOMPREHENSIVE EXAMINATION; AND MEDICAL DRILLING Q, DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 11/30/2017 1112812017 1112912017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C3490 MALIGNANT NEOPLASM PROFESSIONAL $61.42 $190.00 FEMALE SUBSCRIBER 1CCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH OF UNSPECIFIED PART OF INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN UNSPECIFIED BRONCHUS uLl EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN ORLUNG EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR _ 12/1/2017 11/21/2017 1112912017 - - 201810 ENCOUNTER FOR HOSPITAL OUTPATIENT $1,076.57 $1,914.00 FEMALE SUBSCRIBER 1 CCC 3559 PREPROCEOURAL r � V CARDIOVASCULAR IL EXAMINATION ui 12/4/2017 11/29/2017 12/1/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE C3490 MALIGNANT NEOPLASM PROFESSIONAL $61.42 $190.00 FEMALE SUBSCRIBER 1CCC 3559 EVALUATION AND MANAGEMENTOFA PATIENT ,WHICH OF UNSPECIFIED PART OF INPATIENT /HOSPITAL UJ REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS AN UNSPECIFIED BRONCHUS EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN ORLUNG 0 EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. een COUNSELING AND /OR 12/11/2017 11/27/2017 12/8/2017 99292 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE R55 SYNCOPE AND COLLAPSE OTHER MEDICAL $0.00 $270.00 FEMALE SUBSCRIBER 1 CCC 3559 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION V TO CODE FOR PRIMARY SERVICE) 12/12/2017 11/27/2017 12/11/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 1939 PNEUMOTHORAX, PROFESSIONAL $16.29 $41.00 FEMALE SUBSCRIBER 1 CCC 3559 LLJ FRONTAL UNSPECIFIED INPATIENT / HDSPITAL 12/12/2017 11/28/2017 12/11/2017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, 19600 ACUTE RESPIRATORY PROFESSIONAL $16.29 $41.00 FEMALE SUBSCRIBER 1 CCC 3559 FRONTAL FAILURE, UNSPECIFIED INPATIENT /HOSPITAL 0 WHETHER WITH HYPDXIA OR HYPERCAPNIA F 12/14/2017 11/27/2017 12/4/2017 * * * ** * * * ** * * * ** * * * ** * * * ** 11/27/2017 # # # # # # ## $114,932.41 $183,511.00 FEMALE SUBSCRIBER 1 CCC 3559 12/19/201] 11/27/2017 12/18/201] 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST I2 I10 ESSENTIAL (PRIMARVI PROFESSIONAL $8.93 $75.00 FEMALE SUBSCRIBER I CCC 3559 hl LEADS; INTERPRETATION AND REPORT ONLY HYPERTENSION INPATIENT /HOSPITAL 12/20/2017 12/11/2017 12/18/2017 - - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $457.50 $610,00 FEMALE SUBSCRIBER 1 CCC 3559 iL OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS ORLUNG 2 12/20/2017 12/11/2017 12/19/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 19383 OTHER PNEUMOTHORAX PROFESSIONAL $19.23 $67.00 FEMALE FRONTAL AND LATERAL; 1 CCC 3559 W OUTPATIENT /HOSPITAL 12/21/2017 1112712017 1211912017 32671 TH0RAC0S COPY, SURGICAL; WITH REMOVALOF LUNG C3481 MALIGNANT NEOPLASM PROFESSIONAL SUBSCRIBER 1 CCC IPNEUMONECTOMY) OF OVERLAPPING SITES INPATIENT /HOSPITAL OF RIGHT BRONCHUS AND Q! LUNG t_n 12/21/2017 11/27/2017 12/19/2017 32674 TH0RACOSCOPY, SURGICAL; WITH MEDIASTINALANO C3481 MALIGNANT NEOPLASM PROFESSIONAL $975.00 FEMALE SUBSCRIBER REGIONAL LYMPHADENECTOMY (LISTSEPARATELY IN 3559 7 OF OVERLAPPING SITES INPATIENT /HOSPITAL ADDITION TO CODE FOR PRIMARY PROCEDURE) OF RIGHT BRONCHUS AND LUNG 12/21/2017 11/27/2017 12/19/201752900 SURGICAL TECHNIQUES REQUIRING USE OF ROBOTIC C3481 MALIGNANT NEOPLASM PROFESSIONAL SURGICALSYSTEM(LISTSEPARATELY IN ADDITION TO OF OVERLAPPING SITES INPATIENT /HOSPITAL CODE FOR PRIMARY PROCEDURE) CL OF RIGHT BRONCHUSAND CL LUNG 12/28/2017 10/16/2017 12/27/2017 ..... ..... ..x ++ ..... ..... 12/28/2017 12/21/2017 12/27/2017 96372 Therapeutic, prophylactic, o,di,g ... C, injection(cpecify C3490 MALIGNANT NEOPLASM PROFESSIONAL OFFICE substance or drug); subcutaneous or Intramuscular OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS F ORLUNG 12/28/2017 12/21/2017 12/27/201713420 INJECTION, VITAMIN B- 12CYAN0C0BAIAMIN, UPT0 C3490 MALIGNANT NEOPLASM PROFESSIONAL OFFICE 3559 F 1000 MCG OF UNSPECIFIED PART OF D UNSPECIFIED BRONCHUS ORLUNG 12/29/2017 11/27/2017 12/28/2017 541 ANESTHESIA FORTHORACOTOMY PROCEDURES R918 OTHER NONSPECIFIC PROFESSIONAL 1 CCC 3559 INVOLVING LUNGS, PLEURA, DIAPHRAGM, AND ABNORMAL FINDING OF INPATIENT / HDSPITAL O MEDIASTINUM (INCLUDING SURGICAL THORACOSCOPY); LUNG FIELD d UTILIZING 1 LUNG VENTILATION W $129,166.20 Sub Total IX $112.80 $703.00 MALE 1.875E +10 1/4/2017 12/27/2016 1/3/2017 74177 Computed tomography, abdomen and pelvis ; with K8689 OTHER SPECIFIED PROFESSIONAL contrast material(s) DISEASES OF PANCREAS OUTPATIENT /HOSPITAL 1/18/2017 12/27/2016 1/3/2017 - - K8590 ACUTE PANCREATITIS HOSPITAL OUTPATIENT WITHOUT NECROSIS OR t. INFECTION, UNSPECIFIED 1/30/2017 1/3/2017 11912017- - R938 ABNORMAL FINDINGS ON HOSPITAL OUTPATIENT $1,711.95 $4,471.00 MALE DIAGNOSTIC IMAGING OF BCC 3559 OTHER SPECIFIED BODY U STRUCTURES 1/30/2017 1/3/2017 1/11/2017 74181 MAGNETIC RES0NANCE(EG, PROTON) IMAGING, K8590 ACUTE PANCREATITIS PROFESSIONAL SUBSCRIBER RO1 BCC ABDOMEN; WITHOUT CONTRAST MATERIAL(S) WITHOUT NECROSIS OR OUTPATIENT /HOSPITAL INFECTION, UNSPECIFIED 1/30/2017 1/3/2017 1/11/2017 76376 3D RENDERING WITH INTERPRETATION AND REPORTING K8590 ACUTE PANCREATITIS PROFESSIONAL $0.00 $45.00 MALE OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE BCC WITHOUT NECROSIS OR OUTPATIENT/HOSPITAL IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC INFECTION, UNSPECIFIED MODALITY; NOT REQUIRING IMAGE POSTPROCESSING ON Q AN INDEPENDENT WORKSTATION 113012017 1/4/2017 1/18/2017 f'V 1/30/2017 1/7/2017 1/18/2017 SURSCRIRER I BCC 3559 = $70.00 1/30/2017 1/11/2017 1112120171036F CURRENT TOBACCO NON- USER (CAD, CAP, CORD, PV) C251 MALIGNANT NEOPLASM PROFESSIONAL SUBSCRIBER RO1 BCC (DM) HBD) OF BODY OF PANCREAS OUTPATIENT/HOSPITAL C.7.f $19.23 $67.00 FEMALE SUBSCRIBER 1 CCC 3559 W 41 $2,195.66 $7,910.00 FEMALE SUBSCRIBER 1 CCC 3559 N Q! t_n $268.28 $975.00 FEMALE SUBSCRIBER 1 CCC 3559 7 $0.00 $0.00 FEMALE SUBSCRIBER 1 CCC 3559 W } fl i® CL CL Q $95.63 $235.75 FEMALE SUBSCRIBER 1 CCC 3559 v $31.41 $77.44 FEMALE SUBSCRIBER 1 CCC 3559 Q F W $2.65 $5.75 FEMALE SUBSCRIBER 1 CCC 3559 F D $2,258.63 $3,520.00 FEMALE SUBSCRIBER 1 CCC 3559 O d W $129,166.20 $222,945.70 IX $112.80 $703.00 MALE SUBSCRIBER R01 BCC 3559 UJ O $4,452.19 $7,915.00 MALE SUBSCRIBER R01 BCC 3559 W t. $1,711.95 $4,471.00 MALE SUBSCRIBER RO1 BCC 3559 U f' $95.76 $295.00 MALE SUBSCRIBER RO1 BCC 3559 LLJ U $0.00 $45.00 MALE SUBSCRIBER RO1 BCC 3559 Q N f'V $70.00 $150.00 MALE SURSCRIRER I BCC 3559 = $70.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 y $0.01 $0.01 MALE SUBSCRIBER RO1 BCC 3559 C.7.f 1/30/2017 1/11/2017 111212017 1125F INTERMEDIATE " DELAY" OF ANY FLAP, PRIMARY "DELAY" C251 $0.01 MALE OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR BCC DIRECT FLAP, AT FOREHEAD, CHEF 1/30/2017 1/11/2017 1/12/20173074F MOST RECENT SYSTOLIC BLOOD PRESSURE LESS THAN 130 C251 MM HG ADM) IHTN, CKD,CAD) 1/30/2017 1/11/2017 1/12/2017 3078F MOST RECENT DIASTOLIC BLOOD PRESSURE LESS THAN 80 C251 MALIGNANT NEOPLASM PROFESSIONAL MM HG (DM) (HTN, CKD, CAD) 1/30/2017 1/11/2017 111212017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C251 BCC EVALUATION AND MANAGEMENT OF A NEW PATIENT, OF BODY OF PANCREAS OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS :A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH MALIGNANT NEOPLASM PROFESSIONAL COMPLEXITY. COUNSELING AND /OR COORDINATION OF $0.01 MALE CARE WITH OTHER PROVIDERS OR AGE 113012017 1/11/2017 111212017 G8419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C251 OF BODY OF PANCREAS OUTPATIENT /HOSPITAL FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN 1/30/2017 1/11/2017 1/12/2017 68428 CURRENT LISTOF MEDICATIONS NOT DOCUMENTED AS C251 OBTAINED, UPDATED, OR REVIEWED BYTHE ELIGIBLE MALIGNANT NEOPLASM PROFESSIONAL PROFESSIONAL, REASON NOTGIVEN 1/30/2017 1/11/2017 111212017 G8484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C251 BCC REASON NOT GIVEN 1/30/2017 1/11/2017 1/12/201768509 PAIN ASSESSMENT DOCUMENTED AS POSITIVE USINGA C251 STANDARDIZED TOOL, FOLLOW -UP PLAN NOT DOCUMENTED, REASON NOT GIVEN 1/30/2017 1/11/2017 1/18/2017 * * * "" * * * *" *• " ** 1/30/2017 1/18/2017 1/18/2017 * * * ** * * * ** * * * ** 1/30/2017 1/18/2017 1/26/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C250 OF BODY OF PANCREAS OUTPATIENT/HOSPITAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A MALIGNANT NEOPLASM PROFESSIONAL COMPREHENSIVE EXAMINATION; MEDICAL DECISION $0.01 MALE MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR BCC COORDINATION OF CARE WITH 1/30/2017 12/19/2016 1/27/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D125 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY MALIGNANT NEOPLASM PROFESSIONAL COMPONENTS: A DETAILED HISTORY; A DETAILED $0.01 MALE EXAMINATION; MEDICAL DECISION MAKING OF BCC MODERATE COMPLEXITY. COUNSELING AND /OR OF BODY OF PANCREAS OUTPATIENT /HOSPITAL COORDINATION OF CARE WITH OTHER 2/10/2017 1/25/2017 2/3/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC C251 PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO MALIGNANT NEOPLASM PROFESSIONAL DUODENUM 2/13/2017 1/30/2017 2/7/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET)WITH C259 BCC CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY OF BODY OF PANCREAS OUTPATIENT /HOSPITAL (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID -THIGH MALIGNANT NEOPLASM PROFESSIONAL $0.01 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.01 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.01 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $177.77 $660.00 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.01 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS OUTPATIENT/HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.01 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.01 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS OUTPATIENT /HOSPITAL $150.00 MALE SUBSCRIBER R BCC 3559 * * * ** * * * ** $70.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $123.96 $275.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS BENIGN NEOPLASM OF PROFESSIONAL OFFICE $70.18 $346.00 MALE SUBSCRIBER R01 BCC 3559 SIGMOID COLON MALIGNANT NEOPLASM PROFESSIONAL $472.15 $1,050.00 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $148.96 $485.00 MALE SUBSCRIBER R01 BCC 3559 OF PANCREAS, OUTPATIENT /HOSPITAL UNSPECIFIED 2/13/2017 2/3/2017 2/7/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C250 SUBSCRIBER R01 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON OF OTHER PARTS OF OUTPATIENT /HOSPITAL DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), MALIGNANT NEOPLASM PROFESSIONAL CREATININE( 82565(, GLUCOSE (82947), PHOSPHATASE, $4.30 MALE SUBSCRIBER R01 ALKALINE (84075), POTASSIUM (84132(, PROTEIN, 3559 2/13/2017 2/3/2017 2/7/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C250 OUTPATIENT /HOSPITAL HUT, BBC, W BC AND PLATELET COUNT) AND AUTOMATED MALIGNANT NEOPLASM PROFESSIONAL DIFFERENTIAL W BC COUNT $6.50 MALE 2/13/2017 2/3/2017 2/7/2017 85610 PROTHROMBIN TIME; C250 2/13/2017 2/3/2017 2/7/2017 85730 THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR C250 WHOLE BLOOD 2/13/2017 213/2017 2/7/2017 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 SUBSCRIBER R01 CA 19 -9 3559 2/20/2017 1/25/2017 2/3/2017 43259 ESOPHAGOGASTRODUDDENOSCOPY, FLEXIBLE, C251 TRANSORAL; WITH ENDOSCOPIC ULTRASOUND MALIGNANT NEOPLASM PROFESSIONAL EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, $989.00 MALE SUBSCRIBER R01 AND EITHER THE DUODENUM OR A SURGICALLY ALTERED 3559 OF BODY OF PANCREAS OUTPATIENT /HOSPITAL STOMACH WHERE THE JEJUNUM IS EXAMINED DISTAL TO THE ANASTOMOSIS 2/20/2017 1/2S/2017 2/17/2017 88112 CYTOPATHOLOGY, SELECTIVE CELLULAR ENHANCEMENT C257 TECHNIQUE WITH INTERPRETATION (EG, LIQUID BASED SLIDE PREPARATION METHOD), EXCEPT CERVICAL OR VAGINAL 2/20/2017 1/25/2017 2117/2017 88172 CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE C257 ASPIRATE; IMMEDIATE CYTOHISTOLOGIC STUDY TO DETERMINE ADEQUACY FOR DIAGNOSIS, FIRST EVALUATION EPISODE, EACH SITE 2/20/2017 1/25/2017 2/17/2017 88173 CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE C257 ASPIRATE; INTERPRETATION AND REPORT 2/20/2017 1/25/2017 2/17/2017 88305 LEVELIV- SURGICAL PATHOLOGY, GROSS AND C257 MICROSCOPIC EXAMINATION ABORTION - SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION 2/20/2017 2/3/2017 2/16/2017 1125F INTERMEDIATE "DELAY" OFANY FLAP, PRIMARY "OELAY" C250 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR DIRECT FLAP, AT FOREHEAD, CHEE 2/20/2017 2/3/2017 2/16/2017 99245 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED C250 PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTE 2/20/2017 2/3/2017 2/16/2017 G9484 INFLUENZA IMMUNIZATION WAS NOTADMINISTERED, C250 REASON NOT GIVEN MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER R01 BCC OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL C.7.f 3559 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL PROFESSIONAL OF OTHER PARTS OF OUTPATIENT /HOSPITAL PANCREAS MALIGNANT NEOPLASM PROFESSIONAL $0.00 $4.30 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL PROFESSIONAL OF OTHER PARTS OF OUTPATIENT /HOSPITAL PANCREAS MALIGNANT NEOPLASM PROFESSIONAL $0.00 $6.50 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.00 $76.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $358.51 $989.00 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL OF OTHER PARTS OF OUTPATIENT /HOSPITAL PANCREAS MALIGNANT NEOPLASM PROFESSIONAL OF OTHER PARTS OF OUTPATIENT /HOSPITAL PANCREAS MALIGNANT NEOPLASM PROFESSIONAL OF OTHER PARTS OF OUTPATIENT /HOSPITAL PANCREAS MALIGNANT NEOPLASM PROFESSIONAL OF OTHER PARTS OF OUTPATIENT /HOSPITAL PANCREAS MALIGNANT NEOPLASM PROFESSIONAL OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL $63.88 $103.00 MALE SUBSCRIBER R01 BCC $34.64 $134.00 MALE SUBSCRIBER R01 BCC $80.14 $259.00 MALE SUBSCRIBER R01 BCC $43.93 $140.00 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $232.15 $850.00 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 3559 3559 3559 3559 a 2/20/2017 21]1201] 2/16/2017 31653 Bronchoscopy, rigid orflexible, including fluoroscopic C781 SECONDARY MALIGNANT PROFESSIONAL guidance, when performed; with e,d,bronchial NEOPLASM OF OUTPATIENT /HOSPITAL ultrasound(EBUS) guided transtracheal and /or MEDIASTINUM transibrouchial Sampling leg, aspirationASA /biopsyAiesA ), one or two medics • nal and /or hllar lymph node 212012017 21812017 2/16/2017 36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL C250 MALIGNANT NEOPLASM OTHER MEDICAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; OF HEAD OF PANCREAS AGE 5 YEARS DR OLDER 2/20/2017 2/8/2017 2/16/2017 76937 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS C250 MALIGNANT NEOPLASM OTHER MEDICAL REQUIRING ULTRASOUND EVALUATION OF POTENTIAL OF HEAD OF PANCREAS ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION OF VASCULAR NEEDLE ENTRY, 2/20/2017 2/8/2017 2/16/2017 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS C250 MALIGNANT NEOPLASM OTHER MEDICAL DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR OF HEAD OF PANCREAS COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC GUIDANCE FOR VASCULAR ACCESS AND CATHETER MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHYR 2/20/2017 2/8/2017 2/16/2017 99152 Moderate sedation services provided by the same C250 MALIGNANT NEOPLASM OTHER MEDICAL physician or other qualified health care professional OF HEAD OF PANCREAS performing the diagnostic or therapeutic service that 2/20/2017 2/8/2017 2/16/2017 99153 Moderate sedation services provided by the same C250 MALIGNANT NEOPLASM OTHER MEDICAL physician or other qualified health care professional OF HEAD OF PANCREAS performing the diagnostic or therapeutic service that 2/20/2017 2/15/2017 2/17/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C250 MALIGNANT N EOPLASM PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 2/20/2017 2/15/2017 2/17/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED INGE, C250 MALIGNANT NEOPLASM PROFESSIONAL NET, BBC, WBC AND PLATELET COUNT) AND AUTOMATED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 212012017 2/15/2017 2/17/2017 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 2/27/2017 1/22/2017 2/22/2017 2/27/2017 112712017 2/22/2017 * * * «* 2/2]/201] 1/31/2017 212212017 * " * ** 2/27/2017 2/6/2017 2122/2017 2/27/2017 2/13/2017 2/22/2017 * ** «' 2/2]/201] 2/20/2017 2/23/2017 S9374 HOME INFUSION THERAPY, HYDRATION THERAPY; ONE E860 DEHYDRATION OTHER MEDICAL LITER PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM 2/27/2017 '/22/201] 2122/2017 2/27/2017 2/22/2017 212312017 59374 HOME INFUSION THERAPY, HYDRATION THERAPY; ONE E860 DEHYDRATION OTHER MEDICAL LITER PER DAY, ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM $322.40 $1,031.00 MALE SUBSCRIBER R01 BCC $427.70 $1,507.00 MALE SUBSCRIBER R01 BCC $20.24 $59.00 MALE SUBSCRIBER RO1 BCC $22.17 $71.00 MALE SUBSCRIBER R01 BCC $15.05 $49.00 MALE SUBSCRIBER R01 BCC $13.15 $43.00 MALE SUBSCRIBER R01 BCC $0.00 $26.00 MALE SUBSCRIBER R01 BCC $0.00 $10.40 MALE SUBSCRIBER R01 BCC $0.00 $76.00 MALE SUBSCRIBER R01 BCC $70.00 $150.00 MALE SUBSCRIBER RO1 BCC $70.00 $150.00 MALE SUBSCRIBER RO1 BCC $]0.00 $150.00 MALE SUBSCRIBER RO1 BCC $70.00 $150.00 MALE SUBSCRIBER RO1 BCC $70.00 $150.00 MALE SUBSCRIBER R01 DEC $46.12 $61.49 MALE SUBSCRIBER R01 BCC $70.00 $150.00 MALE SUBSCRIBER ROT BCC $46.12 $61.49 MALE SUBSCRIBER R01 BCC C.7.f 3559 w Z MR M Q! 3559 to i 3559 "a fl } fl 3559 A. CL CL Q 4 F 3559 h D 3559 _ O 3559 Q 3559 3559 1 IN C.7.f 3/6/2017 21712017 3/1/2017 88173 CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE R591 GENERALIZED ENLARGED PROFESSIONAL $240.42 $777.00 MALE SUBSCRIBER RO1 BCC 3559 ASPIRATE; INTERPRETATION AND REPORT LYMPH NODES OUTPATIENT /HOSPITAL 3/6/2017 21712017 3/1/2017 88305 LEVELIV- SURGICAL PATHOLOGY, GROSS AND 8591 GENERALIZED ENLARGED PROFESSIONAL $131.79 $420.00 MALE SUBSCRIBER RO1 BCC 3559 UR MICROSCOPIC EXAMINATION ABORTION- LYMPH NODES OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTH ER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF } SURGICAL MARGINS, BREAST, REDUCTION "a 3/6/2017 2/21/2017 3/1/2017 992231 N ITIA L H OSPITA L CA RE, PE R DAY, ED R TH E EVALUATIO N 181 PORTALVEIN OTHER MEDICAL $230.81 $783.00 MALE SUBSCRIBER YET BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THROMBOSIS THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; > } A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING CL AND /OR COORDINATION OF CARE WITH OTHER Q, PROVIDERS OR AGEN 3/6/2017 2/22/2017 3/1/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE 181 PORTALVEIN PROFESSIONAL $123.66 $408.00 MALE SUBSCRIBER R01 BCC 3559 THAN30MINUTES THROMBOSIS INPATIENT /HOSPITAL 3/8/2017 2/14/2017 3/1/20171036F CURRENT TOBACCO NONUSER (CAD, CAP, COPE, PV) C250 MALIGNANT NEOPLASM PROFESSIONAL $0.01 $0.01 MALE SUBSCRIBER R01 BCC 3559 (DM) (IBM OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL W 3/8/2017 2/14/2017 3/1/20171125F INTERMEDIATE " DELAY" OF ANY FLAP, PRIMARY" OEEAY" C250 MALIGNANT NEOPLASM PROFESSIONAL $0.01 $0.01 MALE SUBSCRIBER R01 BCC 3559 F OF SMALL FLAP, OR SECTIONING PEDDLE OF TUBED OR OF HEAD OF PANCREAS OVTPATIENT /HOSPITAL D Z 3/8/2017 2/14/2017 3/1/20171220F DIRECT FLAP, AT FOREHEAD, CHEE PATIENT SCREENED FOR DEPRESSION(SUD) C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.00 MALE SUBSCRIBER R01 BCC 3559 _ OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/8/2017 2/14/2017 3/1/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C250 MALIGNANT NEOPLASM PROFESSIONAL $81.33 $299.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL Q PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY ui COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF U`J MODERATE COMPLEXITY. COUNSELING AND /OR 0 COORDINATION OF CARE WITH OTHER 3/8/2017 2/14/2017 3/1/2017 68419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C250 MALIGNANT NEOPLASM PROFESSIONAL $0.01 $0.01 MALE SUBSCRIBER R01 BCC 3559 LLJ FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/8/2017 2/14/2017 3/1/2017 68427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C250 MALIGNANT NEOPLASM PROFESSIONAL $0.01 $0.01 MALE SUBSCRIBER R01 BCC 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS v 3/8/2017 2/14/2017 3/1/2017 G8484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C250 MALIGNANT NEOPLASM PROFESSIONAL $0.01 $0.01 MALE SUBSCRIBER R01 BCC 3559 REASON NOT GIVEN OF HEAD OF PANCREAS OUTPATIENT/HOSPITAL uj 3/8/2017 2/14/2017 3/1/2017 68509 PAIN ASSESSMENT DOCUMENTEDAS POSITIVE USING A C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 STANDARDIZED TOOL ,FOLLOW - UPPLANNOT OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL U DOCUMENTED, REASON NOT GIVEN 3/8/2017 2/20/2017 3/3/2017 76705 ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE K828 OTHER SPECIFIED PROFESSIONAL $3634 $112.00 MALE SUBSCRIBER R01 BCC 3559 DOCUMENTATION; LIMITED(EG, SINGLE ORGAN, DISEASES OF INPATIENT /HOSPITAL QUADRANT, FOLLOW -UP) GALLBLADDER 3/8/2017 2/21/2017 3/3/2017 74177 Computed mmography, a bd,,,, and pelvis; with 181 PORTALVEIN PROFESSIONAL $106.33 $352.00 MALE SUBSCRIBER R01 BCC 3559 N co nt— t material(') THROMBOSIS INPATIENT /HOSPITAL , C.7.f 3/8/2017 2/28/2017 3/3/2017 80053 COMP RE HE NSIVE METABOLIC PANEL THIS PANEL MUST C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER R01 BCC 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 3/8/2017 2/28/2017 3/3/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $6.60 MALE SUBSCRIBER R01 BCC 3559 EXAMINATIDNWITH MANUAL DIFFERENTIAL WBC COUNT OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/8/2017 2/28/2017 3/3/2017 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $76.00 MALE SUBSCRIBER R01 BCC 3559 CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/13/2017 1/30/2017 2/6/2017- - C2S9 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $7,549.50 $17,223.00 MALE SUBSCRIBER R01 BCC 3559 OF PANCREAS, UNSPECIFIED 3/13/2017 213/2017 2/14/2017- - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $417.74 $1,361.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS 3/13/2017 2/7/2017 2/14/2017 *kb *" * *' ** + *' *' * ** ** * *' ** $5,255.98 $14,82626 MALE SUBSCRIBER R01 BCC 3559 3/13/2017 2/8/2017 2/14/2017- - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $5,192.91 $13,346.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS 3/13/2017 2/20/2017 3/7/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R1084 GENERALIZED PROFESSIONAL $308.08 $1,714.00 MALE SUBSCRIBER R01 BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES ABDOMINAL PAIN OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENTS CLINICAL CONDITION AND /OR MENTALSTATUS: ACDMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 3/17/2017 2/21/2017 3/14/2017- - C250 MALIGNANT NEOPLASM HOSPITAL INPATIENT 2/21/2017 # # # # # # ## $10,489.97 $29,73242 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS 3/17/2017 2/22/2017 3/14/2017 88108 CYTOPATHOLOGY, CONCENTRATION TECHNIQUE, SMEARS R198 OTHER ASCITES PROFESSIONAL $42.96 $86.00 MALE SUBSCRIBER R01 BCC 3559 AND INTERPRETATION (EG, SACCOMANNO TECHNIQUE) INPATIENT /HOSPITAL 3/17/2017 2/22/2017 3/14/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL $175.90 $437.00 MALE SUBSCRIBER R01 BCC 3559 THERAPEUTIC); WITH IMAGING GUIDANCE INPATIENT /HOSPITAL 3/17/2017 2/28/2017 3/7/20171036F CURRENTTOBACCO NON- USER (CAD, CAP, COPD, PV) C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 (DMA (IBC) OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/17/2017 2/28/2017 3/7/20171126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, 3/17/2017 2/28/2017 3/7/20171220F PATIENT SCREENED FOR DEPRESSION (SUD) C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/17/2017 2/28/2017 3/7/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C250 MALIGNANT NEOPLASM PROFESSIONAL $81.33 $299.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 3117/2017 2/28/2017 3/7/2017 68419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $001 MALE SUBSCRIBER R01 BCC 3559 FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/1]/201] 2/28/2017 3/7/201]6842] ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC THE MEDIC AL RECORD THEY OBTAINED, UPDATED, 0R OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS 3/17/2017 2/28/2017 3/7/2017 G8484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC REASON NOT GIVEN OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/17/2017 2/28/2017 3/7/2017 G8731 PAIN ASSESSMENT USING ASTANDARDIZED TOOL IS C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL REQUIRED 3/17/2017 31 3/14/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR 8188 OTHER ASCITES PROFESSIONAL $175.90 $437.00 MALE SUBSCRIBER R01 BCC THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 3/17/2017 3/7/2017 3114/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C2SO MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER R01 BCC INCLUDE THE FOLLOWING, ALBUMIN (82040), BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 3/17/2017 3/7/2017 3/14/2017 85007 BL00D COUNT; BLOOD SMEAR, MICROSCOPIC C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $6.60 MALE SUBSCRIBER R01 BCC EXAMINATIONWITH MANUAL DIFFERENTIAL WBC COUNT OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/1]/201] 31]1201] 3/14/2017 86301 IMMUNOASSAY FOR TUM0R ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $76.00 MALE SUBSCRIBER R01 BCC CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/17/2017 3/14/2017 3/16/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C259 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER R01 BCC INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, OF PANCREAS, OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (8231D), CARBON UNSPECIFIED DIOXIDE (BICARBONATE) (92374), CHL0RIDE (92435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 3/17/2017 3/14/2017 3/16/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C259 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $6.60 MALE SUBSCRIBER R01 BCC EXAMINATIONWITH MANUAL DIFFERENTIAL WBC COUNT OF PANCREAS, OUTPATIENT /HOSPITAL UNSPECIFIED 3/1]/201] 3/14/2017 3/16/2017 86301 IMMUNOASSAY FOR TUM0R ANTIGEN, QUANTITATIVE; C259 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $76.00 MALE SUBSCRIBER RO1 BCC CA 19 -9 OF PANCREAS, OUTPATIENT /HOSPITAL UNSPECIFIED 3/24/2017 2/25/2017 3/23/2017 * * « ** * * * ** *« « ** . * * ** * * * ** $95.00 $150.00 MALE SUBSCRIBER RO1 BCC 3/24/201] 2/28/201] 312312017 * # ° ** * * * ** * " " ** " * * *` * * * ** $95.00 $150.00 MALE SUBSCRIBER RO1 BCC 3/24/2017 3/4/2017 3/23/2017 * * * ** * * *x* °fY ** * * * ** * * * *x $95.00 $150.00 MALE SUBSCRIBER RO1 BCC 3/24/2017 3/7/2017 3/23/20171036F CURRENT TOBACCO NON- USER (CAD, CAP, CDPD, PV) C259 MALIGNANT NEOPLASM OTHER MEDICAL $C.00 $0.01 MALE SUBSCRIBER R01 6CC (DM) (IBD) OF PANCREAS, UNSPECIFIED 3/24/2017 3/]/201] 3/23/20171125F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C259 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF PANCREAS, DIRECT FLAP, AT FOREHEAD, CHEF UNSPECIFIED 3/24/2017 3/7/2017 3/23/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C259 MALIGNANT NEOPLASM OTHER MEDICAL $108.44 $299.00 MALE SUBSCRIBER R01 BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PANCREAS, PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY UNSPECIFIED COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 3/24/2017 3/7/2017 3/23/2017 G8419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C259 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN $0.01 MALE OF PANCREAS, $95.00 $150.00 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER RO1 BCC UNSPECIFIED $0.01 MALE 3/24/2017 3/7/2017 3/23/201768427 ELIGIBLE PROFESSIDNALATTESTSTO DOCUMENTING IN C259 MALIGNANT NEOPLASM OTHER MEDICAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF PANCREAS, REVIEWED THE PATIENT'S CURRENT MEDICATIONS UNSPECIFIED 3/24/2017 3/7/2017 3/23/2017 G8484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C259 MALIGNANT NEOPLASM OTHER MEDICAL REASON NOT GIVEN OF PANCREAS, UNSPECIFIED 3/24/2017 3/7/2017 3/23/2017 68732 NO DOCUMENTATION OF PAIN ASSESSMENT C259 MALIGNANT NEOPLASM OTHER MEDICAL OF PANCREAS, UNSPECIFIED 3/24/2017 3/11/2017 3/23/2017 ..... * * "" +.. *+ ..... ..... 3124/2017 3/14/2017 3/23/2017 1036F CURRENTTOBACCO NON - USER (CAD, CAP, COPQ PV) E876 HYPOKALEMIA OTHER MEDICAL )DM) (IBD) 3/24/2017 3/14/2017 3/23/2017 1125F INTERMEDIATE " DELAY" OF ANY FLAP, PRIMARY "DELAY" E876 HYPOKALEMIA OTHER MEDICAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR DIRECT FLAP, AT FOREHEAD, CHEF 3/24/2017 3/14/2017 3/23/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E876 HYPOKALEMIA OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 3/24/2017 3/14/2017 3/23/2017 G8419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO E876 HYPOKALEMIA OTHER MEDICAL FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN 3/24/2017 3/14/2017 3/23/2017 G9427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN E876 HYPOKALEMIA OTHER MEDICAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR REVIEWED THE PATIENT'S CURRENT MEDICATIONS 3124/2017 3/14/2017 3/23/2017 G8484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, E876 HYPOKALEMIA OTHER MEDICAL REASON NOT GIVEN 3/24/2017 3/14/2017 3/23/2017 G8509 PAIN ASSESSMENT DO CUMENTED AS POSITIVE USING A E876 HYPOKALEMIA OTHER MEDICAL STANDARDIZED TOOL, FOLLOW -UP PLAN NOT DOCUMENTED, REASON NOT GIVEN 3/24/2017 3/18/2017 3/23/2017 k}b.. * * "* ..... ..... ..... 3/24/2017 3/21/2017 3/23/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT/HOSPITAL 3/24/2017 3/21/2017 3/23/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C250 MALIGNANT NEOPLASM PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL )82310), CARBON DIOXIDE IBICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 3/24/2017 3/21/2017 3/23/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C250 MALIGNANT NEOPLASM PROFESSIONAL EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/24/2017 3/21/2017 3/23/2017 863011MMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 3/24/2017 3/23/2017 3/23/2017 ..... ** "* *' " ** .. ". ***" $0.00 $0.01 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $95.00 $150.00 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER RO1 BCC $0.00 $0.01 MALE SUBSCRIBER RO1 BCC $108.44 $299.00 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $95.00 $150.00 MALE SUBSCRIBER R01 BCC $175.90 $437.00 MALE SUBSCRIBER R01 BCC $0.00 $26.00 MALE SUBSCRIBER R01 BCC $0.00 $6.60 MALE SUBSCRIBER R01 BCC $0.00 $76.00 MALE SUBSCRIBER RO1 BCC $95.00 $150.00 MALE SUBSCRIBER R01 BCC C.7.f 3/2]/201] 2/3/2017 3/21/2017- - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $0.00 $1,361.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS W 3/28/2017 1/25/2017 3/22/2017- - C257 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $5,536.44 $14,196.00 MALE SUBSCRIBER R01 BCC 3559 N OF OTHER PARTS OF PANCREAS 3/29/2017 3/21/2017 3/28/20171036F CURRENT TOBACCO NON-USER (CAD, CAP, CORD, PV) C251 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 (DM) (IBD) OF BODY OF PANCREAS OUTPATIENT /HOSPITAL 3/29/2017 3/21/2017 3/28/201]1125F INTERMEDIATE "DEIAV "OF ANY FLAP, PRIMARY "DELAY" C251 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 "a OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF BODY OF PANCREAS OUTPATIENT /HOSPITAL DIRECT FLAP, AT FOREHEAD, CHEF 3/29/2017 3/21/2017 3128/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C251 MALIGNANT NEOPLASM PROFESSIONAL $108.44 $299.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF BODY OF PANCREAS OUTPATIENT /HOSPITAL } PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED N. CL EXAMINATION; MEDICAL DECISION MAKING OF Q, MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 3/29/2017 3/21/2017 3/28/2017 G8420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS C251 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 AND NO FOLLOW -UP PLAN IS REQUIRED OF BODY OF PANCREAS OUTPATIENT /HOSPITAL F 3/29/2017 3/21/2017 3/28/201769427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C251 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 LL! THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF BODY OF PANCREAS OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS 3/29/2017 3/21/2017 3/28/2017 G8484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C251 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 _ REASON NOT GIVEN OF BODY OF PANCREAS OUTPATIENT /HOSPITAL 3/29/2017 3/21/2017 3/28/2017 68509 PAINASSESSMENT DOCUMENTEDAS POSITIVE USINGA C251 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 STANDARDIZED TOOL ,FOLLOW - UPPLANNOT OF BODY OF PANCREAS OUTPATIENT /HOSPITAL a. DOCUMENTED, REASON NOT GIVEN ui 3/30/2017 3/21/2017 3/28/2017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT $2,150.81 $5,813.00 MALE SUBSCRIBER R01 BCC 3559 3/31/2017 3/28/2017 3/30/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER R01 BCC 3559 INCLUDE THE FOLLOWING: ALBUMIN BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT (82040), TOTAL (82247), CALCIUM, TOTAL (82310), CARBON /HOSPITAL DIOXIDE (BICARBONATE) (82374), CHL0RIDE (92435), W CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, �q J 3/31/2017 3/28/2017 3/30/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $6.60 MALE SUBSCRIBER ROl BCC 3559 EXAMINATIONWITH MANUAL DIFFERENTIAL WBC COUNT OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL v 4/4/2017 2/20/2017 4/2/2017- - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $113.25 $113.26 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS LLJ 4/5/2017 21812017 3/21/2017- - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $0.00 $13,346.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS (' 4/10/2017 3/14/2017 4/]/201] - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $5,182.44 $13,638.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC Q CHEMOTHERAPY CN! 4/10/2017 3/14/2017 4/7/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $0.00 $13,638.00 MALE SUBSCRIBER R01 EGG 3559 N ANTINEOPLASTIC CHEMOTHERAPY 4/10/2017 3116/2017 4/7/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $12,588.64 $33,128.00 MALE SUBSCRIBER RO1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY C.7.f 4/10/2017 3/30/2017 4/7/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $99.90 $270.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 4/12/2017 3/21/2017 4/7/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $557.00 $1,382.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 4/12/2017 3/28/2017 4/7/2017 - - Z5111 ENCOUNTERFOR HOSPITAL OUTPATIENT $4,545.18 $11,961.00 MALE SUBSCRIBER RO1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 4/12/2017 4/7/2017 4/11/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER R01 BCE 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE I84D75), POTASSIUM (84132), PROTEIN, 4/12/2017 41712017 4/11/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER R01 BCC 3559 HCF,RBC, WED AND PLATELET COUNT) AND AUTOMATED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DIFFERENTIAL WEE COUNT 4/12/2017 4/7/2017 4/11/2017 863011MMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $76.00 MALE SUBSCRIBER R01 BCC 3559 CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 4/14/2017 4/7/2017 4/13/20171036F CURRENTTOBACCO NON-USER (CAD, CAP, CORD, PV) C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 (DM) (IBD) OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 4/14/2017 4/7/2017 4/13/20171125F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DIRECT FLAP, AT FOREHEAD, CHEF 4/14/2017 4/7/2017 4/13/20171220F PATIENT SCREENED FOR DEPRESSION (SUD) C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 4/14/2017 4/712017 4/13/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C250 MALIGNANT NEOPLASM PROFESSIONAL $10844 $299.00 MALE SUBSCRIBER RD1 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/14/2017 417/2017 4/13/2017 68420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 AND NO FOLLOW -UP PLAN IS REQUIRED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 4/14/2017 4/7/2017 4/13/2017 G8427 ELIGIBLE PROFESSIDNALATTESTSTO DOCUMENTING IN C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 THE MEDIC AL RECORD THEY OBTAINED, UPDATED, OR OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS 4/14/2017 4/7/2017 4/13/2017 G8509 PAIN ASSESSMENT DOCUMENTEDAS POSITIVE USING A C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCE 3559 STANDARDIZED TOOL, FOLLOW-UP PLAN NOT OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DOCUMENTED, REASON NOT GIVEN 4/19/2017 3/30/2017 4112/2017- - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $13,080.98 $35,354.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 4/19/2017 4/10/2017 4/17/2017 - - 182413 ACUTE EMBOLISM AND HOSPITAL OUTPATIENT $3,024.75 $4,033.00 MALE SUBSCRIBER R01 BCC 3559 THROMBOSIS OF FEMORALVEIN, BILATERAL 4/20/2017 4/7/2017 4/18/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST C251 MALIGNANT NEOPLASM PROFESSIONAL $99.53 $236.00 MALE SUBSCRIBER R01 BCC 3559 MATERIAL(S) OF BODY OF PANCREAS OUTPATIENT /HOSPITAL 4/20/2017 4/7/2017 4/18/2017 74177 Computed tomography, abdomen and pelvis; with C251 MALIGNANT NEOPLASM PROFESSIONAL $141.78 $352.00 MALE SUBSCRIBER R01 BCC 3559 contrast material(') OF BODY OF PANCREAS OUTPATIENT /HOSPITAL C.7.f 4/20/2017 4/10/2017 411812017 71275 COMPUTED TOM OG RAP HIC ANG I OG RAP HY, CHEST R0602 SHORTNESS OF BREATH PROFESSIONAL $156.64 $349.00 MALE SUBSCRIBER R01 BCC 3559 (NONCORONARY), WITH CONTRAST MATERIAL(S), INPATIENT /HOSPITAL INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING N 4/20/2017 4/10/2017 4/18/2017 99223 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION 182409 ACUTE EMBOLISM AND PROFESSIONAL $282.08 $783.00 MALE SUBSCRIBER RO1 BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THROMBOSISOF INPATIENT /HOSPITAL THESE3 KEYCOMPONENTS: A COMPREHENSIVE HISTORY; UNSPECIFIED DEEP VEINS A COMPREHENSIVE EXAMINATION; AND MEDICAL OF UNSPECIFIED LOWER DECISION MAKING OF HIGH COMPLEXITY. COUNSELING EXTREMITY } AND /OR COORDINATION OF CARE WITH OTHER "a PROVIDERS OR AGEN 4/20/2017 4/10/2017 4/18/2017 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING R2242 LOCALIZED SWELLING, PROFESSIONAL WAS $115.00 MALE SUBSCRIBER R01 BCC 3559 RESPONSES TO COMPRESSION AND OTHER MANEUVERS; MASS AND LUMP, LEFT OUTPATIENT /HOSPITAL } COMPLETE BILATERAL STUDY LOWER LIMB 4/20/2017 4/10/2017 4/18/2017 99284 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION M7999 OTHER SPECIFIED SOFT PROFESSIONAL $182.40 $443.00 MALE SUBSCRIBER R01 BCC 3559 CL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES TISSUE DISORDERS OUTPATIENT /HOSPITAL Q, THESE 3 KEYCOMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION v MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER .� PROVIDERS OR AG ENCIES ARE PR �+ F 4/20/2017 4/11/2017 4/18/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R1084 GENERALIZED PROFESSIONAL $103.51 $276.00 MALE SUBSCRIBER R01 BCC 3559 UZI EVALUATION AND MANAGEMENT OF A PATIENT, WHICH ABOOMINALPAIN INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN — EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL _ DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR O 4/20/2017 4/11/2017 4/18/2017 94620 PULMONARY STRESS TESTING; SIMPLE BEG, 6- MINUTE R0602 SHORTNESS OF BREATH PROFESSIONAL $48.84 $113.00 MALE SUBSCRIBER R01 BCC 3559 Q WALK TEST, PROLONGED EXERCISE TEST FOR INPATIENT /HOSPITAL {EI BRONCHOSPASM WITH PRE -AND POST- SPIROMETRY AND OXIMETRY) Uy 4/25/2017 4/10/2017 4/24/2017 - - 182402 ACUTE EMBOLISM AND HOSPITAL INPATIENT 4/10/2017 # ## ## # ## $8,372.29 $21,404.94 MALE SUBSCRIBER R01 BCC 3559 THROMBOSIS OF UNSPECIFIED DEEP VEINS Q OF LEFT LOWER lJLJ EXTREMITY 4/25/2017 4/21/2017 4/24/2017 83036 HEMOGLOBIN; GLYCOSYLATED(AlC) C259 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER R01 BCC 3559 OF PANCREAS, OUTPATIENT /HOSPITAL J UNSPECIFIED v 4/25/2017 4/21/2017 4/24/2017 84443 THYROID STIMULATING HORMONE (TSH) C259 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $10.00 MALE SUBSCRIBER R01 BCC 3559 OF PANCREAS, OUTPATIENT /HOSPITAL UNSPECIFIED W 4/25/2017 4/21/2017 4/24/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER RO1 BCC 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 0 TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, Q ALKALINE (84075), POTASSIUM (84132), PROTEIN, N 4/25/2017 4/21/2017 4/24/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $6.60 MALE SUBSCRIBER R01 BCC 3559 Cy EXAMINATIONWITH MANUAL DIFFERENTIAL WBC COUNT OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL = 4/25/2017 4/21/2017 4/24/2017 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $76.00 MALE SUBSCRIBER ROl BCC 3559 CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL ._ 4/26/2017 3/28/2017 4/25/2017 " "* * *x.x xxxr. : * *xx xxxx. $95.00 $150.00 MALE SUBSCRIBER R01 BCC 3559 C.7.f 4/26/2017 3/28/2017 4/25/2017 ** * ** * * * ** * * * ** 4/26/2017 4/1/2017 4/25/2017 $95.00 4/26/2017 4/1/2017 4/25/2017 3559 * * »xx 4/26/2017 4/4/201] 4/25/2017 SUBSCRIBER RO1 BCC 4/26/2017 4/4/2017 4/25/2017 $95.00 $150.00 MALE 4/26/2017 4/10/2017 4/25/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 182402 $0.00 $150.00 MALE SUBSCRIBER RO1 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 3559 ACUTE EMBOLISM AND PROFESSIONAL $410.78 THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS SUBSCRIBER RO1 BCC 3559 THROMBOSIS OF IMPOSED BY THE VRGENCY OF THE PATIENT'S CLINICAL $936.00 MALE SUBSCRIBER R01 BCC 3559 CONDITION .AND /OR MENTAL STATUS: A COMPREH ENSIVE UNSPECIFIED DEEP VEINS HISTORY; A COMPREHENSIVE EXAMINATION; AND FEMORAL VEIN, OF LEFT LOWER MEDICAL DEC15 4/26/2017 4/11/201] 4/25/2011 EXTREMITY 4/26/2017 4/11/2017 4/25/2017 ACUTE EMBOLISM AND 4/26/2017 4/18/2017 4/25/2017 $150.00 MALE SUBSCRIBER R01 4/26/201] 4/18/20 17 4/25/2017 * * * ** * * * ** * * * ** 4/26/201] 4/25/201] 4/25/2017 3559 4/26/2017 4/25/2017 4/25/2017 SUBSCRIBER RO1 BCC 4/28/2017 4/21/2017 4/27/2017 1036F CURRENTTOBACCO NON - USER(CAD, CAP,COPD, PV) C250 SUBSCRIBER RO1 BCC 3559 )DMI (RED) * * * ** 4/28/2017 4/21/2017 4/27/2017 1126F INTERMEDIATE " DELAY" OFANY FLAP, PRIMARY "DELAY" C250 OUTPATIENT /HOSPITAL $0.00 OF SMALL FLAP, OR SECTIONING PEDICLE DELUDED OR SUBSCRIBER RO1 BCC 3559 MALIGNANT NEOPLASM DIRECT FLAP, AT EYELIDS NOSE, $0.00 4/28/2017 4/21/2017 4/27/2017 1220F PATIENTSCREENED FOR DEPRESSION(SUD) C250 4/28/2017 4/21/2017 4127/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C250 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED $0.01 MALE SUBSCRIBER RO1 BCC 3559 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY OUTPATIENT /HOSPITAL COMPONENTS: A DETAILED HISTORY; A DETAILED MALIGNANT NEOPLASM PROFESSIONAL $0.00 EXAMINATION; MEDICAL DECISION MAKING OF SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER MALIGNANT NEOPLASM 4128/2017 4/21/2017 4/27/2017 G8420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS C250 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL AND NO FOLLOW -UP PLAN IS REQUIRED 412812017 4/21/2017 4/27/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C250 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR REVIEWED THE PATIENT'S CURRENT MEDICATIONS 4/28/2017 4/21/2017 4/27/2017 G8731 PAIN ASSESSMENT USING ASTANDARDIZED TOOL IS C250 DOCUMENTED AS NEGATIVE, NO FOLLOW -UP PLAN REQUIRED 5/4/2017 4/10/2017 5/3/2017 A0425 GROUND MILEAGE, PER STATUTE MILE 182413 S/4/2017 4/10/2017 5/3/2017 A0427 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, 182413 EMERGENCY TRANSPORT, LEVEL 1 )AISI- EMERGENCY) 5/5/2017 5/2/2017 5/4/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C250 INCLUDE THE FOLLOWING: ALBUMIN )8204D), BILIRUBIN, TOTAL (82247), CALCIUM, TOTAL )82310), CARBON DIOXIDE LBICARSO NATE) (82374), CHL0RIDE (92435), CREATININE( 82565), G LUCOSE(82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, * * * ** * * * ** $0.00 $150.00 MALE SUBSCRIBER I BCC 3559 OUTPATIENT /HOSPITAL $95.00 $150.00 MALE SUBSCRIBER R BCC 3559 * * »xx * * » »* $0.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 * * * ** * * * ** $95.00 $150.00 MALE SUBSCRIBER ED, BCC 3559 PROFESSIONAL $0.00 $0.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 ACUTE EMBOLISM AND PROFESSIONAL $410.78 $1,714.00 MALE SUBSCRIBER RO1 BCC 3559 THROMBOSIS OF OUTPATIENT /HOSPITAL $936.00 MALE SUBSCRIBER R01 BCC 3559 THROMBOSIS OF UNSPECIFIED DEEP VEINS FEMORAL VEIN, OF LEFT LOWER BILATERAL EXTREMITY ACUTE EMBOLISM AND * * + ** * * * ** $95.00 $150.00 MALE SUBSCRIBER R01 BCC 3559 $0.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 $95.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 SIR B $150. D0 MALE SUBSCRIBER RO1 BCC 3559 ** * * * ** $95.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 OUTPATIENT /HOSPITAL $0.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER RO1 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER RO1 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $108.44 $299.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL ACUTE EMBOLISM AND OTHER MEDICAL $720.00 $936.00 MALE SUBSCRIBER R01 BCC 3559 THROMBOSIS OF FEMORAL VEIN, BILATERAL ACUTE EMBOLISM AND OTHER MEDICAL $402.94 $850.00 MALE SUBSCRIBER RO1 BCC 3559 THROMBOSIS OF FEMORAL VEIN, BILATERAL MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL C.7.f 5/5/2017 5/2/2017 5/4/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER R01 BCC 3559 HCT,REG,WBC AND PLATELET COUNT) AND AUTOMATED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT Z 5/5/2017 5/2/2017 5/4/2017 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $76.00 MALE SUBSCRIBER R01 BCC 3559 N CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL OR 4D 5/11/2017 5/2/2017 5/9/20171036F CURRENTTOBACCO NON-USER (CAD, CAP, CORD, PV) C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS )DMf (IBD) 7 5/11/2017 5/2/2017 5/9/2017 1126F INTERMEDIATE "DEIAV "OF ANY FLAP, PRIMARY "DELAY" C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 "a OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF HEAD OF PANCREAS OR DIRECT FLAP, AT EYELIDS NOSE, 5/11/2017 5/2/2017 5/9/2017 1220F PATIENT SCREENED FOR DEPRESSION (SUD) C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS } fl 5/11/2017 5/2/2017 5/9/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C250 MALIGNANT NEOPLASM OTHER MEDICAL $10844 $299.00 MALE SUBSCRIBER R01 BCC 3559 N. CL EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF HEAD OF PANCREAS Q, PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER F 511112017 5/2/2017 5/9/2017 G9419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 uj FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN OF HEAD OF PANCREAS 5/11/2017 5/2/2017 5/9/2017 G8427 ELIGIBLE PROFESSIDNALATTESTSTO DOCUMENTING IN C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF HEAD OF PANCREAS _ REVIEWED THE PATIENT'S CURRENT MEDICATIONS 5/11/2017 5/2/2017 5/9/2017 68732 NO DOCUMENTATION OF PAIN ASSESSMENT C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS Q W 5/16/2017 4/7/2017 5/10/2017- - C251 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $3,947.44 $10,388.00 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS U`J 5/16/2017 4/21/2017 5/10/2017- - C251 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $853.10 $2,245.00 MALE SUBSCRIBER R01 BCC 3559 OF BODY OF PANCREAS J 5/19/2017 5/17 /2017 5/17/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C259 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $186.31 $275.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF ANEW PATIENT, OF PANCREAS, WHICH REQUIRES THESE 3 KEY COMPONENTS :A UNSPECIFIED J COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF v MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR W 5/19/2017 5/17/2017 5/17/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C259 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $275.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF ANEW PATIENT, OF PANCREAS, WHICH REQUIRES THESE 3 KEY COMPONENTS :A UNSPECIFIED (' COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR {hj Cy 5/22/2017 5/15/2017 5/19/2017 76705 ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE C250 MALIGNANT N EOPLASM PROFESSIONAL $4845 $112.00 MALE SUBSCRIBER ROT BCC 3559 DOCUMENTATION; LIMITED(EG, SINGLE ORGAN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL = QUADRANT, FOLLOW -UP) �j C.7.f 5/22/2017 5/16/2017 5/19/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER R01 BCC 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565(, GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132(, PROTEIN, 5/22/2017 5/16/2017 5/19/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $6.60 MALE SUBSCRIBER R01 BCC 3559 EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 5/22/2017 5/16/2017 5/19/2017 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $76.00 MALE SUBSCRIBER R01 BCC 3559 CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 5/24/2017 5/1/2017 5123/2017 *" " «* * *rrr *` « ** » * * *» * *zxr $95.00 $150.00 MALE SUBSCRIBER R01 BCC 3559 5/24/2017 5/1/2017 5/23/2017 * * »»* + +.". ss**z " + +.. + +.." $0.00 $150.00 MALL SUBSCRIBER 1 1 BCC 3559 5/24/201] 5/1/201] 5/23/2017 + + + »+ * * *.w * » » ++ » * * ** * * * *" $0.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 5/24/2017 5/1/2017 5/23/2017 $0.00 $150.00 MALE SUBSCRIBER RO1 DEC 3559 5/24/2017 5/6/2017 5/23/2017 * * «" * * * ". *xx ** » » » ** * * * *" $95.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 5/24/201] 5/6/2017 5/23/2017 + +r «+ * * * ** 'rr ++ » * * ** * * * ** $0.00 $150.00 MALE SUBSCRIBER ROT BCC 3559 5/24/2017 5/6/2017 5/23/2017 * * * "* * +r +« * » » ** + * +r. * +rx+ $0.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 5/24/2017 5/6/2017 5/23/2017 * *.x. * » * "* *« « ** » * + +* * » * *" $0.00 $150.00 MALE SUBSCRIBER R01 BCC 3559 5/24/201] 5/11/201] 5/23/2017 *r » ++ * * * ** * » » ** " * * "` * * * "* $95.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 5/24/2017 5/11/2017 5/23/2017 * *r ** * *r+« * * " ** « * * ** * * * *+ $0.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 5/24/2017 5/11/2017 5/23/2017 * * * «* * *r «r *« « ** » * * ** * * +r« $0.00 $150.00 MALE SUBSCRIBER R01 BCC 3559 5/24/2017 5/11/2017 5/23/2017 * * * "* * * " ** * " " ** * * * "` * * " "* $0.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 5/24/2017 5/18/2017 5/23/2017 * «r ** * * * «* ° " " ** « * * *« * * * *« $95.00 $150.00 MALE SUBSCRIBER R BCC 3559 5/24/2017 5/18/2017 5/23/2017 * * « "* * * » »* *. " ** r * * *» * * * *» $0.00 $150.00 MALE SUBSCRIBER R01 BCC 3559 5/24/201] 5/18/2017 5/23/2017 * *r «r . » »».w r« «rr . * » »> * » » »» $0.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 5/24/2017 5/18/2017 5/23/201] * *a ** * * * «* ° " * ** « * * *« * * *+« $0.00 $150.00 MALE SUBSCRIBER R01 BCC 3559 5/24/2017 5/23/2017 5/23/2017 * *' «* * * » »* * « " ** * * * ** * * * »» $95.00 $150.00 MALE SUBSCRIBER R BCC 3559 5/24/2017 5/23/2017 5/23/201] * *r«r .. ».* xxr»r .x +.* * * * ». $0.00 $150.00 MALE SUBSCRIBER R01 BCC 3559 5/24/2017 5/23/2017 5/23/201] $0.00 $150.00 MALE SUBSCRIBER R01 BCC 3559 5/24/2017 S/23/2017 5/23/2017 * * * «* * * » »* *` « ** » * * *» * * * »» $0.00 $150.00 MALE SUBSCRIBER RO1 BCC 3559 5/25/2017 5/15/201] 5/24/2017- - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,89].4] $7,831.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS 5125/2017 5/16/2017 5/24/2017 1036F CURRENTTOBACCO NON - USER (CAD, CAP, COPD, PV) C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 (DM) (IBD) OF HEAD OF PANCREAS 5/25/2017 5/16/2017 5/24/2017 1126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF HEAD OF PANCREAS DIRECT FLAP, AT EYELIDS NOSE, 5/25/2017 5/16/2017 5/24/2017 1220F PATIENT SCREENED FOR DEPRESSION (SUD) C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS 5/25/2017 5/16/2017 5/24/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C250 MALIGNANT NEOPLASM OTHER MEDICAL $108.44 $299.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF HEAD OF PANCREAS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5/25/2017 5/16/2017 5/24/2017 68420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 AND NO FOLLOW -UP PLAN IS REQUIRED OF HEAD OF PANCREAS 5/25/2017 5/16/2017 5/24/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 TH E MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF HEAD OF PANCREAS REVIEWED THE PATIENT'S CURRENT MEDICATIONS C.7.f 5/25/2017 5/16/2017 5/24/2017 G8731 PAIN ASSESSMENT USING A STANDARDIZED TOOL 15 C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN OF HEAD OF PANCREAS REQUIRED 5/26/2017 5/10/2017 5/24/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D125 BENIGN NEOPLASM OF PROFESSIONAL OFFICE $95.18 $347.00 MALE SUBSCRIBER R01 BCC 3559 N EVALUATION AND MANAGEMENT OF AN ESTABLISHED SIGMOID COLON PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 7 COORDINATION OF CARE WITH OTHER "a 5/26/2017 5/23/2017 5/25/2017 83036 HEMOGLOBIN; GLYCOSYIATED(A1C) C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $10.80 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL W 5/26/2017 5/23/2017 5/25/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER ROl BCC } 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL N. CL TOTAL (82247), CALCIUM, TOTAL )82310), CARBON Q, DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), 'Q CREATININE( 82565), GLUCOSE (92947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 5/26/2017 5/23/2017 5/25/2017 84439 THYROXINE; FREE C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $22.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL W 5/26/2017 5/23/2017 5/25/2017 84443 THYROID STIMULATING HORMONE)TSH) C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $10.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 5/26/2017 5/23/2017 5/25/2017 85025 BLOOD COUNT; COMPLETE)CBC), AUTOMATED HEGB, C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER R01 BCC 3559 _ HCT, BBC, WEE AND PLATELET COUNT) AND AUTOMATED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 5/26/2017 5/23/2017 5/25/2017 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $76.00 MALE SUBSCRIBER R01 BCC 3559 CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL Q W 5/30/2017 S/2/2017 5/22/2017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT $3,060.64 $8,27100 MALE SUBSCRIBER R01 BCC 3559 5/30/2017 5/25/2017 5/27/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R198 OTHER ASCITES PROFESSIONAL $175.90 $437.00 MALE SUBSCRIBER R01 BCC 3559 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 6/2/2017 5/2/2017 6/1/2017 49083 ABDOMINAL PARACENTE5I5(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL $175.90 $437.00 MALE SUBSCRIBER R01 BCC 3559 LLJ THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL e 6/2/2017 5/23/2017 6/1/20171036F CURRENTTOBACCO NON- USER (CAD, CAP, COPE, PV) C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 )DM) (IBD) OF HEAD OF PANCREAS v 6/2/2017 5/23/2017 6/1/20171126F INTERMEDIATE " DELAY "DF ANY FLAP, PRIMARY "DELAY" C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER ROl BCC 3559 f' OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF HEAD OF PANCREAS DIRECT FLAP, AT EYELIDS NOSE, uJ 6/2/2017 5/23/2017 6/1/2017 1220F PATIENT SCREENED FOR DEPRESSION (SUD) C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS U 6/2/2017 5/23/2017 6/1/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C250 MALIGNANT NEOPLASM OTHER MEDICAL $10844 $299.00 MALE SUBSCRIBER 301 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF HEAD OF PANCREAS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED {j EXAMINATION; MEDICAL DECISION MAKING OF hl MODERATE COMPLEXITY, COUNSELING AND /DR COORDINATION OF CARE WITH OTHER C 6/2/2017 5123/2017 6/1/2017 G8420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 AND NO FOLLOW -UP PLAN IS REQUIRED OF HEAD OF PANCREAS C.7.f 6/2/2017 5/23/2017 6/1/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 THE MEDIC AL RECORD THEY OBTAINED, UPDATED, OR OF HEAD OF PANCREAS REVIEWED THE PATIENT'S CURRENT MEDICATIONS 6/2/2017 5/23/2017 6/1/2017 G8509 PAIN ASSESSMENT DOCUMENTED AS POSITIVE USINGA C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 STANDARDIZED TOOL ,FOLLOW - UPPLANNOT OF HEAD OF PANCREAS DOCUMENTED, REASON NOT GIVEN 6/12/2017 5/16/2017 6/9/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $557.00 $1,382.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 6/12/2017 5/23/2017 6/9/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $5,063.50 $13,325.00 MALE SUBSCRIBER RD1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 6/12/2017 S/23/2017 6/9/2017- - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $0.00 $13,325.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 6/13/2017 515/2017 6/12/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $0.00 $34,318.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 6/15/2017 5/5/2017 6/12/2017 - - Z5111 ENCOUNTERFOR HOSPITAL OUTPATIENT $13,040.84 $34,318.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 6/15/2017 6/12/2017 6/14/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL $175.90 $437.00 MALE SUBSCRIBER R01 BCC 3559 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 6/16/2017 2/28/2017 6/13/2017- - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $5,295.20 $13,238.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 6/16/2017 6/13/2017 6/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 MALE SUBSCRIBER R01 BCC 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565(, GLUCOSE (92947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 6/16/2017 6/13/2017 6/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $10.40 MALE SUBSCRIBER R01 BCC 3559 PUT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 6/16/2017 6/13/2017 6/15/2017 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $76.00 MALE SUBSCRIBER R01 BCC 3559 CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 6/19/2017 5/3/2017 6/9/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $4,243.46 $13,25200 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 6/21/2017 211712017 6/14/2017- - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $11,348.00 $28,497.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 6/21/2017 6/12/2017 6/20/2017- - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,582.23 $6,979.00 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS 6/21/2017 6/13/2017 6/20/2017 1036F CURRENTTOBACCO NON-USER (CAD, CAP, CORD, PV) K8689 OTHER SPECIFIED OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 (DM) (IBD) DISEASES OF PANCREAS 6/21/2017 6/13/2017 6/20/20171126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" K8689 OTHER SPECIFIED OTHER MEDICAL $0.00 $001 MALE SUBSCRIBER R01 BCC 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR DISEASES OF PANCREAS DIRECT FLAP, AT EYELIDS NOSE, 6/21/2017 6/13/2017 6/20/2017 1220F PATIENT SCREENED FOR DEPRESSION (SUD) K8689 OTHER SPECIFIED OTHER MEDICAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 DISEASES OF PANCREAS 6/21/2017 6/13/2017 6/20/2017 6/21/2017 6/13/2017 6/20/2017 G8420 6/21/2017 6/13/2017 6/20/2017 68428 6/21/2017 6/13/2017 6/20/2017 G8731 6/23/2017 317/2017 6/20/2017 - 6/30/2017 6/23/2017 6/29/2017 71312017 6/23/2017 6/30/2017 - 7/6/2017 2/15/2017 6/27/2017 - 7/10/2017 5/25/2017 7/7/2017 - 7/10/2017 7/3/2017 7/7/2017 711012017 7/5/2017 7/7/2017 711012017 7/5/2017 7/7/2017 7/10/2017 7/5/2017 7/7/2017 7/11/2017 6/13/2017 7/10/2017 - 7/12/2017 7/5/2017 7/11/2017 1036F 7/12/2017 7/5/2017 7/11/2017 1126F 7/12/2017 715/2017 7/11/2017 1220F 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K8689 OTHER SPECIFIED OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED SUBSCRIBER R01 BCC DISEASES OF PANCREAS $0.01 MALE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $557.00 $3,867.00 MALE SUBSCRIBER RO1 BCC COMPONENTS: A DETAILED HISTORY; A DETAILED $437.00 MALE SUBSCRIBER RO1 BCC $2,543.01 EXAMINATION; MEDICAL DECISION MAKING OF SUBSCRIBER R01 BCC $5,747.60 $14,369.00 MALE MODERATE COMPLEXITY. COUNSELING AND /OR $6,614.00 $39,990.00 MALE SUBSCRIBER 301 BCC COORDINATION OF CARE WITH OTHER $437.00 MALE SUBSCRIBER RO1 BCC $0.00 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS K8689 OTHER SPECIFIED OTHER MEDICAL AND NO FOLLOW -UP PLAN IS REQUIRED DISEASES OF PANCREAS CURRENT LISTOF MEDICATIONS NOT DOCUMENTED AS K8689 OTHER SPECIFIED OTHER MEDICAL OBTAINED, UPDATED, OR REVIEWED BY THE ELIGIBLE DISEASES OF PANCREAS PROFESSIONAL, REASON NOT GIVEN PAIN ASSESSMENT USING A STANDARDIZED TOOL IS K8689 OTHER SPECIFIED OTHER MEDICAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN DISEASES OF PANCREAS REQUIRED - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR C250 MALIGNANT NEOPLASM PROFESSIONAL THERAPEUTIC); WITH IMAGING GUIDANCE OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL - 3188 OTHER ASCITES HOSPITAL OUTPATIENT - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C250 MALIGNANT NEOPLASM PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHL0RIDE (92435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84D75), POTASSIUM (84132), PROTEIN, 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C250 MALIGNANT NEOPLASM PROFESSIONAL HCT,RBC, WBC AND PLATELET COUNT) AND AUTOMATED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF HEAD OF PANCREAS CURRENTTOBACCO NON- USER (CAD, CAP, CORD, PV) C250 MALIGNANT NEOPLASM OTHER MEDICAL (DM) (IBD) OF HEAD OF PANCREAS INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C250 MALIGNANT NEOPLASM OTHER MEDICAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF HEAD OF PANCREAS DIRECT FLAP, AT EYELIDS NOSE, PATIENT SCREENED FOR DEPRESSION (SUB) C250 MALIGNANT NEOPLASM OTHER MEDICAL OF HEAD OF PANCREAS $108.44 $299.00 MALE SUBSCRIBER RO1 BCC $0.00 $0.01 MALE SUBSCRIBER RO1 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER RO1 BCC $557.00 $3,867.00 MALE SUBSCRIBER RO1 BCC $175.90 $437.00 MALE SUBSCRIBER RO1 BCC $2,543.01 $6,873.00 MALE SUBSCRIBER R01 BCC $5,747.60 $14,369.00 MALE SUBSCRIBER RO1 BCC $6,614.00 $39,990.00 MALE SUBSCRIBER 301 BCC $175.90 $437.00 MALE SUBSCRIBER RO1 BCC $0.00 $26.00 MALE SUBSCRIBER RO1 BCC $0.00 $10.40 MALE SUBSCRIBER R01 BCC $0.00 $76.00 MALE SUBSCRIBER RO1 BCC $0.00 $13,121.00 MALE SUBSCRIBER RO1 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER RO1 BCC $0.00 $0.01 MALE SUBSCRIBER RO1 BCC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 7/12/2617 7/5/2017 7/11/2017 7/12/2017 7/5/2017 7/11/2017 G8420 7/12/2017 7/5/2017 7/11/2017 G8427 7/12/2017 7/5/2017 7/11/2017 G8509 7/13/2017 6/13/2017 7/10/2017 - 7/13/2017 6/15/2017 7/10/2017 - 711712017 7/3/2017 7/13/2017 - 7/24/2017 7/18/2017 7/21/2017 7/26/2017 7/18 /2017 7 /25/2017 - 7/31/2017 7/26/2017 7/28/2017 7/31/2017 7/26/2017 7/28/2017 7/31/2017 7/26/2017 7/28/2017 8/3/2017 7/21/2017 7/27/2017 - 8/10/2017 7 /21/2017 8/9/2017 8/10/2017 7/21/2017 8/9/2017 8/10/2017 7/26/2017 8/9/2017 1036F 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C250 MALIGNANT NEOPLASM OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED SUBSCRIBER R01 BCC OF HEAD OF PANCREAS $0.01 MALE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $4,985.98 $13,121.00 MALE SUBSCRIBER R01 BCC COMPONENTS: A DETAILED HISTORY; A DETAILED $33,318.00 MALE SUBSCRIBER R01 BCC $3,408.81 EXAMINATION; MEDICAL DECISION MAKING OF SUBSCRIBER RO1 BCC $175.90 $437.00 MALE MODERATE COMPLEXITY. COUNSELING AND /OR $3,542.38 $9,574.00 MALE SUBSCRIBER R01 BCC COORDINATION OF CARE WITH OTHER $26.00 MALE SUBSCRIBER RO1 BCC BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS C250 MALIGNANT NEOPLASM OTHER MEDICAL AND NO FOLLOW -UP PLAN IS REQUIRED OF HEAD OF PANCREAS ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C250 MALIGNANT NEOPLASM OTHER MEDICAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF HEAD OF PANCREAS REVIEWED THE PATIENT'S CURRENT MEDICATIONS PAIN ASSESSMENT DOCUMENTED AS POSITIVE USING A C250 MALIGNANT NEOPLASM OTHER MEDICAL STANDARDIZED TOOL FOLLOW -UP PLAN NOT OF HEAD OF PANCREAS DOCUMENTED, REASON NOT GIVEN - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF HEAD OF PANCREAS - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF HEAD OF PANCREAS - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF HEAD OF PANCREAS 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL THERAPEUTIC(; WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL - R188 OTHER ASCITES HOSPITAL OUTPATIENT 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C250 MALIGNANT NEOPLASM PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED LIEGE, C250 MALIGNANT NEOPLASM PROFESSIONAL HCT,REG, WBC AND PLATELET COUNT) AND AUTOMATED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; C250 MALIGNANT NEOPLASM PROFESSIONAL CA 19 -9 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL - C258 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF OVERLAPPING SITES OF PANCREAS 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST C259 MALIGNANT NEOPLASM PROFESSIONAL MATERIALS) OF PANCREAS, OUTPATIENT /HOSPITAL UNSPECIFIED 74177 Computed tomography, a bdomen and pelvis; with C259 MALIGNANT NEOPLASM PROFESSIONAL contrast material(s) OF PANCREAS, OUTPATIENT /HOSPITAL UNSPECIFIED CURRENTTOBACCO NON - USER (CAD, CAP, CORD, PV) C250 MALIGNANT NEOPLASM PROFESSIONAL (DM) (IBD) OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL $108.44 $299.00 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER R01 BCC $0.00 $0.01 MALE SUBSCRIBER RO1 BCC $4,985.98 $13,121.00 MALE SUBSCRIBER R01 BCC $12,660.84 $33,318.00 MALE SUBSCRIBER R01 BCC $3,408.81 $9,213.00 MALE SUBSCRIBER RO1 BCC $175.90 $437.00 MALE SUBSCRIBER RO1 BCC $3,542.38 $9,574.00 MALE SUBSCRIBER R01 BCC $0.00 $26.00 MALE SUBSCRIBER RO1 BCC $0.00 $10.40 MALE SUBSCRIBER RO1 BCC $0.00 $76.00 MALE SUBSCRIBER RO1 BCC $3,405.00 $9,835.00 MALE SUBSCRIBER R01 BCC $9933 $236.00 MALE SUBSCRIBER RO1 BCC $141.78 $352.00 MALE SUBSCRIBER RO1 BCC $0.00 $0.01 MALE SUBSCRIBER RO1 BCC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 C.7.f 811012017 7/26/2017 8/9/20171126F INTERMEDIATE" DELAY" DEANY FLAP, PRIMARY "DELAY" C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, 811012017 7/26/2017 8/9/20171220F PATIENT SCREENED FOR DEPRESSION(SUD) C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 8/10/2017 7/26/2017 8/9/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C250 MALIGNANT NEOPLASM PROFESSIONAL $108.44 $299.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 8/10/2017 7/26/2017 8/9/201768420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER ROE BCC 3559 AND NO FOLLOW -UP PLAN 15 REQUIRED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 811012017 7/26/2017 8/9/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 THE MEDICAL RECORD THEYOBTAINED, UPDATED, OR OF HEAD OF PANCREAS OUTPATIENT/HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS 8/10/2017 7/26/2017 8/9/2017 G8731 PAIN ASSESSMENT USING A STANDARDIZED TOOL IS C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL REQUIRED 811012017 713112017 81912017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR 3188 OTHER ASCITES PROFESSIONAL $175.90 $437.00 MALE SUBSCRIBER R01 BCC 3559 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 8/10/2017 8/2/2017 8/9/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C250 MALIGNANT NEOPLASM OTHER MEDICAL $237.03 $660.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF A NEW PATIENT, OF HEAD OF PANCREAS WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE 8/11/2017 7/5/2017 8/10/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $0.00 $13,397.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 8/14/2017 7/5/2017 811012017 - - Z5111 ENCOUNTERFOR HOSPITAL OUTPATIENT $5,090.86 $13,397.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 8/14/2017 7/7/2017 8/11/2017- - 75111 ENCOUNTER FOR HOSPITAL OUTPATIENT $13,030.20 $34,290.00 MALE SUBSCRIBER RO1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 8/17/2017 8/11/2017 8/16/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL $175.90 $437.00 MALE SUBSCRIBER R01 BCC 3559 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 812112017 7/26/2017 8/10/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $557.00 $1,291.00 MALE SUBSCRIBER RO1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 8/23/2017 7/31/2017 8118/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $3,402.15 $10,616.00 MALE SUBSCRIBER RO1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 8/24/2017 8/21/2017 8/23/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R188 OTHERASCITES PROFESSIONAL $175.90 $437.00 MALE SUBSCRIBER R01 BCC 3559 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 8/31/2017 8/26/2017 8/30/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL $175.90 $437.00 MALE SUBSCRIBER R01 BCC 3559 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 91112017 8/10/2017 812612017 77332 TREATMENT DEVICES, DESIGN AND CONSTRUCTION; C250 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $104.00 MALE SUBSCRIBER R01 BCC 3559 SIMPLE (SIMPLE BLOCK, SIMPLE BOLUS) OF HEAD OF PANCREAS C.7.f 9/1/2017 8/10/2017 8/26/2017 77334 TREATMENT DEVICES, DESIGN AND CONSTRUCTION; C250 MALIGNANT NEOPLASM OTHER MEDICAL $98.94 $237.00 MALE SUBSCRIBER R01 BCC 3559 COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, OF HEAD OF PANCREAS COMPENSATORS, WEDGES, MOLDS OR CASTS) 9/1/2017 8/11/2017 8/26/2017 77263 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; C250 MALIGNANT NEOPLASM OTHER MEDICAL $253.38 $634.00 MALE SUBSCRIBER R01 BCC 3559 COMPLEX OF HEAD OF PANCREAS 9/7/2017 8/28/2017 9/6/2017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT $1,958.04 $5,292.00 MALE SUBSCRIBER R01 BCC 3559 9/8/2017 8/21/2017 8129/2017 *'' *" * * * ** * " ** * * * ** * * * »* $299.17 $714.00 MALE SUBSCRIBER RO1 BCC 3559 91 8/24/2017 9/7/2017 - - Z510 ENCOUNTER FOR HOSPITAL OUTPATIENT $6,068.98 $15,971.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC RADIATION THERAPY 9/8/2017 8/25/2017 9/7/2017 - - Z530 ENCOUNTER FOR HOSPITAL OUTPATIENT $598.88 $1,576.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC RADIATION THERAPY 9/8/2017 8/30/2017 9/7/2017 - - Z510 ENCOUNTER FOR HOSPITAL OUTPATIENT $6,068.98 $15,971.00 MALE SUBSCRIBER RO1 BCC 3559 ANTINEOPLASTIC RADIATION THERAPY 9/8/2017 8/31/2017 9/7/2017 - - Z510 ENCOUNTER FOR HOSPITAL OUTPATIENT $21,603.38 $56,851.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC RADIATION THERAPY 9/13/2017 8/10/2017 91 - - Z510 ENCOUNTER FOR HOSPITAL OUTPATIENT $1,694.80 $4,460.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC RADIATION THERAPY 9/13/2017 8/30/2017 9/7/2017- - Z510 ENCOUNTER FOR HOSPITAL OUTPATIENT $15,534.40 $40,880.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC RADIATION THERAPY 9/14/2017 8/21/2017 9/6/2017 77300 BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL C250 MALIGNANT NEOPLASM OTHER MEDICAL $494.70 $1,200.00 MALE SUBSCRIBER R01 BCC 3559 AXIS DEPTH DOSE CALCULATION, TDF, NSD, GAP OF HEAD OF PANCREAS CALCULATION, OFF AXIS FACTOR, TISSUE INHOMOGENEITY FACTORS, CALCULATION OF NON - IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN PRESCRIBED BY THE TREATING 9/14/2017 8/21/2017 91 77301 INTENSITY MODULATED RADIOTHERAPY PLAN, C250 MALIGNANT NEOPLASM OTHER MEDICAL $640.55 $1,538.00 MALE SUBSCRIBER R01 BCC 3559 INCLUDING DOSE- VOLUME HISTOGRAMS FOR TARGET OF HEAD OF PANCREAS AND CRITICAL STRUCTURE PARTIAL TOLERANCE SPECIFICATIONS 9/14/2017 8/21/2017 9/6/2017 77338 Multi leaf collimator(MLC) device(s) for intensity C250 MALIGNANT N EOPLASM OTHER MEDICAL $365.25 $829.00 MALE SUBSCRIBER RO1 BCC 3559 modulated radiation therapy (IMRT), design and OF HEAD OF PANCREAS anstruction per IMRT plan 9/14/2017 8/22/2017 9/6/2017 77300 BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL C250 MALIGNANT NEOPLASM OTHER MEDICAL $494.70 $1,200.00 MALE SUBSCRIBER R01 BCC 3559 AXIS DEPTH DOSE CALCULATION, TDF, RED, GAP OF HEAD OF PANCREAS CALCULATION, OFF AXIS FACTOR, TISSUE INHOMOGENEITY FACTORS, CALCULATION OF NON - IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN PRESCRIBED BY THE TREATING 9/14/2017 8/22/2017 9/6/2017 77301 INTENSITY MODULATED RADIOTHERAPY PLAN, C250 MALIGNANT NEOPLASM OTHER MEDICAL $640.55 $1,538.00 MALE SUBSCRIBER R01 BCC 3559 INCLUDING DOSE- VOLUME HISTOGRAMS FOR TARGET OF HEAD OF PANCREAS AND CRITICAL STRUCTURE PARTIAL TOLERANCE SPECIFICATIONS 9/14/2017 8/22/2017 9/6/2017 77338 Multi leaf collimator(MLC) device(s) for intensity C250 MALIGNANT N EOPLASM OTHER MEDICAL $36515 $829.00 MALE SUBSCRIBER R01 BCC 3559 modulated radiation therapy (IMRT), design and OF HEAD OF PANCREAS construction per IMRT plan 9/15/2017 8/21/2017 9/14/2017- - Z510 ENCOUNTER FOR HOSPITAL OUTPATIENT $6,614.00 $66,124.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC RADIATION THERAPY 9/15/2017 8/22/2017 9/14/2017 - - Z510 ENCOUNTER FOR HOSPITA L OUTPATIENT $21,603.38 $56,851.00 MALE SUBSCRIBER RO1 BCC 3559 ANTINEOPLASTIC RADIATION THERAPY C.7.f 9/21/2017 8/11/2017 9/14/2017 - - Z510 ENCOUNTER FOR HOSPITAL OUTPATIENT $2,626.63 $7,099.00 MALE SUBSCRIBER R01 BCC 3559 ANTINEOPLASTIC W RADIATION THERAPY 9/25/2017 9/15/2017 9/22/2017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT $3,211.65 $8,235.00 MALE SUBSCRIBER R01 BCC 3559 N 10/9/2017 9/5/2017 10/6/2017- - C259 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $210.00 $280.00 MALE SUBSCRIBER R01 BCC 3559 OF PANCREAS, UNSPECIFIED 10/18/2017 9/6/2017 10117/2017- - C250 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $593.00 $1,787.00 MALE SUBSCRIBER RO1 BCC 3559 "a OF HEAD OF PANCREAS 10/20/2017 8/31/2017 10/3/2017 77300 BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL C250 MALIGNANT NEOPLASM OTHER MEDICAL $4947 $1,200.00 MALE SUBSCRIBER R01 BCC 3559 AXIS DEPTH DOSE CALCULATION, TDF, NSD, GAP OF HEAD OF PANCREAS } CALCULATION, OFF AXIS FACTOR, TISSUE INHOMOGENEITY FACTORS, CALCULATION OF NON- N. CL IONIZING RADIATION SURFACE AND DEPTH DOSE, AS Q, REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN PRESCRIBED BY THE TREATING 1012012017 8/31/2017 101312017 77301 INTENSITY MODULATED RADIOTHERAPY PLAN, C250 MALIGNANT NEOPLASM OTHER MEDICAL $640.55 $1,538.00 MALE SUBSCRIBER R01 BCC 3559 INCLUDING DOSE - VOLUME HISTOGRAMS FOR TARGET OF HEAD OF PANCREAS rf AND CRITICAL STRUCTURE PARTIAL TOLERANCE SPECIFICATIONS (- 10/20/2017 8/31/2017 101 77338 Multi -leaf mlllmator(MILC)device(s)for intensity C250 MALIGNANT N EOPLASM OTHER MEDICAL $365.25 $829.00 MALE SUBSCRIBER R01 BCC 3559 modulated radiation therapy (IMRT), design and OF HEAD OF PANCREAS h D 11/6/2017 9/6/2017 11/3/20171036F anst —U.n per IMRT plan CURRENTTOBACCO NON-USER (CAD, CAP, CORD, PV) C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 (DM) (IBD) OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL _ 11/6/2017 9/6/2017 11/3/20171126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER RU1 BCC 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, Q 11/6/2017 9/6/2017 11/3/20171220F PATIENT SCREENED FOR DEPRESSION (SUD) C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 11/6/2017 9/6/2017 111312017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C250 MALIGNANT NEOPLASM PROFESSIONAL $120.11 $299.00 MALE SUBSCRIBER RUT BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED IELJ EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER J 11/6/2017 9/6/2017 11/3/2017 G8420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 v AND NO FOLLOW -UP PLAN IS REQUIRED OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL 11/6/2017 9/6/2017 11/3/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS U 11/6/2017 9/6/2017 11/3/2017 G8731 PAIN ASSESSMENT USING ASTANDARDIZED T00L 15 C250 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 DOCUMENTEDAS NEGATIVE, NO FOLLOW- UP PLAN OF HEAD OF PANCREAS OUTPATIENT /HOSPITAL REQUIRED 11/6/2017 9/15/2017 11/3/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES OTHER MEDICAL $154.42 $437.00 MALE SUBSCRIBER RO1 BCC 3559 THERAPEUTIC); WITH IMAGING GUIDANCE N 11/6/2017 9/19/2017 11/3/2017 1036F CURRENTTOBACCO NON - USER (CAD, CAP, CORD, PV) R188 OTHER ASCITES PROFESSIONAL OFFICE SO.DD $0.01 MALE SUBSCRIBER RDl BCC hl 3559 (DM) (IBM 11/6/2017 9/19/2017 11/3/20171126F INTERMEDIATE " DELAY" OF ANY FLAP, PRIMARY "DELAY" 8188 OTHER ASCITES PROFESSIONAL OFFICE $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR DIRECT FLAP, AT EYELIDS NOSE, ._ C.7.f 11/6/2017 9/19/2017 11/3/2017 99204 OFFICE 0R OTHER OUTPATIENT VISIT FOR THE R188 OTHER ASCITES PROFESSIONAL OFFICE $254.11 $507.00 MALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF ANEW PATIENT, y� WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREH ENSIVE N EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR t 11/6/2017 9/19/2017 11/3/2017 68420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS R188 OTHER ASCITES PROFESSIONAL OFFICE $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 7 AND NO FOLLOW -UP PLAN IS REQUIRED 11/6/2017 9/19/2017 11/3/2017 68427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN 8188 OTHER ASCITES PROFESSIONAL OFFICE $0.00 $0.01 MALE SUBSCRIBER RD1 BCC 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR REVIEWED THE PATIENT'S CURRENT MEDICATIONS } fl 11/6/2017 9/19/2017 11/3/2017 G8731 PAIN ASSESSMENT USING A STANDARDIZED T00L 15 R198 OTHER ASCITES PROFESSIONAL OFFICE $0.00 $0.01 MALE SUBSCRIBER R01 BCC 3559 S. CL DOCUMENTED AS NEGATIVE, NO FOLLOW -UP PLAN Q, REQUIRED < 11/9/2017 8/30/2017 11/3/2017 77300 BASIC RADIATION D0SIMETRY CALCULATION, CENTRAL C250 MALIGNANT NEOPLASM OTHER MEDICAL $494.70 $1,200.00 MALE SUBSCRIBER R01 BCC 3559 AXIS DEPTH DOSE CALCULATION, TDF, NED, GAP OF HEAD OF PANCREAS CALCULATION, OFF AXIS FACTOR, TISSUE rf INHOMOGENEITY FACTORS, CALCULATION OF NON - IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN F PRESCRIBED BY THE TREATING 11/9/2017 8/30/2017 11/3/2017 77301 INTENSITY MODULATED RADIOTHERAPY PLAN, C250 MALIGNANT NEOPLASM OTHER MEDICAL $640.55 $1,538.00 MALE SUBSCRIBER R01 BCC 3559 INCLUDING DOSE- VOLUME HISTOGRAMS FOR TARGET OF HEAD OF PANCREAS AND CRITICAL STRUCTURE PARTIAL TOLERANCE _ SPECIFICATIONS 11/9/2017 8/30/2017 11/3/2017 77338 Multi - leaf collimator(MLE)device(s( for ntensity C250 MALIGNANT N EOPLASM OTHER MEDICAL $365.25 $829.00 MALE SUBSCRIBER R01 BCC 3559 modulated radiation therapy (IMRT), design and OF HEAD OF PANCREAS construction per IMRT plan [L 11/10/2017 9/6/2017 11/3/2017 99213 OFFICE 0R OTHER OUTPATIENT VISIT FOR THE C250 MALIGNANT NEOPLASM OTHER MEDICAL $78.63 $193.00 MALE SUBSCRIBER R01 BCC 3559 LJJ EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF HEAD OF PANCREAS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY U COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD ILLJ 0 Sub Total $317,480.50 $1,011,644.63 1.875E +10 1/3/2017 12/13/2016 12/31/2016 ** * * * ** * * * ** $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 J 1/5/2017 12/10/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $205.85 FEMALE SPOUSE 16CC 3559 MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), v INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL f' PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND LLJ NURSING VISITS CODED SEPARATELY), 1/5/2017 12/11/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC 3559 (' MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), N ,,,, 1/5/2017 12/12/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/13/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/14/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/15/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/16/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/17/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/18/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/19/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/20/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/21/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/22/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/23/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/24/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/25/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/26/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/27/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/28/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/29/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCD MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/5/2017 12/29/2016 1/4/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R509 FEVER, UNSPECIFIED PROFESSIONAL $11.37 $34.00 FEMALE SPOUSE 1 BCC FRONTAL INPATIENT /HOSPITAL 1/5/2017 12/29/2016 1/4/2017 93971 DUPLEXSCAN OF EXTREMITYVEINS INCLUDING R509 FEVER, UNSPECIFIED PROFESSIONAL $28.51 $84.00 FEMALE SPOUSE 1 BCC RESPONSES TO COMPRESSION AND OTHER MANEUVERS; INPATIENT /HOSPITAL UNILATERAL OR LIMITED STUDY 1/5/2017 12/30/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 11512017 12/31/2016 1/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCD MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/11/2017 12/29/2016 1/9/2017 - - A4151 SEPSIS DUE TO HOSPITAL INPATIENT 12/29/2016 1/3/2017 $8,580.14 $11,681.30 FEMALE SPOUSE 1 BCC ESCHERICHIA COLI [E. COLT] 1/17/2017 10121/2016 1/10/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $11,849.60 $29,624.00 FEMALE SPOUSE 1 BCC ANTINEOPLASTIC CHEMOTHERAPY 1/23/2017 12/2/2016 1/9/2017 - - C7800 SECONDARY MALIGNANT HOSPITAL OUTPATIENT $1,083.60 $30,430.00 FEMALE SPOUSE 1 BCC NEOPLASM OF UNSPECIFIED LUNG 112312017 12/29/2016 112012017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION L03115 CELLULITIS OF RIGHT PROFESSIONAL $267.47 $1,793.00 FEMALE SPOUSE 1 BCC AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LOWER LIMB OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF TH E PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 1/30/2017 1/1/2017 1/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $98.45 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/30/2017 1/2/2017 1/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $10.40 FEMALE MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), 1 BCC $0.00 $8.95 FEMALE SPOUSE INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/30/2017 1/3/2017 1/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/30/2017 1/4/2017 1/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/30/2017 1/5/2017 1/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/30/2017 1/6/2017 1/7/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C499 MALIGNANT NEOPLASM PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF CONNECTIVE AND OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SOFT TISSUE, DIOXIDE (BICARBONATE)(82374), CHLORIDE (82435), UNSPECIFIED CREATININE (82565(, GLUCOSE (82947), PHOSPHATASE, ALKALINE 184075), POTASSIUM (84132), PROTEIN, 1/30/2017 1/6/2017 1/7/2017 83735 MAGNESIUM C499 MALIGNANT NEOPLASM PROFESSIONAL OF CONNECTIVE AND OUTPATIENT /HOSPITAL SOFT TISSUE, UNSPECIFIED 1/30/2017 1/6/2017 1/7/2017 85025 BLOOD COUNT; COMPLETE(CBCE AUTOMATED(HGB, C499 MALIGNANT NEOPLASM PROFESSIONAL HUT, RBC,WBC AND PLATELET COUNT) AND AUTOMATED OF CONNECTIVE AND OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT SOFT TISSUE, UNSPECIFIED 1/30/2017 1/6/2017 1/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/30/2017 1/6/2017 1/11/20171036F CURRENTTOBACCO NON-USER (CAD, CAP, COPD, PV) C414 MALIGNANT NEOPLASM PROFESSIONAL (DM)(IBD( OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 1/30/2017 1/6/2017 1111120171126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C414 MALIGNANT NEOPLASM PROFESSIONAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OF PELVIC BONES, OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, SACRUM AND COCCYX $0.00 $8.95 FEMALE SPOUSE 1 BCC $0.00 $8.95 FEMALE SPOUSE 1 BCC $0.00 $8.95 FEMALE SPOUSE 1 BCC $0.00 $8.95 FEMALE SPOUSE 1 BCC $0.00 $26.00 FEMALE SPOUSE 1 BCC $0.00 $10.80 FEMALE SPOUSE 1 BCC $0.00 $10.40 FEMALE SPOUSE 1 BCC $0.00 $8.95 FEMALE SPOUSE 1 BCC $0.00 $0.01 FEMALE SPOUSE 1 BCC $0.00 $0.01 FEMALE SPOUSE 1 BCC 1/30/2017 1/6/2017 1/11/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C414 MALIGNANT NEOPLASM PROFESSIONAL $0.01 FEMALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC OF PELVIC BONES, OUTPATIENT /HOSPITAL SPOUSE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $0.00 SACRUM AND COCCYX SPOUSE 1 BCC COMPONENTS: A DETAILED HISTORY; A DETAILED $236.00 FEMALE SPOUSE 1 BCC $0.00 EXAMINATION; MEDICAL DECISION MAKING OF SPOUSE 1 BCC MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 1/30/2017 1/6/2017 1/11/201768419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C414 MALIGNANT NEOPLASM PROFESSIONAL FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 1/30/2017 1/6/2017 1/11/201768427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C414 MALIGNANT NEOPLASM PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF PELVIC BONES, OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS SACRUM AND COCCYX 113012017 1/6/2017 1/11/2017 G8484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C414 MALIGNANT NEOPLASM PROFESSIONAL REASON NOT GIVEN OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 1/30/2017 1/6/2017 1/11/201768731 PAIN ASSESSMENT USING A STANDARDIZED TOOL 15 C414 MALIGNANT NEOPLASM PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UPPLAN OF PELVIC BONES, OUTPATIENT /HOSPITAL REQUIRED SACRUM AND COCCYX 1/30/2017 1/6/2017 1/11/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST 1189 PNEUMONIA, PROFESSIONAL MATERIALS) UNSPECIFIED ORGANISM OUTPATIENT /HOSPITAL 1/30/2017 1/7 /2017 1/11/2017 S5501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/30/2017 1/8/2017 1/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 113012017 119/2017 1/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ 8232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/30/2017 1/10/2017 1/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 1/30/2017 1/11/2017 1/17/2017 71250 COMPUTED TOMOGRAPHY, THORAX; WITHOUT R0602 SHORTNESS OF BREATH PROFESSIONAL CONTRAST MATERIAL OUTPATIENT /HOSPITAL $0.00 $299.00 FEMALE SPOUSE 1 BCC $0.00 $0.01 FEMALE SPOUSE 1 BCC $0.00 $0.01 FEMALE SPOUSE 1 BCC $0.00 $0.01 FEMALE SPOUSE 1 BCC $0.00 $0.01 FEMALE SPOUSE 1 BCC $0.00 $236.00 FEMALE SPOUSE 1 BCC $0.00 $8.95 FEMALE SPOUSE 1 BCC $0.00 $8.95 FEMALE SPOUSE 1 BCC $0.00 $8.95 FEMALE SPOUSE 1 BCC $0.00 $8.95 FEMALE SPOUSE 1 BCC $0.00 $235.00 FEMALE SPOUSE 1 BCC 1/30/2017 1/12/2017 1/26/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R509 FEVER, UNSPECIFIED PROFESSIONAL $18.00 FEMALE SPOUSE AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 3559 $0.00 OUTPATIENT /HOSPITAL 1 BCC THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS $0.00 $13.00 FEMALE SPOUSE 1 BCC 3559 IMPOSED BY THE URGENCY OF TH E PATIENT'S CLINICAL $18.00 FEMALE SPOUSE 1 BCC 3559 $0.00 CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE 1 BCC 3559 HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 1/30/2017 1/13/2017 1/26/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R509 FEVER, UNSPECIFIED PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF TH E PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A CDMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 113012017 1/14/2017 112012017 - - N390 URINARY TRACT HOSPITAL OUTPATIENT INFECTION, SITE NOT SPECIFIED 1/30/2017 1/14/2017 1/26/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 8509 FEVER, UNSPECIFIED PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DELIS 1/31/2017 1/11/2017 1/27/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL N390 URINARY TRACT PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL (823101 CARBON DIOXIDE (82374) CHLORIDE (82435) SPECIFIED CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 1/31/2017 1/11/2017 1127/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE N390 URINARY TRACT PROFESSIONAL THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, SPECIFIED ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) 1/31/2017 1/11/2017 1/27/2017 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR N390 URINARY TRACT PROFESSIONAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INFECTION, SITE NOT OUTPATIENT /HOSPITAL LEUI(OCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, SPECIFIED UROBILINDGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 1/31/2017 1/11/2017 1/27/2017 83520 IMMUNOASSAY, ANALYTE, QUANTITATIVE; NOT N390 URINARY TRACT PROFESSIONAL OTHERWISE SPECIFIED INFECTION, SITE NOT OUTPATIENT /HOSPITAL SPECIFIED 1/31/2017 1/11/2017 1/27/2017 83735 MAGNESIUM N390 URINARY TRACT PROFESSIONAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL SPECIFIED 1/31/2017 1/11/2017 1127/2017 84145 Pl,lllllronin(PUT) N390 URINARY TRACT PROFESSIONAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL SPECIFIED 1/31/2017 1/11/2017 1/27/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, N390 URINARY TRACT PROFESSIONAL PUT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED INFECTION, SITE NOT OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT SPECIFIED 1/31/2017 1111/2017 1/27/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION N390 URINARY TRACT PROFESSIONAL AND PRESUMPTIVE IDENTIFICATION OF ISOLATES INFECTION, SITE NOT OUTPATIENT /HOSPITAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) SPECIFIED $203.94 $400.00 FEMALE SPOUSE 1 BCC $20334 $400.00 FEMALE SPOUSE 1 BCC $12,010.24 $27,253.00 FEMALE SPOUSE 1 BCC $203.94 $400.00 FEMALE SPOUSE 1 BCC $0.00 $35.00 FEMALE SPOUSE 1 BCC $0.00 $35.00 FEMALE SPOUSE 1 BCC $0.00 $12.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $18.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $13.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $13.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $18.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $23.00 FEMALE SPOUSE 1 BCC 3559 1/31/2017 1/11/2017 1/27/2017 87088 WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF N390 URINARYTRACT PROFESSIONAL $0.00 EACH ISOLATE, URINE 1 BCC INFECTION, SITE NOT OUTPATIENT /HOSPITAL $14.00 FEMALE SPOUSE 1 BCC 3559 SPECIFIED $35.00 FEMALE SPOUSE 1/31/2017 1/12/2017 1/27/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL N390 URINARYTRACT PROFESSIONAL 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL $35.00 FEMALE INFECTION, SITE NOT OUTPATIENT /HOSPITAL 3559 (823101 CARBON DIOXIDE (82374) CHLORIDE (82435) SPECIFIED CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM 184295) UREA NITROGEN (BUN) (84520) 1/31/2017 1/12/2017 1127/2017 80076 HEPATIC FUNCTION PANELTHIS PANEL MUST INCLUDE N390 URINARYTRACT PROFESSIONAL THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, SPECIFIED ALKALINE (94075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 1131/2017 1/12/2017 1/27/2017 83690 LIPASE N390 U I NARY TRACT PROFESSIONAL INFECTION, SITE NOT OUTPATIENT/HOSPIFAL SPECIFIED 113112017 1/12/2017 112712017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, N390 URINARY TRACT PROFESSIONAL HOT BBC, WBC AND PLATELET COUNT) AND AUTOMATED INFECTION, SITE NOT OUTPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT SPECIFIED 1/31/2017 1/12/2017 1/27/2017 85610 PROTHROMBIN TIME; N390 URINARY TRACT PROFESSIONAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL SPECIFIED 1/31/2017 1/13/2017 1/27/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL N390 URINARY TRACT PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) SPECIFIED CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM 184295) UREA NITROGEN (BUN) (84520) 1/31/2017 1/13/2017 1/27/2017 80016 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE N390 URINARY TRACT PROFESSIONAL THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, SPECIFIED ALKALINE (94075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) 113112017 1/13/2017 1/27/2017 83690 LIPASE N390 URINARY TRACT PROFESSIONAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL SPECIFIED 1/31/2017 1/13/2017 1/27/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, N390 URINARY TRACT PROFESSIONAL HOT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED INFECTION, SITE NOT OUTPATIENT/HOSPITAL DIFFERENTIAL WBC COUNT SPECIFIED 1/31/2017 1/13/2017 1/27/2017 85610 PROTHROMBIN TIME; N390 URINARY TRACT PROFESSIONAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL SPECIFIED 1/31/2017 1/14/2017 1/27/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL N390 URINARY TRACT PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) SPECIFIED CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 1/31/2017 1/14/2017 1127/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE N390 URINARY TRACT PROFESSIONAL THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, SPECIFIED ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) $0.00 $35.00 FEMALE SPOUSE $0.00 $35.00 FEMALE SPOUSE C.7.f 1 BCC 3559 w Z 1 BCC 3559 N $0.00 $35.00 FEMALE SPOUSE 1 BCC t ;til $0.00 $17.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $18.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $14.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $35.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $35.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $17.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $18.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $14.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $35.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $35.00 FEMALE SPOUSE 1 BCC 3559 rl 1/31/2017 1/14/2017 1/27/2017 85610 PROTHROMBIN TIME; N390 URINARY TRACT PROFESSIONAL $18.00 FEMALE SPOUSE 1 BCC INFECTION, SITE NOT OUTPATIENT /HOSPITAL SPOUSE 1 BCC SPOUSE SPECIFIED 3559 2/1/2017 1/14/2017 1/27/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED)HGB, N390 URINARY TRACT PROFESSIONAL $1.80 HOT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED SPOUSE INFECTION, SITE NOT OUTPATIENT /HOSPITAL $114.98 DIFFERENTIAL W BC COUNT SPOUSE SPECIFIED 3559 2/1/2017 1/25/2017 1/26/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C499 MALIGNANT NEOPLASM OTHER MEDICAL OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED 2/10/2017 1/11/2017 2/2/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 N390 URINARY TRACT PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY INFECTION, SITE NOT OUTPATIENT /HOSPITAL SPECIFIED 2/13/2017 112712017 1/31/20171036F CURRENTTOBACCO NON- USER (CAD, CAP, CORD, PV) C414 MALIGNANT NEOPLASM PR0FE55IONAL (DM)(IBD) OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 2/13/2017 1/27/2017 1/31/20171126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C414 MALIGNANT NEOPLASM PROFESSIONAL OF SMALL FLAP, DR SECTIONING PEDICLE OF TUBED OR OF PELVIC BONES, OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, SACRUM AND COCCYX 2/13/2017 1/27/2017 1/31/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C414 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PELVIC BONES, OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SACRUM AND COCCYX COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 2/13/2017 1/27/2017 1/31/201768419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C414 MALIGNANT NEOPLASM PROFESSIONAL FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 2/13/2017 1/27/2017 1/31/201768427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C414 MALIGNANT NEOPLASM PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF PELVIC BONES, OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS SACRUM AND COCCYX 2/13/2017 1127/2017 1/31/201768484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C414 MALIGNANT NEOPLASM PROFESSIONAL REASON NOT GIVEN OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 2/13/2017 1/27/2017 1/31/2017 G8732 NO DOCUMENTATION OF PAIN ASSESSMENT C414 MALIGNANT NEOPLASM PROFESSIONAL OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 2/13/2017 21112017 2/2/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C499 MALIGNANT NEOPLASM OTHER MEDICAL OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED 2/13/2017 2/3/2017 2/9/2017 99254 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED L0311S CELLULITIS OF RIGHT PROFESSIONAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS:A LOWER LIMB INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED C $0.00 $14.00 FEMALE SPOUSE 1 BCC $0.00 $18.00 FEMALE SPOUSE 1 BCC $1.80 $56.00 FEMALE SPOUSE 1 BCC C.7.f 3559 w Z 3559 N m w 3559 $5.83 $98.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $81.33 $299.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 ECG 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $1.80 $56.00 FEMALE SPOUSE 1 BCC 3559 $114.98 $415.00 FEMALE SPOUSE 1 BCC 3559 E 2/13/2017 2/6/2017 2/9/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL $47.16 $181.00 FEMALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 2/17/2017 1/12/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $631 $277.45 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/13/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/14/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/15/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2117/2017 1/16/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/17/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/18/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/19/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/20/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/21/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/22/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/23/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/24/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/25/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/26/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/27/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/28/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/29/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/30/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 1/31/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 2/1/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 2/2/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 2/3/2017 2/8/2017 73630 RADIOLDGIC EXAMINATION, FOOT; COMPLETE, 599921A UNSPECIFIED INJURY OF PROFESSIONAL MINIMUM OF THREE VIEWS RIGHT FOOT, INITIAL OUTPATIENT /HOSPITAL ENCOUNTER 2/17/2017 2/3/2017 2/9/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, Z452 ENCOUNTER FOR PROFESSIONAL FRONTAL ADJUSTMENT AND OUTPATIENT /HOSPITAL MANAGEMENT OF VASCULAR ACCESS DEVICE $6.71 $8.95 FEMALE SPOUSE 1 BCC $6.71 $8.95 FEMALE SPOUSE 1 BCC $6.71 $8.95 FEMALE SPOUSE 1 BCC $6.71 $8.95 FEMALE SPOUSE 1 BCC $6.71 $8.95 FEMALE SPOUSE 1 BCC $6.71 $8.95 FEMALE SPOUSE 1 BCC $6.71 $8.95 FEMALE SPOUSE 1 BCC $11.43 $43.00 FEMALE SPOUSE 1 BCC $11.88 $41.00 FEMALE SPOUSE 1 BCC 2/17/2017 2/3/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 2/4/2017 2/9/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL $47.16 $181.00 FEMALE SPOUSE 1BCD EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LOWER LIMB INPATIENT / HDSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 2/17/2017 2/4/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 2/5/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 2/6/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIESAND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2117/2017 2/7/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 2/8/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 2/9/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $6.71 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/17/2017 2/10/2017 2/11/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 2/20/2017 2/15/2017 2/16/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C499 MALIGNANT NEOPLASM OTHER MEDICAL OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED 2/21/2017 12/30, 16 2/20/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A419 SEPSIS, UNSPECIFIED OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH ORGANISM REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING DF MODERATE COMPLEXITY. COUNSELING AND /OR 2/21/2017 12/31/2016 212012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A419 SEPSIS, UNSPECIFIED OTHER MEDICAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH ORGANISM REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 2/27/2017 1/1/2017 2/20/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A419 SEPSIS, UNSPECIFIED OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH ORGANISM REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITV. COUNSELING AND /OR 2/27/2017 1/2/2017 212012017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A419 SEPSIS, UNSPECIFIED OTHER MEDICAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH ORGANISM REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 2/27/2017 1/3/2017 212012017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE A419 SEPSIS, UNSPECIFIED OTHER MEDICAL THAN 3D MINUTES ORGANISM 2/27/2017 2/3/2017 2/20/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION L03115 CELLULITIS OF RIGHT OTHER MEDICAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LOWER LIMB THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR 2/27/2017 2/5/2017 2/20/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RI6HT OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB REQUIRES AT LEAST 2 OF THESE 3 KEY COMPON ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $6.71 $8.95 FEMALE SPOUSE 1 BCC $1.80 $56.00 FEMALE SPOUSE 1 BCC $75.14 $152.00 FEMALE SPOUSE 1 BCC $75.14 $152.00 FEMALE SPOUSE 1 BCC $5635 $153.00 FEMALE SPOUSE 1 BCC $56.35 $153.00 FEMALE SPOUSE 1 BCC $81.09 $227.00 FEMALE SPOUSE 1 BCC $62.59 $397.00 FEMALE SPOUSE 1 BCC $52.09 $343,00 FEMALE SPOUSE 1 BCC 2/27/2017 2/17/2017 2121120171036F CURRENTTOBACCO NON- USER(CAD, CAP,COPD, PV) C414 MALIGNANT NEOPLASM PROFESSIONAL FEMALE SPOUSE (CHU BIBB) $299.00 OF PELVIC BONES, OUTPATIENT /HOSPITAL SPOUSE 1 BCC 3559 $0.00 SACRUM AND COCCYX SPOUSE 2/27/2017 2/17/2017 2/21/20171126F INTERMEDIATE "DEIRY" OF ANY FLAP, PRIMARY "DELAY" C414 MALIGNANT NEOPLASM PROFESSIONAL 3559 $0.00 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR SPOUSE OF PELVIC BONES, OUTPATIENT /HOSPITAL $0.00 $18.00 FEMALE DIRECT FLAP, AT EYELIDS NOSE, 1 BCC SACRUM AND COCCYX $0.00 2/27/2017 2/17/2017 2/21/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C414 MALIGNANT NEOPLASM PROFESSIONAL SPOUSE 1 BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED $0.00 OF PELVIC BONES, OUTPATIENT /HOSPITAL 1 BCC 3559 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $12.00 FEMALE SACRUM AND COCCYX 1 BCC 3559 $0.00 COMPONENTS: A DETAILED HISTORY; A DETAILED SPOUSE 1 BCC 3559 $0.00 $16.00 FEMALE EXAMINATION; MEDICAL DECISION MAKING OF 1 BCC 3559 $0.00 $35.00 FEMALE SPOUSE MODERATE COMPLEXITY. COUNSELING AND /OR 3559 COORDINATION OF CARE WITH OTHER 2/27/2017 211712017 212112017 G8419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C414 MALIGNANT NEOPLASM PROFESSIONAL FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 2/27/2017 2/17/2017 2/21/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C414 MALIGNANT NEOPLASM PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF PELVIC BONES, OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS SACRUM AND COCCYX 2/27/2017 2/17/2017 212112017 G8434 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C414 MALIGNANT NEOPLASM PROFESSIONAL REASON NOT GIVEN OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 2/27/2017 2/17/2017 2/21/2017138731 PAIN ASSESSMENT USING A STANDARDIZED TOOL IS C414 MALIGNANT NEOPLASM PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN OF PELVIC BONES, OUTPATIENT /HOSPITAL REQUIRED SACRUM AND COCCYX 3/1/2017 1/11/2017 2/15/2017 83605 LACTATE (LACTIC ACID) N390 URINARY TRACT PROFESSIONAL INFECTION, SITE NOT OUTPATIENT /HOSPITAL SPECIFIED 3/1/2017 2/2/2017 2/17/2017 80051 ELECTROLYTE PANEL L03115 CELLULITIS OF RIGHT PROFESSIONAL LOWER LIMB INPATIENT /HOSPITAL 3/1/2017 2/2/2017 2/17/2017 82565 CREATININE; BLOOD L03115 CELLULITIS OF RIGHT PROFESSIONAL LOWER LIMB INPATIENT /HOSPITAL 3/1/2017 2/2/2017 2/17/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT L03115 CELLULITIS OF RIGHT PROFESSIONAL STRIP) LOWER LIMB INPATIENT /HOSPITAL 3/1/2017 2/2/2017 2/17/2017 84520 UREA NITROGEN; QUANTITATIVE L03115 CELLULITIS OF RIGHT PROFESSIONAL LOWER LIMB INPATIENT /HOSPITAL 3/1/2017 2/2/2017 2/17/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, L03115 CELLULITIS OF RIGHT PROFESSIONAL HCT BBC, WBC AND PLATELET COUNT) AND AUTOMATED LOWER LIMB INPATIENT /HOSPITAL DIFFERENTIAL W BE COUNT 3/1/2017 2/3/2017 2/17/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR L03115 CELLULITIS OF RIGHT PROFESSIONAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LOWER LIMB INPATIENT / HDSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 3/1/2017 2/3/2017 2/17/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION L03115 CELLULITIS OF RIGHT PROFESSIONAL AND PRESUMPTIVE IDENTIFICATION OF ISOLATES LOWER LIMB INPATIENT / HDSPITAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) 3/1/2017 2/3/2017 2/17/2017 87077 CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL L03115 CELLULITIS OF RIGHT PROFESSIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, LOWER LIMB INPATIENT /HOSPITAL EACH ISOLATE 3/1/2017 21312017 2/17/2017 87088 WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF L03115 CELLULITIS OF RIGHT PROFESSIONAL EACH ISOLATE, URINE LOWER LIMB INPATIENT /HOSPITAL $0.00 $0.01 FEMALE SPOUSE $0.00 $0.01 FEMALE SPOUSE $8133 $299.00 FEMALE SPOUSE 1 BCC 1 BCC 1 BCC C.7.f 3559 w N 3559 Q! 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $23.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $41.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $18.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $14.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $14.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $18.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $12.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $23.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $16.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $35.00 FEMALE SPOUSE 1 BCC 3559 C.7.f 3/1/2017 2/3/2017 2/17/2017 87186 SUSCEPTIBILITY STUD I ES, ANTI MIC ROD ALAGENT; L03115 CELLULITIS OF RIGHT PROFESSIONAL $0.00 $17.00 FEMALE SPOUSE 1BCC 3559 MICRODILUTION ORAGAR DILUTION (MINIMUM LOWER LIMB INPATIENT /HOSPITAL INHIBITORY CONCENTRATION AMICA" OR BREAKPOINT), {S! EACH MULTI - ANTIMICROBIAL, PER PLATE N m 3/1/2017 2/4/2017 2/17/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, L03115 CELLULITIS OF RIGHT PROFESSIONAL $0.00 $18.00 FEMALE SPOUSE 1 BCC 3559 HCF, RBC,WBCAND PLATELETCOUNT) LOWER LIMB INPATIENT /HOSPITAL 3/1/2017 2/17/2017 2/18/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C55 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $26.00 FEMALE SPOUSE 1 BCC 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF UTERUS, PART OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON UNSPECIFIED DIOXIDE )BICARBONATE)(82374), CHLORIDE (82435), t6 CREATININE( 92565), GLUCOSE (92947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, W 3/1/2017 2/17/2017 2/18/2017 83735 MAGNESIUM C55 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $10.80 FEMALE SPOUSE 1 BCC 3559 } OF UTERUS, PART OUTPATIENT /HOSPITAL CL UNSPECIFIED Q, Q 3/1/2017 2/1]/201] 2/18/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED)HGB, C55 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $10.40 FEMALE SPOUSE 1 BCC 3559 v HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED OF UTERUS, PART OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT UNSPECIFIED rf 3/6/2017 2/22/2017 2/24/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C499 MALIGNANT NEOPLASM OTHER MEDICAL $1.80 $56.00 FEMALE SPOUSE 1 BCC 3559 OF CONN ECTIVE AND W SOFTTISSUE, � UNSPECIFIED Z 3/13/2017 1/6/2017 2/7/2017 - - 1189 PNEUMONIA, HOSPITAL OUTPATIENT $3,310.17 $5,511.00 FEMALE SPOUSE 1 BCC 3559 UNSPECIFIED ORGANISM 3/13/2017 1/27/2017 2/10/2017 - - C7800 SECONDARY MALIGNANT HOSPITAL OUTPATIENT $1,343.20 $3,358.00 FEMALE SPOUSE 1 BCC 3559 NEOPLASM OF IL UNSPECIFIED LUNG uj 3/13/2017 2/2/2017 2/13/2017 - - L03115 CELLULITIS OF RI6HT HOSPITAL INPATIENT 2/2/2017 2/6/2017 $3,943.50 $32,536.00 FEMALE SPOUSE 1 BCC 3559 U`J LOWER LIMB 3113/2017 2/27/2017 3/6 /2017 * * ° "* ' * "* * * " ** e..xx * * "' $70.00 $150.00 FEMALE SPOUSE 1 BCC 3559 3/13/2017 3/3/201] 3/6/2017 .xxxx * * * ** .xxxx . * * ** * * * ** $]0.00 $150.00 FEMALE SPOUSE 1 BCC 3559 3/1312017 3/6/2017 3/612017 * * *" * * * ** * *` ** " * * ** * * * ** $70.00 $150.00 FEMALE SPOUSE 1 BCC 3559 LLJ 3/13/2017 3/8/2017 3/9/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C499 MALIGNANT NEOPLASM OTHER MEDICAL $1.80 $56.00 FEMALE SPOUSE 1 BCC 3559 OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED v 3/17/2017 2/17/2017 3/8/2017- - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $1,738.40 $4,346.00 FEMALE SPOUSE 16CC 3559 f' ANTINEOPLASTIC CHEMOTHERAPY LLJ 3/17/2017 2/24/2017 3/8/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $1,051.61 $30,517.00 FEMALE SPOUSE 1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY (' 3/17/2017 3/10/2017 3/16/2017 * * * ** * * * ** * * * ** * * * ** * * * ** $108.44 $299.06 FEMALE SPOUSE 1 BCC 3559 3/28/2017 3/24/201] 3/27/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C499 MALIGNANT NEOPLASM OTHER MEDICAL $1.80 $56.00 FEMALE SPOUSE 1 BCC 3559 OF CONNECTIVE AND SOFT TISSUE, N UNSPECIFIED f'V 3/30/2011 3/10/2017 3/29/2017 *' * ** *xxx. * * * ** x *..x * °.xx $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 = 3/30/201] 3/15/201] 3/29/2017 'xxxx * * * +* .xxxx . * + *" * * * *+ $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 y 3/30/2017 3/22/2017 3/29/2017 * * " ** ..xxx .xx ++ x..xx ..xrx $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 3/30/2017 3/29/2017 3/29/2017 * * * "* * * *'* * * " ** x. * *' * * *" $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 3/30/2017 12/29/2016 3/28/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FORTH EVALUATION A419 SEPSIS, UNSPECIFIED PROFESSIONAL AND MANAGEMENTOF A PATIENT, WHICH REQUIRES ORGANISM INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 4/5/2017 3/4/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/5/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/6/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/7/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/8/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/9/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/10/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), $143.77 $290.00 FEMALE SPOUSE 1 BCC $8.95 $277.45 FEMALE SPOUSE 1 BCC $8.95 $8.95 FEMALE SPOUSE 1 BCC $8.95 $8.95 FEMALE SPOUSE 1 BCC $8.95 $8.95 FEMALE SPOUSE 1 BCC $8.95 $8.95 FEMALE SPOUSE 1 BCC $8.95 $8.95 FEMALE SPOUSE 1 BCC $8.95 $8.95 FEMALE SPOUSE 1 BCC 4/5/2017 3/11/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/12/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/13/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/14/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/15/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/16/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/17/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/18/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/19/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/20/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/21/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/22/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/23/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/24/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/25/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/26/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/27/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/28/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/29/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/30/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 3/31/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 4/1/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/5/2017 4/2/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/4/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $277.45 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/5/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/6/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/7/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/8/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/9/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/10/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/11/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/12/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/13/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/14/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/15/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/16/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/17/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/18/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/19/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/20/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/21/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 3/22/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $0.00 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND 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MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 4/1/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/6/2017 4/2/2017 4/4/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 4/10/2017 3/10/2017 4/7/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 4/10/2017 4/5/2017 4/8/2017 72170 RADIOLOGIC EXAMINATION, 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COUNSELING AND /OR COORDINATION OF CARE WITH OTHER C.7.f $0.00 $8.95 FEMALE SPOUSE 1 BCC 3559 41 N Q! $0.00 $8.95 FEMALE SPOUSE 1 BCC 3559 fl } $0.00 $8.95 FEMALE SPOUSE 1 BCC 3559 53 $0.00 $8.95 FEMALE SPOUSE 1 BCC 3559 $0.00 $8.95 FEMALE SPOUSE 1 BCC 3559 $1,256.66 $3,307.00 FEMALE SPOUSE 1 BCC 3559 $13.94 $70.00 FEMALE SPOUSE 1 BCC 3559 $173.76 $711.00 FEMALE SPOUSE 1 BCC 3559 $94.93 $385.00 FEMALE SPOUSE 1 BCC 3559 $20043 $225.00 FEMALE SPOUSE 1 BCC 3559 C.7.f 4/11/2017 4/5/2017 411012017 - - C495 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $7,115.76 $9,883.00 FEMALE SPOUSE 1 BCC 3559 OF CONN ECTIVE AND W SOFTTISSUE OF PELVIS U) N 4/12/2017 3/17/2017 4/7/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $1,308.72 $36,327.00 FEMALE SPOUSE 1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 4/13/2017 1/11/2017 4/11/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R000 TACHYCARDIA, PROFESSIONAL $278.09 $775.00 FEMALE SPOUSE 1 BCC 3559 AND MANAGEMENTOFA PATIENT, WHICH REQUIRES UNSPECIFIED OUTPATIENT /HOSPITAL r THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS "a IMPOSED BY THE URGENCY OF TH E PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS } fl 4/14/2017 4/5/2017 4/13/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M6291 MUSCLE WEAKNESS PROFESSIONAL $134.95 $144.00 FEMALE SPOUSE 1BCC 3559 CL EVALUATION AND MANAGEMENTOFAN ESTABLISHED (GENERALIZED) OUTPATIENT /HOSPITAL Q, PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. 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(DM) (IBD) (VALVE) STENOSIS OUTPATIENT /HOSPITAL {jJ 4/24/2017 4/18/2017 4/20/20171126F INTERMEDIATE "DEIAY" DEANY FLAP, PRIMARY "DELAY" 1350 NONRHEUMATIC AORTIC PROFESSIONAL $O.OD $0.01 FEMALE SPOUSE 1BCC 3559 UJ OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR (VALVE) STENOSIS OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, 0 4124/2017 4/18/2017 4/20/2017 1220F PATIENTSCREENED FOR DEPRESSION (SUD) 1350 NONRHEUMATIC AORTIC PROFESSIONAL $0.00 $0.00 FEMALE SPOUSE 1 BCC 3559 (VALVE) STENOSIS OUTPATIENT /HOSPITAL LLJ V 4/24/2017 4/18/2017 412012017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1350 NONRHEUMATIC AORTIC PROFESSIONAL $237.03 $660.00 FEMALE SPOUSE 1 BCC 3559 EVALUATION AND MANAGEMENT OF ANEW PATIENT, (VALVE) STENOSIS OUTPATIENT /HOSPITAL J WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE U EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR CDDRDINATION OF CARE WITH OTHER PROVIDERS OR AGE W M 4/24/2017 4/18/2017 412012017 69419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO 1350 NONRHEUMATIC AORTIC PROFESSIONAL $0.00 $0.01 FEMALE SPOUSE 1BCC 3559 FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN (VALVE) STENOSIS OUTPATIENT /HOSPITAL U Q 4/24/2017 4/18/2017 4/20/201768427 ELIGIBLE PROFESSIDNALATTESTSTO DOCUMENTING IN 1350 NONRHEUMATIC AORTIC PROFESSIONAL $0.00 $0.01 FEMALE SPOUSE 1BCC 3559 THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR (VALVE) STENOSIS OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS N N 4/24/2017 4/18/2017 4/20/2017 68732 NO DOCUMENTATION OF PAIN ASSESSMENT 1350 NONRHEUMATIC AORTIC PROFESSIONAL $0.00 $0.01 FEMALE SPOUSE 1 BCC 3SS9 (VALVE) STENOSIS OUTPATIENT /HOSPITAL C 4/24/2017 4118/2017 4/21/2017 84520 UREA NITROGEN; QUANTITATIVE C414 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $19.00 FEMALE SPOUSE 1 BCC 3559 OF PELVIC BONES, INPATIENT /HOSPITAL SACRUM AND COCCYX 2 4/25/2017 4/18/2017 4/24/2017 - - 1350 NONRHEUMATIC AORTIC HOSPITAL OUTPATIENT R9431 ABNORMAL HOSPITAL OUTPATIENT (VALVE) STENOSIS $8,057.00 FEMALE 4/25/2017 12/31/2016 4/20/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A4150 GRAM - NEGATIVE SEPSIS, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL 4/21/2017 5/1/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1350 DECISION MAKING OF MODERATE COMPLEXITY. PROFESSIONAL $14.56 $32.00 FEMALE SPOUSE COUNSELING AND /OR LEADS; INTERPRETATION AND REPORT ONLY 4/26/2017 1/112017 4/21/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A4150 GRAM - NEGATIVE SEPSIS, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH 4/23/2017 UNSPECIFIED INPATIENT /HOSPITAL A419 REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN HOSPITAL INPATIENT 4/23/2017 4####44# $5,025.30 $27,819.90 FEMALE SPOUSE EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. 4/23/2017 5/3/2017 83605 LACTATE (LACTICACID) A419 COUNSELING AND /OR PROFESSIONAL $0.00 $7.60 FEMALE 4/26/2017 4/18/2017 4/25/2017 93306 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL -TIME WITH 1350 NONRHEUMATIC AORTIC PROFESSIONAL IMAGE DOCUMENTATION(2D), INCLUDES M -MODE INPATIENT /HOSPITAL (VALVE) STENOSIS OUTPATIENT/HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH 4/23/2017 5/3/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION A419 SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH PROFESSIONAL $0.00 $36.40 FEMALE SPOUSE COLOR FLOW DOPPLER ECHOCARDIOGRAPHY AND PRESUMPTIVE IDENTIFICATION OF ISOLATES 4/27/2017 1/2/2017 4/21/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A4150 GRAM - NEGATIVE SEPSIS, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM ED ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN 4/23/2017 5/3/2017 87077 CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL A419 EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL PROFESSIONAL $0.00 $14.00 FEMALE SPOUSE DECISION MAKING OF MODERATE COMPLEXITY. METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, COUNSELING AND /OR INPATIENT /HOSPITAL $797.59 $4,691.71 FEMALE SPOUSE $75.14 $152.00 FEMALE SPOUSE C.7.f 1 BCC 3559 w 1�1 1 BCC 3559 N $75.14 $153.00 FEMALE SPOUSE 1 BCC $111.71 $235.00 FEMALE SPOUSE 1 BCC $75.14 $153.00 FEMALE SPOUSE 1 BCC 5/1/2017 4/23/2017 4128/2017 - - R9431 ABNORMAL HOSPITAL OUTPATIENT $4,627.20 $8,057.00 FEMALE SPOUSE ELECTROCARDIOGRAM [ECG] [EKG[ 5/2/2017 4/21/2017 5/1/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1350 NONRHEUMATIC AORTIC PROFESSIONAL $14.56 $32.00 FEMALE SPOUSE LEADS; INTERPRETATION AND REPORT ONLY (VALVE) STENOSIS OUTPATIENT /HOSPITAL 5/2/2017 4/23/2017 5/1/2017 - - A419 SEPSIS, UNSPECIFIED HOSPITAL INPATIENT 4/23/2017 4####44# $5,025.30 $27,819.90 FEMALE SPOUSE ORGANISM 5/4/2017 4/23/2017 5/3/2017 83605 LACTATE (LACTICACID) A419 SEPSIS, UNSPECIFIED PROFESSIONAL $0.00 $7.60 FEMALE SPOUSE ORGANISM INPATIENT /HOSPITAL 5/4/2017 4/23/2017 5/3/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION A419 SEPSIS, UNSPECIFIED PROFESSIONAL $0.00 $36.40 FEMALE SPOUSE AND PRESUMPTIVE IDENTIFICATION OF ISOLATES ORGANISM OUTPATIENT /HOSPITAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) 5/4/2017 4/23/2017 5/3/2017 87077 CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL A419 SEPSIS, UNSPECIFIED PROFESSIONAL $0.00 $14.00 FEMALE SPOUSE METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, ORGANISM INPATIENT /HOSPITAL EACH ISOLATE 5/4/2017 4/23/2017 5/3/2017 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, A419 SEPSIS, UNSPECIFIED PROFESSIONAL $0.00 $12.00 FEMALE SPOUSE URINE ORGANISM INPATIENT / HDSPITAL S/4/2017 4/23/2017 5/3/2017 87186 SUSCEPTIBILITY STUDIES, ANTIMICROBIALAGENT; A419 SEPSIS, UNSPECIFIED PROFESSIONAL $0.00 $13.00 FEMALE SPOUSE MICRODILUTION OR AGAR DILUTION (MINIMUM ORGANISM INPATIENT /HOSPITAL INHIBITORY CONCENTRATION AMICA OR BREAKP01 NT), EACH MULTI - ANTIMICROBIAL, PER PLATE Is1(: 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC i] 1111: 3559 3559 3559 3559 3559 3559 3559 rl 5/4/2017 4/23/2017 5/3/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST A419 SEPSIS, UNSPECIFIED PROFESSIONAL $10.40 FEMALE INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, 1 BCC ORGANISM OUTPATIENT /HOSPITAL SPOUSE TOTAL (82247), CALCIUM, TOTAL (82310), CARBON $0.00 $6.50 FEMALE SPOUSE 1 BCC DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), $11.30 FEMALE SPOUSE 1 BCC $0.00 CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, SPOUSE 1 BCC $58.36 $203.00 FEMALE ALKALINE (84075), POTASSIUM (84132), PROTEIN, 1 BCC $176.13 $460.00 FEMALE 5/4/2017 4/23/2017 5/3/2017 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR A419 SEPSIS, UNSPECIFIED PROFESSIONAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, ORGANISM OUTPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 5/4/2017 4/23/2017 5/3/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, A419 SEPSIS, UNSPECIFIED PROFESSIONAL HCT, BBC, WBCAND PLATELETCDUNT) AND AUTOMATED ORGANISM OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 5/4/2017 4/23/2017 5/3/2017 85610 PROTHROMBIN TIME; A419 SEPSIS, UNSPECIFIED PROFESSIONAL ORGANISM OVTPATIENT /HOSPITAL 5/4/2017 4/23/2017 5/3/2017 85730 THROMBOPIASTIN TIME, PARTIAL(PTT); PLASMA OR A419 SEPSIS, UNSPECIFIED PROFESSIONAL WHOLE BLOOD ORGANISM OUTPATIENT /HOSPITAL 5/4/2017 4/23/2017 5/3/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, P02, A419 SEPSIS, UNSPECIFIED PROFESSIONAL CO2, HCO3 (INCLUDING CALCULATED 02 SATURATION); ORGANISM OUTPATIENT /HOSPITAL 5/4/2017 4/23/2017 5/3/2017 83605 LACTATE (EACTICACID) A419 SEPSIS, UNSPECIFIED PROFESSIONAL ORGANISM OUTPATIENT /HOSPITAL 5/4/2017 4/24/2017 5/3/2017 93306 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH 1082 RHEUMATIC DISORDERS PROFESSIONAL IMAGE DOCUMENTATION(2D), INCLUDES M -MODE OF BOTH AORTIC AND INPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH TRICUSPID VALVES SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 5/4/2017 4/24/2017 5/3/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1350 NONRHEUMATIC AORTIC PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES (VALVE) STENOSIS INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 5/4/2017 4/26/2017 5/3/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1350 NONRHEUMATIC AORTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH (VALVE) STENOSIS INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM DON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 5/5/2017 4/23/2017 5/3/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION A419 SEPSIS, UNSPECIFIED PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES ORGANISM OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 5/5/2017 4/23/2017 5/4/2017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, R0602 SHORTNESS OF BREATH PROFESSIONAL FRONTAL OVTPATIENT /HOSPITAL $0.00 $26.00 FEMALE SPOUSE 1 BCC $0.00 $6.00 FEMALE SPOUSE 1 BCC $0.00 $10.40 FEMALE SPOUSE 1 BCC $0.00 $4.30 FEMALE SPOUSE 1 BCC $0.00 $6.50 FEMALE SPOUSE 1 BCC $0.00 $11.30 FEMALE SPOUSE 1 BCC $0.00 $7.60 FEMALE SPOUSE 1 BCC $58.36 $203.00 FEMALE SPOUSE 1 BCC $176.13 $460.00 FEMALE SPOUSE 1 BCC $62.88 $160.00 FEMALE SPOUSE 1 BCC $186.72 $670.00 FEMALE SPOUSE 1 BCC $15.84 $41.00 FEMALE SPOUSE 1 BCC 5/5/2017 4/25/2017 5/3/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1350 NONRHEUMATIC AORTIC PROFESSIONAL 1 BCC 3559 $0.00 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH 1 BCC (VALVE) STENOSIS INPATIENT /HOSPITAL $22.00 FEMALE SPOUSE 1 BCC 3559 REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN $18.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $14.00 FEMALE SPOUSE 1 BCC EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN $0.00 $17.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $13.00 FEMALE SPOUSE EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL 3559 $0.00 $12.00 FEMALE SPOUSE 1 BCC 3559 $0.00 DECISION MAKING OF MODERATE COMPLEXITY. 1 BCC 3559 $0.00 $6.00 FEMALE SPOUSE 1 BCC 3559 COUNSELING AND /OR $14.00 FEMALE SPOUSE 1 BCC 3559 5/8/2017 4/23/2017 5/5/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE R9431 ABNORMAL PROFESSIONAL 3559 $0.00 $14.00 FEMALE SPOUSE THE FOLLOWING: ALBUMIN (9204D), BILIRUBIN, TOTAL 3559 ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, [ECG] [EKG[ ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SEPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) 5/8/2017 4/23/2017 5/5/2017 82150 AMYLASE R9431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG] 5/8/2017 4/23/2017 5/5/2017 82310 CALCIUM; TOTAL 89431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG] 5/8/2017 4/23/2017 5/5/2017 82435 CHLORIDE; BLOOD R9431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OVTPATIENT /HOSPITAL [ECG][EI(G) 5/8/2017 4/23/2017 5/5/2017 82550 CREATINE KINASE(CK),(CPK); TOTAL 89431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG[ 5/8/2017 4/23/2017 5/5/2017 82565 CREATININE; BLOOD R9431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OVTPATIENT /HOSPITAL [ECG] [EKG] 5/8/2017 4/23/2017 5/5/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT R9431 ABNORMAL PROFESSIONAL STRIP) ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG] S/8/2017 4/23/2017 5/5/2017 83690 LIPASE R9431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG) 5/8/2017 4/23/2017 5/5/2017 83735 MAGNESIUM R9431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG] 5/8/2017 4/23/2017 5/5/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); 89431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG] 5/8/2017 4/23/2017 5/5/2017 84132 POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD R9431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OVTPATIENT /HOSPITAL [ECG][EI(G) 5/8/2017 4/23/2017 5/5/2017 84295 SODIUM; SERUM, PLASMA OR WHOLE BLOOD 89431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG[ S/8/2017 4/23/2017 5/5/2017 84520 UREA NITROGEN; QUANTITATIVE R9431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OVTPATIENT /HOSPITAL [ECG] [EKG] 5/8/2017 4/23/2017 5/5/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, R9431 ABNORMAL PROFESSIONAL HOT RBC,WBC AND PLATELET COUNT) AND AUTOMATED ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT [ECG] [EKG[ S/8/2017 4/23/2017 5/5/2017 85379 FIBRIN DEGRADATION PRODUCTS, D - DIVER; R9431 ABNORMAL PROFESSIONAL QUANTITATIVE ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG] 5/8/2017 4/23/2017 5/5/2017 85610 PROTHROMBIN TIME; R9431 ABNORMAL PROFESSIONAL ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG] $62.88 $160.00 FEMALE SPOUSE 1 BCC C.7.f 3559 $0.00 $35.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $16.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $7.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $7.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $22.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $18.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $14.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $17.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $13.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $12.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $9.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $6.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $14.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $18.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $29.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $14.00 FEMALE SPOUSE 1 BCC 3559 C.7.f 5/8/2017 4/23/2017 5/5/2017 85652 SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED R9431 ABNORMAL PROFESSIONAL $0.00 $9.00 FEMALE SPOUSE 1 BCC 3559 ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECGI [EKG[ Z 5/8/2017 4/23/2017 5/5/2017 85730 THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR 89431 ABNORMAL PROFESSIONAL $0.00 $18.00 FEMALE SPOUSE 1BCC 3559 SO WHOLE BLOOD ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG[ 5/8/2017 5/2/2017 5/6/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST 1350 NONRHEUMATIC AORTIC PROFESSIONAL $99.53 $236.00 FEMALE SPOUSE 1 BCC 3559 MATERIALS) (VALVE) STENOSIS OUTPATIENT /HOSPITAL 7 5/8/2017 5/2/2017 5/6/2017 ]55]4 Computed tomographlc angiographY, heart, coronary 1350 NONRHEUMATIC AORTIC PROFESSIONAL $183.17 $447.00 FEMALE SPOUSE 1 BCC 3559 arteries and bVpass grafts (.he, p resent), with contrast (VALVE) STENOSIS OUTPATIENT /HOSPITAL OR material, including 3D image p,Xtpmce,si,g (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluatio . O 5/9/2017 12130/2016 4/20/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A4150 GRAM - NEGATIVE SEPSIS, PROFESSIONAL $108.14 $219.00 FEMALE SPOUSE 1BCC 3559 CL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL Q, FOOD I R ES AT LEAST 2 OF TH ESE 3 KEY COM PC IN ENTS: A v DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI F 5/9/2017 12/301 4/20/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION A4150 GRAM NEGATIVE SEPSIS, PROFESSIONAL $0.00 ($427.00) FEMALE SPOUSE 1 BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES UNSPECIFIED INPATIENT /HOSPITAL ~ THESES KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING _ AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN O 5/9/2017 12/30/2016 5/2/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE A4150 GRAM - NEGATIVE SEPSIS, PROFESSIONAL $0.00 $219.00 FEMALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; UJ MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI W 5/11/2017 4/23/2017 5/10/2017 93010 ELECTROCARDIOGRAM ROUTINE ECG WITH AT LEAST 12 R9431 ABNORMAL PROFESSIONAL $13.39 $98.00 FEMALE SPOUSE 1 BCC 3559 , LEADS; INTERPRETATION AND REPORT ONLY ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG] J 5/15/2017 4/23/2017 511212017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION A419 SEPSIS, UNSPECIFIED PROFESSIONAL $278.09 $]]5.00 FEMALE SPOUSE 16CC 3559 AND MANAGEMENTOFA PATIENT, WHICH REQUIRES ORGANISM OUTPATIENT /HOSPITAL v THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF TH E PATIENT'S CLINICAL CONDITION AND /DR MENTALSTATUS: ACDMPREHENSIVE LLJ HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS U 511512017 5/2/2017 5/12/2017 ]417] Computed tomographV, abdomen and pelvis; with K769 LIVER DISEASE, PROFESSIONAL $141.78 $352.00 FEMALE SPOUSE 1 BCC 3559 contrast materials) UNSPECIFIED OUTPATIENT /HOSPITAL 5/16/2017 5/2/2017 5/8/2017 - - 1350 NONRHEUMATIC AORTIC HOSPITAL OUTPATIENT $51100 $19,215.43 FEMALE SPOUSE 1 BCC 3559 (VALVE) STENOSIS N 5/17/2017 5/10/2017 5/16/20171036F CURRENTTOBACCO NON-USER (CAD, CAP, COPD, PV) L309 DERMATITIS, UNSPECIFIED PROFESSIONAL OFFICE $0.00 $0.01 FEMALE SPOUSE 1BCC 3559 = (DM) (IBD) BID 5/17/2017 5110/2017 5/16/20171126F INTERMEDIATE " DELAY" OF ANY FLAP, PRIMARY "DELAY" L309 DERMATITIS, UNSPECIFIED PROFESSIONAL OFFICE $0.00 $0.01 FEMALE SPOUSE 1BCC 3559 OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR DIRECT FLAP, AT EYELIDS NOSE, m 5/17/2017 5/10/2017 5/16/2017 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L309 DERMATITIS, U N S P ECI F I ED P ROFESS IO NAL OF F I CE $0.00 EVALUATION AND MANAGEMENT OF A NEW PATIENT, 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 MAKING OF LOW COMPLEXITY. COUNSELING AND /OR $0.01 FEMALE SPOUSE 1 BCC 3559 $69.77 COORDINATION OF CARE WITH OTHER PROVIDERS OR 1 BCC 3559 AGENCIES ARE P 5/17/2017 5/10/2017 5/16/2017 G8419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO L309 DERMATITIS, U N S P ECI F I ED P ROFESS IO NAL OF F I CE FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN 5/17/2017 5/10/2017 5/16/2017 68427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN L309 DERMATITIS, UNSPECIFIED PROFESSIONAL OFFICE THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR REVIEWED THE PATIENT'S CURRENT MEDICATIONS 5/17/2017 5/10/2017 5/16/2017 G8732 NO DOCUMENTATION OF PAIN ASSESSMENT L309 DERMATITIS, UNSPECIFIED PROFESSIONAL OFFICE 5117/2017 5/12/2017 5/16/2017 1036F CURRENTTOBACCO NON - USER (CAD, CAP, CORD, PV) L03119 CELLULITIS OF PROFESSIONAL )DM) (IED) UNSPECIFIED PART OF OUTPATIENT /HOSPITAL LIMB 5/17/2017 5/12/2017 5/16/20171126F INTERMEDIATE " DELAY" OF.ANY FLAP, PRIMARY "DELAY" L03119 CELLULITISOF PROFESSIONAL OFSMALL FLAP, ORSECTIONING PEDICLE OFTUBEDOR UNSPECIFIED PARTOF OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, LIMB 5/17/2017 5/12/2017 5/16/20171220F PATIENTSCREENED FOR DEPRESSION (SUD) L03119 CELLULITISOF PROFESSIONAL UNSPECIFIED PARTOF OUTPATIENT /HOSPITAL LIMB 5/17/2017 5/12/2017 5/16/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L03119 CELLULITISOF PROFESSIONAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED UNSPECIFIED PARTOF OUTPATIENT /HOSPITAL PATIENT,WHICH REQUIRES AT LEAST 20F THESE 3 KEY LIMB COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 5/17/2017 5/12/2017 5/16/2017 G8419 BMI DOCUMENTED OUTSIDE NORMALPARAMETERS,NO L03119 CELLULITISOF PROFESSIONAL FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN UNSPECIFIED PARTOF OUTPATIENT /HOSPITAL LIMB 5/17/2017 5112/2017 5/16/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN L03119 CELLULITISOF PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR UNSPECIFIED PARTOF OUTPATIENT /HOSPITAL REVIEWEDTHE PATIENT'S CURRENT MEDICATIONS LIMB 5/17/2017 5/12/2017 5/16/2017 G8731 PAIN ASSESSMENT USING A STANDARDIZED TOOL IS L03119 CELLULITISOF PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN UNSPECIFIED PART OF OUTPATIENT /HOSPITAL REQUIRED LIMB 5/18/2017 4/23/2017 5/17 /2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION L03115 CELLULITIS OF RIGHT PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LOWER LIMB INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; ACOMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 5 /18 /2017 4/24/2017 5/17/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR $148.62 $304.00 FEMALE SPOUSE 1 SCE C.7.f 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $69.77 $193.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $225.00 FEMALE SPOUSE 1 BCC 3559 $6435 $100.00 FEMALE SPOUSE 1 BCC 5/23/2017 4/24/2017 5/22/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FORTH E EVALUATION C495 MALIGNANT NEOPLASM PROFESSIONAL 3559 $95.00 $150.00 FEMALE SPOUSE AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 3559 OF CONNECTIVE AND INPATIENT /HOSPITAL 1 BCC 3559 $95.00 THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; 1 BCC SOFT TISSUE OF PELVIS $95.00 $150.00 FEMALE SPOUSE 1 BCE 3559 A COMPREHENSIVE EXAMINATION; AND MEDICAL $150.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $65.08 FEMALE SPOUSE 1 BCC DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 5/23/2017 4/25/2017 5/22/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C495 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH OF CONNECTIVE AND INPATIENT / HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN SOFT TISSUE OF PELVIS EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 5/23/2017 4/26/2017 5/22/2017 99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES C495 MALIGNANT NEOPLASM PROFESSIONAL OR LESS OF CONNECTIVE AND INPATIENT /HOSPITAL SOFT TISSUE OF PELVIS 5/25/2017 4/14/2017 5/24/2017 * * * ** 5/25/2017 4/18/2017 5/24/2017 5/25/2017 4/21/2017 "24/2017 5/25/2017 5/8/2017 5/24/2017 5/25/2017 5/18/2017 5/24/2017 * * " 5/25/2017 5/24/2017 5/24/2017 5/26/2017 3/1S/2017 5/24/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C499 MALIGNANT NEOPLASM OTHER MEDICAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF CONNECTIVE AND TOTAL (82247), CALCIUM, TOTAL (8231D), CARBON SOFT TISSUE, DIOXIDE (SOARED MATE) (92374), CHLORIDE (92435), UNSPECIFIED CREATININE( 82565), G LUCOSE(82947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 5/26/2017 3/15/2017 5/24/2017 83735 MAGNESIUM C499 MALIGNANT NEOPLASM OTHER MEDICAL OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED 5/26/2017 3/15/2017 5/24/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED HHGB, C499 MALIGNANT NEOPLASM OTHER MEDICAL HCT,RBC, WBC AND PLATELET COUNT) AND AUTOMATED OF CONNECTIVE AND DIFFERENTIAL WBC COUNT SOFT TISSUE, UNSPECIFIED 5/30/2017 5/25/2017 5/27/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C7800 SECONDARY MALIGNANT PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED NEOPLASM OF OUTPATIENT /HOSPITAL PATIENT, WHI CH REQUIRES AT LEAST 2 OF THESE 3 KEY UNSPECIFIED LUNG COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5/30/2017 5/26/2017 5/27/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 C7802 SECONDARY MALI6NANT PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY NEOPLASM OF LEFT LUNG OUTPATIENT /HOSPITAL $0.00 $200.00 FEMALE SPOUSE 1 BCC $6142 $100.00 FEMALE SPOUSE 1 BCC C.7.f 3559 ®' $60.16 $200.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCE 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $65.08 FEMALE SPOUSE 1 BCC 3559 $0.00 $55.12 FEMALE SPOUSE 1 BCC 3559 $0.00 $42.18 FEMALE SPOUSE 1 BCC 3559 $200.43 $225.00 FEMALE SPOUSE 1 BCC 3559 $15.88 $57.00 FEMALE SPOUSE 1 BCC mg 5/31/2017 5/26/2017 5/30/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C7800 SECONDARY MALIGNANT PROFESSIONAL $78.84 EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC NEOPLASM OF OUTPATIENT /HOSPITAL $19.00 FEMALE SPOUSE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY 3559 UNSPECIFIED LUNG $3,236.65 FEMALE SPOUSE 1 BCC COMPONENTS: A DETAILED HISTORY; A DETAILED $36.58 $50.80 FEMALE SPOUSE 1 BCC 3559 EXAMINATION; MEDICAL DECISION MAKING OF $385.00 FEMALE SPOUSE 1 BCC 3559 $15.02 MODERATE COMPLEXITY. COUNSELING AND /OR 1 BCC 3559 $0.00 $10.40 FEMALE SPOUSE COORDINATION OF CARE WITH OTHER 3559 $120.00 $180.00 FEMALE SPOUSE 5/31/2017 5/26/2017 5/30/2017- - C7802 SECONDARY MALIGNANT HOSPITAL OUTPATIENT 3559 $0.00 $26.00 FEMALE SPOUSE NEOPLASM OF LEFT LUNG 3559 5/31/2017 5/27/2017 5/30/2017 86077 BLOOD BANK PHYSICIAN SERVICES; DIFFICULT CROSS C7802 SECONDARY MALIGNANT PROFESSIONAL $369.00 FEMALE SPOUSE MATCH AND /OR EVALUATION OF IRREGULAR 3559 NEOPLASM OF LEFT LUNG OUTPATIENT /HOSPITAL ANTIBODY(S), INTERPRETATION AND WRITTEN REPORT 5/31/2017 5/27/2017 5/30/2017 86885 ANTIHUMAN GLOBULIN TEST(COOMBS TEST); INDIRECT, C7802 SECONDARY MALIGNANT PROFESSIONAL QUALITATIVE, EACH REAGENT RED CELL NEOPLASM OF LEFT LUNG OUTPATIENT /HOSPITAL 6/6/2017 6/1/2017 6/5/2017- - C7802 SECONDARY MALIGNANT HOSPITAL OUTPATIENT NEOPLASM OF LEFT LUNG 6/7/2017 5/30/2017 6/6/2017- - Z452 ENCOUNTER FOR HOSPITAL OUTPATIENT ADJUSTMENT AND MANAGEMENT OF VASCULAR ACCESS DEVICE 6/8/2017 6/2/2017 6/7/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST R918 OTHER NONSPECIFIC PROFESSIONAL MATERIALS) ABNORMAL FINDING OF OUTPATIENT /HOSPITAL LUNG FIELD 6/8/2017 6/2/2017 6/7/2017 76376 3D RENDERING WITH INTERPRETATION AND REPORTING R918 OTHER NONSPECIFIC PROFESSIONAL OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE ABNORMAL FINDING OF OUTPATIENT /HOSPITAL IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC LUNG FIELD MODALITY; NOT REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION 6/15/2017 6/13/2017 6/14/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C414 MALIGNANT NEOPLASM PROFESSIONAL HCT,RBC,WBC AND PLATELET COUNT) AND AUTOMATED OF PELVIC BONES, OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT SACRUM AND COCCYX 6/16/2017 4/23/2017 6/15/2017 A0425 GROUND MILEAGE, PER STATUTE MILE 1499 CARDIAC ARRHYFH MIA, OTHER MEDICAL UNSPECIFIED 6/16/2017 4/23/2017 6/15/2017 A0427 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, 1499 CARDIAC ARRHYTH MIA, OTHER MEDICAL EMERGENCY TRANSPORT, LEVEL 1(ALSl- EMERGENCY) UNSPECIFIED 6/16/2017 6/13/2017 6/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C414 MALIGNANT NEOPLASM PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF PELVIC BONES, OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SACRUM AND COCCYX DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84D7S), POTASSIUM (84132), PROTEIN, 6/16/2017 6/13/2017 6/15/2017 83735 MAGNESIUM C414 MALIGNANT NEOPLASM PROFESSIONAL OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 6/19/2017 6/13/2017 6/16/2017 36569 INSERTI0N OF PERIPHERALLY INSERTED CENTRAL VENOUS C414 MALIGNANT NEOPLASM PROFESSIONAL CATHETER( ICE), WITHOUT SUBCUTANEOUS PORTOR OF PELVIC BONES, OUTPATIENT /HOSPITAL PUMP; AGE 5 YEARS OR OLDER SACRUM AND COCCYX $200.43 $225.00 FEMALE SPOUSE 1 BCC C.7.f 3559 $1,029.60 $1,430.00 FEMALE SPOUSE 1 BCC 3559 $78.84 $289.00 FEMALE SPOUSE 1 BCC 3559 $5.50 $19.00 FEMALE SPOUSE 1 BCC 3559 $2,330.39 $3,236.65 FEMALE SPOUSE 1 BCC 3559 $36.58 $50.80 FEMALE SPOUSE 1 BCC 3559 $94.93 $385.00 FEMALE SPOUSE 1 BCC 3559 $15.02 $70.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $10.40 FEMALE SPOUSE 1 BCC 3559 $120.00 $180.00 FEMALE SPOUSE 1 BCC 3559 $402.94 $855.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $26.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $10.80 FEMALE SPOUSE 1 BCC 3559 $166.36 $369.00 FEMALE SPOUSE 1 BCC 3559 6/19/2017 6/13/2017 6/16/2017 76937 ULTRASOUND GU I DANCE FOR VASCULAR ACCESS C414 MALIGNANT NEOPLASM PROFESSIONAL 1 BCC 3559 REQUIRING ULTRASOUND EVALUATION OF POTENTIAL $56.00 FEMALE SPOUSE OF PELVIC BONES, OUTPATIENT /HOSPITAL $95.00 $150.00 FEMALE SPOUSE ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL 3559 SACRUM AND COCCYX $0.01 FEMALE SPOUSE 1 BCC 3559 PATENCY, CONCURRENT REACTIVE ULTRASOUND $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE VISUALIZATION OF VASCULAR NEEDLE ENTRY, 3559 $108.44 $299.00 FEMALE SPOUSE 6/20/2017 6/12/2017 6/19/2017 • « « »+ *.... z « »zz . *z.r *.. *. 11111211 6/19/2017 6/20/2017 6/16/2017 6/19/2017 36415 COLLECTI DNOFVENOUSBLOODBYVENIPUNCTURE C499 MALIGNANTNEOPLASM OTHER MEDICAL OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED 6/20/2017 6/19/2017 6/19/2017 * * * ** * * * ** * * * ** zzzzz zzzzz 6/21/2017 6/13/2017 6/20/20171036F CURRENTTOBACCO NON- USER(CAD, CAP,COPD, PV) C414 MALIGNANT NEOPLASM PROFE55IONAL (DM) (113C) OF PELVIC BON ES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 6/21/2017 6/13/2017 6/20/20171126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" C414 MALIGNANT NEOPLASM PROFESSIONAL OF SMALL FLAP, DR SECTIONING PEDICLE OF TUBED OR OF PELVIC BONES, OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, SACRUM AND COCCYX 6/21/2017 6/13/2017 6/20/20171220F PATIENT SCREENED FOR DEPRESSION (SUD) C414 MALIGNANT NEOPLASM PROFE55IONAL OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 6/21/2017 6/13/2017 6/20/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C414 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PELVIC BONES, OUTPATIENT /HOSPITAL PATIENT, WHI CH REQUIRES AT LEAST 2 OF THESE 3 KEY SACRUM AND COCCYX COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/21/2017 6/13/2017 6/20/201768419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C414 MALIGNANT NEOPLASM PROFESSIONAL FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 6/21/2017 6113/2017 612012017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C414 MALIGNANT NEOPLASM PROFE55IONAL TH E MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF PELVIC BONES, OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS SACRUM AND COCCYX 6/21/2017 6/13/2017 6/20/2017 G8731 PAIN ASSESSMENT USING A STANDARDIZED TOOL IS C414 MALIGNANT NEOPLASM PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW-UP PLAN OF PELVIC BONES, OUTPATIENT /HOSPITAL REQUIRED SACRUM AND COCCYX 6/23/2017 5/30/2017 6/22/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 140 BRONCHITIS, NOT PROFE55IONAL FRONTALAND LATERAL; SPECIFIED AS ACUTE OR OUTPATIENT /HOSPITAL CHRONIC 6/23/2017 5/30/2017 6/22/2017 99051 SERVICE(S) PROVIDED IN THE OFFICE DURING REGULARLY 140 BRONCHITIS, NOT PROFESSIONAL SCHEDULED EVENING, WEEKEND, DR HOLIDAY OFFICE SPECIFIED ASACUTE OR OUTPATIENT /HOSPITAL HOURS, IN ADDITION TO BASIC SERVICE CHRONIC 6/23/2017 5/30/2017 6/22/2017 99204 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 140 BRONCHITIS, NOT PROFE55IONAL EVALUATION AND MANAGEMENTOF A NEW PATIENT, SPECIFIED AS ACUTE OR OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEYCDMPONENTS: A CHRONIC COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR $26.99 $59.00 FEMALE SPOUSE 1 BCC C.7.f 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $1.80 $56.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $108.44 $299.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $25.10 $55.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $25.00 FEMALE SPOUSE 1 BCC 3559 $169.02 $286.00 FEMALE SPOUSE 1 BCC 3559 6/27/2017 4/23/2017 6/26/2017 71010 RADIOLOGIC EXAM I NATION, CHEST; SINGLE VIEW, K8020 CALCULUS OF PROFESSIONAL 1 BCC 3559 FRONTAL $1,049.00 FEMALE SPOUSE GALLBLADDER WITHOUT INPATIENT /HOSPITAL $0.00 $26.00 FEMALE SPOUSE 1 BCC 3559 CHOLECYSTITIS WITHOUT OBSTRUCTION 6/27/2017 4/23/2017 6/26/2017 71275 COMPUTED TOMOGRAPHIC ANGIOGRAPHY ,CHEST K9020 CALCULUS OF PROFESSIONAL (NONCORONARY), WITH CONTRAST MATERIAL(S), GALLBLADDER WITHOUT INPATIENT /HOSPITAL INCLUDING NDNCDNTRAST IMAGES, IF PERFORMED, AND CHOLECYSTITIS WITHOUT IMAGE POSTPROCESSING OBSTRUCTION 6/27/2017 4/23/2017 6/26/2017 74174 COMPUTED TDMDGRAPHIC ANGIOGRAPHY, ABDOMEN K8020 CALCULUS OF PROFESSIONAL AND PELVIS, WITH CONTRAST MATERIAL(S), INCLUDING GALLBLADDER WITHOUT INPATIENT /HOSPITAL NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE CHOLECYSTITIS WITHOUT POSTPROCESSING OBSTRUCTION 6/27/2017 4/23/2017 6/26/2017 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING K8020 CALCULUS OF PROFESSIONAL RESPONSES TO COMPRESSION AND OTHER MANEUVERS; GALLBLADDER WITHOUT INPATIENT /HOSPITAL COMPLETE BILATERAL STUDY CHOLECYSTITIS WITHOUT OBSTRUCTION 71712017 3/17/2017 4/7/2017- - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 71712017 3/17/2017 4/7/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 7/11/2017 6/27/2017 7/10/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 7/11/2017 7/7/2017 7/10/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C414 MALIGNANT NEOPLASM PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF PELVIC BONES, OUTPATIENT /HOSPITAL TOTAL ( 82247), CALCIUM, TOTAL (82310), CARBON SACRUM AND COCCYX DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 711112017 71712017 7/10/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C414 MALIGNANT NEOPLASM PROFESSIONAL HCT,RBC, WBC AND PLATELET COUNT) AND AUTOMATED OF PELVIC BONES, OUTPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT SACRUM AND COCCYX 7/12/2017 7/7/2017 7/11/20171036F CURRENTTDBACCO NON- USER(CAD, CAP,COPD, PV) C414 MALIGNANT NEOPLASM PROFESSIONAL (DM)(IED) OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 711212017 71712017 7/11/20171126F INTERMEDIATE "DELAY" OFANY FLAP, PRIMARY "DELAY" C414 MALIGNANT NEOPLASM PROFESSIONAL OFSMALL FLAP, OR SECTIONING PEDICLE OFTUBEDOR OF PELVIC BONES, OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, SACRUM AND COCCYX 7/12/2017 7/7/2017 7111/20171220F PATIENTSCREENED FOR DEPRESSION (SUD) C414 MALIGNANT NEOPLASM PROFESSIONAL OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX $0.00 $55.00 FEMALE SPOUSE 1 BCC $129.42 $350.00 FEMALE SPOUSE 1 BCC $15646 $200.00 FEMALE SPOUSE 1 BCC $50.80 $110.00 FEMALE SPOUSE 1 BCC C.7.f 3559 w Z N Q! 3559 A 3559 fl } fl E. CL CL Q 3559 v $13,804.26 $36,327.00 FEMALE SPOUSE 1 BCC 3559 ($1,306.121 ;$36,327.00] FEMALE SPOUSE 1 BCC 3559 $557.00 $1,049.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $26.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $10.40 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 $0.00 $0.01 FEMALE SPOUSE 1 BCC 3559 7/12/2017 71712017 7/11/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C414 MALIGNANT NEOPLASM PROFESSIONAL 1 BCC $0.00 $0.01 FEMALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC OF PELVIC BONES, OUTPATIENT /HOSPITAL SPOUSE 1 BCC $7,317.91 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SPOUSE SACRUM AND COCCYX $95.00 $150.00 FEMALE SPOUSE 1 BCC COMPONENTS: A DETAILED HISTORY; A DETAILED $150.00 FEMALE SPOUSE 1 BCC $8.95 $277.45 FEMALE SPOUSE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 7/12/2017 71712017 7/11/201768419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C414 MALIGNANT NEOPLASM PROFESSIONAL FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN OF PELVIC BONES, OUTPATIENT /HOSPITAL SACRUM AND COCCYX 7/12/2017 7/7/2017 7/11/201768427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C414 MALIGNANT NEOPLASM PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OF PELVIC BONES, OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS SACRUM AND COCCYX 711212017 71712017 7/11/2017 G8731 PAIN ASSESSMENT USING A STANDARDIZED TOOL IS C414 MALIGNANT NEOPLASM PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN OF PELVIC BONES, OUTPATIENT /HOSPITAL REQUIRED SACRUM AND COCCYX 7/17/2017 6/27/2017 7/12/2017 - - 75111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 7/18/2017 6/13/2017 7/17/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 712012017 7/16/2017 7/19/2017 * * * "+ 7/20/2017 1/19/2017 7/19/2017 7/24/2017 6/21/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX AMORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 6/22/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX AMORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 6/23/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX AMORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 6/24/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), $108.44 $299.00 FEMALE SPOUSE 1 SCC $0.00 $0.01 FEMALE SPOUSE 1 BCC $0.00 $0.01 FEMALE SPOUSE 1 BCC $0.00 $0.01 FEMALE SPOUSE 1 BCC $13,804.26 $36,327.00 FEMALE SPOUSE 1 BCC $7,317.91 $23,980.00 FEMALE SPOUSE 1 BCC $95.00 $150.00 FEMALE SPOUSE 1 BCC $95.00 $150.00 FEMALE SPOUSE 1 BCC $8.95 $277.45 FEMALE SPOUSE 1 BCC $8.95 $8.95 FEMALE SPOUSE 1 BCC $8.95 $8.95 FEMALE SPOUSE 1 BCC $8.95 $8.95 FEMALE SPOUSE 1 BCC 7/24/2017 6/25/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 6/26/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 6/27/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 6/28/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 6/29/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 6/30/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/1/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/2/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/3/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/4/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/5/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/6/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/7/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/8/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/9/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/10/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/11/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/12/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/13/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/14/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/15/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/16/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/17/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/18/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $8.95 $8.95 FEMALE SPOUSE 1BCC MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/24/2017 7/19/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL $30,517.00 FEMALE SPOUSE MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), 3559 LE 1,05IC") (537,517 -007 FEMALE SPOUSE 1 BCC INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL $12,172.00 $30,430.00 FEMALE SPOUSE 1 BCC 3559 PHARMACY SERVICES, CARE COORDINATION, AND ALL {$30,430.D0j FEMALE SPOUSE 1 BCC 3559 $9933 NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND SPOUSE 1 BCC 3559 NURSING VISITS CODED SEPARATELY), 7/24/2017 7/20/2017 7/21/201755501 HOME INFUSION THERAPY, CATHETER CARE/ R232 FLUSHING OTHER MEDICAL MAINTENANCE, COMPLEX (MORE THAN ONE LUMEN), INCLUDES ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), 7/26/2017 2/3/2017 7/25/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION L03115 CELLULITIS OF RIGHT PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LOWER LIMB INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 7/26/2017 2/4/2017 7/25/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RIGHT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT , WHICH LOWER LIMB INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 7/26/2017 2/5/2017 7/25/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE L03115 CELLULITIS OF RI6HT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LOWER LIMB INPATIENT / HDSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 7/26/2017 2/6/2017 7/25/2017 99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES L03115 CELLULITIS OF RIGHT PROFESSIONAL OR LESS LOWER LIMB INPATIENT /HOSPITAL 7/27/2017 2/24/2017 3/8/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 712712017 2/24/2017 3/8/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 712712017 12/2/2016 1/9/2017- - C7800 SECONDARY MALIGNANT HOSPITAL OUTPATIENT NEOPLASM OF UNSPECIFIED LUNG 7/27/2017 12/2/2016 1/9/2017- - C7800 SECONDARY MALIGNANT HOSPITAL OUTPATIENT NEOPLASM OF UNSPECIFIED LUNG 7/31/2017 7/16/2017 7/28/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST C787 SECONDARY MALIGNANT PROFESSIONAL MATERIAL(S) NEOPLASM OF LIVER AND OUTPATIENT /HOSPITAL INTRAHEPATIC BILE DUCT C.7.f $8.95 $8.95 FEMALE SPOUSE 1 BCC 3559 41 N Q! $8.95 $8.95 FEMALE SPOUSE 1 BCC 3559 fl } $236.17 $500.00 FEMALE SPOUSE 1 BCC 3559 53 $83.68 $250.00 FEMALE SPOUSE 1 BCC 3559 $83.68 $250.00 FEMALE SPOUSE 1 BCC 3559 $83.89 $175.00 FEMALE SPOUSE 1 BCC 3559 $11,914.01 $30,517.00 FEMALE SPOUSE 1 BCC 3559 LE 1,05IC") (537,517 -007 FEMALE SPOUSE 1 BCC 3559 $12,172.00 $30,430.00 FEMALE SPOUSE 1 BCC 3559 {$1,U83.60j {$30,430.D0j FEMALE SPOUSE 1 BCC 3559 $9933 $236.00 FEMALE SPOUSE 1 BCC 3559 7/31/2017 7/16/2017 7/28/2017 74177 Computed tomography, abdomen and pelvis; with C787 SECONDARY MALIGNANT PROFESSIONAL SPOUSE 1 BCC $3,193.00 contrast materials) SPOUSE NEOPLASM OF LIVER AND OUTPATIENT /HOSPITAL $1,149.00 FEMALE SPOUSE 1 BCC $18,389.00 FEMALE SPOUSE INTRAHEPATIC BILE DUCT 3559 7/31/2017 7/21/2017 7/25/2017 * * " 1 BCC 3559 $6,657.43 $23,980.00 FEMALE 8/3/2017 7/21/2017 7/27/2017- - C7801 SECONDARY MALIGNANT HOSPITAL OUTPATIENT 3559 NEOPLASM OF RIGHT LUNG 8/4/2017 7/16/2017 8/3/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 81013 EPIGASTRIC PAIN PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR 8/7/2017 8/4/2017 8/5/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HER, C499 MALIGNANT NEOPLASM PROFESSIONAL HOT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED OF CONNECTIVE AND OUTPATIENT /HOSPITAL DIFFERENTIAL WEE COUNT SOFT TISSUE, UNSPECIFIED 8/8/2017 7/7/2017 8/7/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 8/8/2017 8/4/2017 8/7/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C499 MALIGNANT NEOPLASM PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, OF CONNECTIVE AND OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SOFT TISSUE, DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), UNSPECIFIED CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 8/8/2017 8/4/2017 8/7/2017 83735 MAGNESIUM C499 MALIGNANT NEOPLASM PROFESSIONAL OF CONNECTIVE AND OUTPATIENT /HOSPITAL SOFT TISSUE, UNSPECIFIED 8/11/2017 7/21/2017 81912017 74170 COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT K769 LIVER DISEASE, PROFESSIONAL CONTRAST MATERIAL, FOLLOWED BY CONTRAST UNSPECIFIED OUTPATIENT /HOSPITAL MATERIALS) AND FURTHER SECTIONS 8/14/2017 7/18/2017 8/12/2017 93010 ELECTRDCARDIDGRAM , ROUTI NE ECG WITH AT LEAST 12 701810 ENCOUNTER FOR PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY PREPROCEDURAL OUTPATIENT /HOSPITAL CARDIOVASCULAR EXAMINATION 8/21/2017 8/4/2017 8/10/2017- - C414 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PELVIC BONES, SACRUM AND COCCYX 8/21/2017 8/4/2017 8/10/2017- - C414 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PELVIC BONES, SACRUM AND COCCYX 8/24/2017 6/13/2017 7/17/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 8/24/2017 6/13/2017 7/17/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY $141.78 $352.00 FEMALE SPOUSE 1 BCC $108.44 $299.06 FEMALE SPOUSE 1 BCC $3,193.00 $6,549.00 FEMALE SPOUSE 1 BCC $281.81 $1,149.00 FEMALE SPOUSE 1 BCC $0.00 $10.40 FEMALE SPOUSE 1 BCC C.7.f 3559 w Z N 3559 3559 i' 3559 fl } fl E. CL CL Q 3559 v $1,678.84 $4,418.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $26.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $10.80 FEMALE SPOUSE 1 BCC 3559 $113.00 $266.00 FEMALE SPOUSE 1 BCC 3559 $14.56 $32.00 FEMALE SPOUSE 1 BCC 3559 $10,066.00 $18,389.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $18,389.00 FEMALE SPOUSE 1 BCC 3559 $6,657.43 $23,980.00 FEMALE SPOUSE 1 BCC 3559 $0.00 FEMALE SPOUSE 1 BCC 3559 8/25/2017 8/4/2017 8/23/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET)WITH C414 MALIGNANT NEOPLASM PROFESSIONAL 3559 $1,196.00 $3,372.14 FEMALE SPOUSE CONCURRENTLY ACQU I RED COMPUTED TOMOGRAPHY 3559 OF PELVIC BONES, OUTPATIENT /HOSPITAL 1 BCC 3559 $95.00 (CT( FOR ATTENUATION CORRECTION AND ANATOMICAL 1 BCC SACRUM AND COCCYX $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 LOCALIZATION IMAGING; SKULL BASE TO MID -THIGH $150.00 FEMALE SPOUSE 1 BCC 3559 8/31/2017 7/16/2017 8/30/2017 - - R1013 EPIGASTRIC PAIN HOSPITAL OUTPATIENT 9/25/2017 9/19/2017 9/23/2017 74178 COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; C7800 SECONDARY MALIGNANT PROFESSIONAL 1 BCC 3559 $95.00 WITHOUT CONTRAST MATERIAL IN I OR BOTH BODY 1 BCC NEOPLASM OF OUTPATIENT /HOSPITAL $150.00 FEMALE SPOUSE 1 BCC 3559 REGIONS, FOLLOWED BY CONTRAST MATERIAL(S)AND $125.00 FEMALE SPOUSE UNSPECIFIED LUNG 3559 $60.00 $150.00 FEMALE SPOUSE 1 BCC FURTHER SECTIONS IN 1 OR BOTH BODY REGIONS $676.50 $902.00 FEMALE SPOUSE 1 BCC 9/27/2017 9/19/2017 9/25/2017 - - E806 OTHER DISORDERS OF HOSPITAL OUTPATIENT 1 BCC 3559 $6,336.00 $10,560.00 FEMALE SPOUSE 1 BCC BILIRUBIN METABOLISM $0.00 10/2/2017 9122/2017 9/29/2017- - C419 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF BONE AND ARTICULAR CARTILAGE, UNSPECIFIED 10/4/2017 7/20/2017 10/3/2017 * * * ** 10/4/2017 7/25/2017 10/3/2017 * * * *+ 10/4/2017 ]/30/2017 10/3/2017 10/4/2017 8/11/2017 10/3/2017 10/4/2017 8/15/2017 10/3/2017 10/4/2017 8/20/2017 10/3/2017 * * * ** 10/4/2017 8/27/2017 10/3/2017 10/4/201] 9/3/2017 10/3/201] 1D/4/2017 9/5/201] 10/3/2017 *x *.* 10/4/2017 10/2/2017 10/3/2017 92014 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H2513 AGE - RELATED NUCLEAR PROFESSIONAL OFFICE AND EVALUATION, WITH INITIATION OR CONTINUATION CATARACT, BILATERAL OF DIAGNOSTIC AND TREATMENT PROGRAM; COMPREHENSIVE, ESTABLISHED PATIENT, ONE OR MORE VISITS 10/4/2017 10/2/2017 10/3/2017 10/19/2017 9/25/2017 10/17/2017- - Z0189 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT SPECIFIED SPECIAL EXAMINATIONS 10/19/2017 9/29/2017 10/17/2017- - Z0189 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT SPECIFIED SPECIAL EXAMINATIONS 10/19/2017 10/9/2017 10/17/2017 - - Z515 ENCOUNTER FOR HOSPITAL OUTPATIENT PALLIATIVE CARE 10/19/2017 10/9/2011 10/17/2017 + «.«x 10/23/2017 2/2/2017 10/2012017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION L03115 CELLULITIS OF RIGHT PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LOWER LIMB OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENTS CLINICAL CONDITION AND /DR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 10/23/2017 10/9/2017 10/21/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R0602 SHORTNESS OF BREATH PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 10/24/2017 10/9/2017 10/23/2017 * * * ** * * * ** 10/25/2017 6/13/201] 7/1]/2017 - - 15111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 10/25/2017 10/9/2017 10/23/2017 * * * ** * * * ** * * * ** * * * ** * * * ** $198.62 $485.00 FEMALE SPOUSE 1 BCC C.7.f 3559 $2,555.00 $22,497.01 FEMALE SPOUSE 1 BCC 3559 $125.06 $372.00 FEMALE SPOUSE 1 BCC 3559 $1,196.00 $3,372.14 FEMALE SPOUSE 1 BCC 3559 $593.00 $1,008.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $95.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $76.05 $125.00 FEMALE SPOUSE 1 BCC 3559 $60.00 $150.00 FEMALE SPOUSE 1 BCC 3559 $676.50 $902.00 FEMALE SPOUSE 1 BCC 3559 $885.00 $1,180.00 FEMALE SPOUSE 1 BCC 3559 $1,831.50 $2,44100 FEMALE SPOUSE 1 BCC 3559 $6,336.00 $10,560.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $775.00 FEMALE SPOUSE 1 BCC 3559 $1619 $41.00 FEMALE SPOUSE 1 BCC 3559 $556.00 $556.00 FEMALE SPOUSE 1 BCC 3559 i$66048) $23,980.00 FEMALE SPOUSE 1 BCC 3559 $268.82 $665.00 FEMALE SPOUSE 1 BCC 3559 10/30/2017 9/19/2017 10/27/2017 99283 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION E806 OTHER DISORDERS OF PROFESSIONAL 1 BCC $17035 $429.06 FEMALE AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 1 BCC BILIRUBIN METABOLISM OUTPATIENT /HOSPITAL SPOUSE 1 BCC $365.72 THESE 3 KEYCOMPONENTS: AN EXPANDED PROBLEM SPOUSE 1 BCC $2,896.60 $2,896.60 FEMALE SPOUSE 1 B CC FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED $6.00 FEMALE SPOUSE 1 BCC $2.34 $6.00 FEMALE SPOUSE EXAMINATION; AND MEDICAL DECISION MAKING OF $2.34 $6.00 FEMALE SPOUSE 1 BCC $127.19 $372.00 FEMALE MODERATE COMPLEXITY. COUNSELING AND /OR 1 BCC 1$125.061 (5372.00) FEMALE SPOUSE 1 BCC $0.00 COORDINATION OF CARE WITH SPOUSE 1 BCC $2,898.00 10/30/2017 10/8/2017 10/27/2017 x. * ** $173,609.14 $535,961.26 10/30/2017 10/9/2011 10/28/2017 BCC $3,516.00 $4,688.00 FEMALE SUBSCRIBER RO1 11/6/2017 9/22/201] 11/3/2017 SUBSCRIBER RO1 BCC 11/6/2017 10/9/2017 11/2/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R0602 SHORTNESS OF BREATH PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 11/9/2017 10/8/201] 111812017 11/10/2.17 10/5/201] 111912017 11/17/2017 8/9/2017 11/15/2017 36415 COLLECTION OFVENOUS BLOOD BYVENIPUNCTURE C499 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED 11/17/2017 8/16/2017 11/15/2017 36415 COLLECTION OFVENOUS BLOOD BYVENIPUNCTURE C499 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED 11/17/2017 10/2/2017 11/15/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C499 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED 12/1/2017 9/19/2017 9/23/2017 74178 COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; C7800 SECONDARY MALIGNANT PROFESSIONAL WITHOUT CONTRAST MATERIAL IN I OR BOTH BODY NEOPLASM OF OUTPATIENT/HOSPITAL REGIONS, FOLLOWED BY CONTRAST MATERIALS) AND UNSPECIFIED LUNG FURTHER SECTIONS IN 1 OR BOTH BODY REGIONS 12/1/2017 9/19/2017 9/23/2017 74178 COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; C7800 SECONDARY MALIGNANT PROFESSIONAL WITHOUT CONTRAST MATERIAL IN I OR BOTH BODY NEOPLASM OF OUTPATIENT /HOSPITAL REGIONS, FOLLOWED BY CONTRAST MATERIAL(S)AND UNSPECIFIED LUNG FURTHER SECTIONS IN 1 OR BOTH BODY REGIONS 12/1/2017 10/9/2017 11/29/2017 x * * ** —1 12/20/2017 10/9/2017 12/13/2017 ..... ... +. Sub Total 1.875E +10 1/5/2017 12/22/2016 1/3/2017 45380 COLONOSC OPY , FLEXIBLE; WITH BIOPSY, SINGLE OR Z1211 ENCOUNTERFOR PROFESSIONAL MULTIPLE SCREENING FOR OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM OFCOLON 1/13/2017 12/22/2016 1/11/2017 - - Z1211 ENCOUNTER FOR HOSPITAL OUTPATIENT SCREENING FOR MALIGNANT NEOPLASM OFCOLON 1/30/2017 1/3/2017 1/23/2017 99204 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C20 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, OF RECTUM WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR $102.73 $827.00 FEMALE SPOUSE 1 BCC $268.82 $695.00 FEMALE SPOUSE 1 BCC $0.00 $372.00 FEMALE SPOUSE 1 BCC $17035 $429.06 FEMALE SPOUSE 1 BCC $738 $98.00 FEMALE SPOUSE 1 BCC $365.72 $545.60 FEMALE SPOUSE 1 BCC $2,896.60 $2,896.60 FEMALE SPOUSE 1 B CC $2.34 $6.00 FEMALE SPOUSE 1 BCC $2.34 $6.00 FEMALE SPOUSE 1 BCC $2.34 $6.00 FEMALE SPOUSE 1 BCC $127.19 $372.00 FEMALE SPOUSE 1 BCC 1$125.061 (5372.00) FEMALE SPOUSE 1 BCC $0.00 $372.00 FEMALE SPOUSE 1 BCC $2,898.00 $4,716.00 FEMALE SPOUSE 1 DEC $173,609.14 $535,961.26 $269.50 $737.00 FEMALE SUBSCRIBER R01 BCC $3,516.00 $4,688.00 FEMALE SUBSCRIBER RO1 BCC $126.80 $541.00 FEMALE SUBSCRIBER RO1 BCC C.7.f 1/30/2017 1/4/2017 1/9/2017- - K6289 OTHER SPECIFIED HOSPITAL OUTPATIENT $2,719.05 $6,709.00 FEMALE SUBSCRIBER R01 BCC 3559 DISEASES OF ANUS AND W RECTUM 1/30/2017 1/4/2017 1/11/2017 72197 MAGNETIC RESONANCE LEG, PROTON) IMAGING, PELVIS; D490 NEOPLASM OF PROFESSIONAL $148.17 $458.00 FEMALE SUBSCRIBER R01 BCC 3559 N WITHOUT CONTRAST M.ATERIAL(S), FOLLOWED BY UNSPECIFIED BEHAVIOR OUTPATIENT /HOSPITAL CONTRAST MATERIAL(5) AND FURTHER SEQUENCES OF DIGESTIVE SYSTEM 2/7/2017 12/22/2016 1/3/2017 45380 COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR Z1211 ENCOUNTER FOR PROFESSIONAL $0.00 $737.00 FEMALE SUBSCRIBER R01 BCC 3559 MULTIPLE SCREENING FOR OUTPATIENT /HOSPITAL } MALIGNANT NEOPLASM "a OFCOLON 2/7/2017 12/22/2016 1/3/2017 45380 COLONOSC OPY , FLEXIBLE; WITH BIOPSY, SINGLE OR Z1211 ENCOUNTER FOR PROFESSIONAL $0.00 $0.00 FEMALE SUBSCRIBER R01 BCC 3559 MULTIPLE SCREENING FOR OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM } OFCOLON 2/7/2017 12/22/2016 1/31/2017 45380 COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR Z1211 ENCOUNTER FOR PROFESSIONAL $269.77 $737.00 FEMALE SUBSCRIBER RO1 BCC 3559 E. CL MULTIPLE SCREENING FOR OUTPATIENT /HOSPITAL Q, MALIGNANT NEOPLASM OFCOLON 2/13/2017 2/2/2017 2/7/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLEVIEW, Z452 ENCOUNTER FOR PROFE55IONAL $11.74 $58.00 FEMALE SUBSCRIBER RO1 BCC 3559 FRONTAL ADIUSTMENTAND OUTPATIENT/HOSPITAL MANAGEMENT OF VASCULAR ACCESS DEVICE W 2/13/2017 2/2/2017 2/7/2017 76000 FLUOROSCOPY (SEPARATE PROCEDURE), UP TO 1 HOUR Z452 ENCOUNTER FOR PROFESSIONAL $0.00 $94.00 FEMALE SUBSCRIBER RO1 BCC 3559 h PHYSICIAN TIME, OTHER THAN 71023 OR 71034(EG, CARDIAC FLUOROSCOPY) ADIUSTMENTAND MANAGEMENT OF OUTPATIENT /HOSPITAL VASCULAR ACCESS DEVICE _ 2/16/2017 1/26/2017 1131/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST C210 MALIGNANT NEOPLASM PROFESSIONAL $80.62 $383.00 FEMALE SUBSCRIBER R01 BCC 3559 MATERIALS) OF ANUS, UNSPECIFIED OUTPATIENT /HOSPITAL d 2/16/2017 1/26/2017 1/31/2017 74117 Computed tomography, abdomen and pelvis; with C210 MALIGNANT NEOPLASM PROFESSIONAL $112.80 $774.00 FEMALE SUBSCRIBER R01 BCC 3559 {j ca ntrast materials) OF ANUS, UNSPECIFIED OUTPATIENT /HOSPITAL 3/3/2017 2/14/2017 2/24/2017 78815 POSITRON EMI55ION TOMOGRAPHY(PET)WITH K639 DISEASE OF INTESTINE, PROFE55IONAL $166.14 $501.00 FEMALE SUBSCRIBER R01 BCC 3559 CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY UNSPECIFIED OUTPATIENT /HOSPITAL 0 (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID THIGH ILLJ I V 3/8/2017 2/2/2017 3/3/2017 36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL C218 MALIGNANT NEOPLASM PROFESSIONAL $284.97 $1,234.00 FEMALE SUBSCRIBER R01 BCC 3559 VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; OF OVERLAPPING SITES OUTPATIENT /HOSPITAL J AGE 5 YEARS OR OLDER OF RECTUM, ANUS AND ANALCANAL v 3/8/2017 2/2/2017 3/3/2017 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS C218 MALIGNANT NEOPLASM PROFESSIONAL $14.40 $269.00 FEMALE SUBSCRIBER R01 BCC 3559 DEVICE PLACEM ENT, REPLACEMENT (CATHETER ONLY OR OF OVERLAPPING SITES OUTPATIENT /HOSPITAL LLJ COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC OF RECTUM, ANUS AND GUIDANCE FOR VASCULAR ACCESS AND CATHETER ANALCANAL MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS (' THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHYR 3/9/2017 2/22/2017 3/2/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C19 MALIGNANT NEOPLASM PROFESSIONAL $9421 $300.00 FEMALE SUBSCRIBER RO1 BCC 3559 EVALUATION AND MANAGEMENT OF ANEW PATIENT, OF RECTOSIGMOID OUTPATIENT /HOSPITAL N WHICH REQUIRES THESE 3 KEVCOMPONENTS:A JUNCTION COMPREHENSIVE HISTORY; A COMPREH ENSIVE _ EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR C.7.f 3/13/2017 1/16/2017 2/6/2017- - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $215.55 $479.00 FEMALE SUBSCRIBER R01 BCC 3559 OF RECTUM W 41 3/13/2017 2/2/2017 2/8/2017- - C218 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $11,588.89 $19,267.00 FEMALE SUBSCRIBER RO1 BCC 3559 N OF OVERLAPPING SITES OF RECTUM, ANUS AND ANALCANAL t 3/13/2017 3/7/2017 3110/2017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, 195811 POSTPROCEDURAL PROFESSIONAL $8.53 $34.00 FEMALE SUBSCRIBER RO1 BCC 3559 7 FRONTAL PNEUMOTHORAX INPATIENT /HOSPITAL 3/13/2017 3/]1201] 3/10/2017 71035 RADIOLDGIC EXAMINATION, CHEST, SPECIAL VIEWS(EG, 195811 POSTPROCEDURAL PROFESSIONAL $17.06 $68.00 FEMALE SUBSCRIBER R01 BCC 3559 LATERAL DECUBITUS, BUCKY STUDIES) PNEUMOTHORAX INPATIENT /HOSPITAL 3/15/2017 1/26/2017 1/30/2017- - C210 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $6,898.50 $12,264.00 FEMALE SUBSCRIBER R01 BCC 3559 OF ANUS, UNSPECIFIED } fl 3/17/2017 212/2017 3/9/2017 532 ANESTHESIA FOR ACCESS TO CENTRAL VENOUS C20 MALIGNANT NEOPLASM PROFESSIONAL $366.19 $770.00 FEMALE SUBSCRIBER R01 BCC 3559 N. 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COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE 4/14/2017 4/3/2017 4/13/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C19 MALIGNANT NEOPLASM PROFESSIONAL TREATMENTS OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 4/14/2017 4/3/2017 4/13/2017 G6002 STEREOSCOPIC X -RAY GUIDANCE C19 MALIGNANT NEOPLASM PROFESSIONAL OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 4/14/2017 4/4/2017 4/13/2017136002 STEREOSCOPIC X -RAY GUIDANCE C19 MALIGNANT NEOPLASM PROFESSIONAL OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 4/14/2017 4/5/2017 413/2017 G6002 STEREOSCOPIC X -RAY GUIDANCE C19 MALIGNANT NEOPLASM PROFESSIONAL OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 4/14/2017 416/2017 4/13/2017 G6002 STEREOSCOPICX -RAY GUIDANCE C19 MALIGNANT NEOPLASM PROFESSIONAL OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 4/14/2017 4/6/2017 4/13/2017 77280 THERAPEUTIC RADIOLOGY SIM ULATION -AIDED FIELD C19 MALIGNANT NEOPLASM PROFESSIONAL SETTING; SIMPLE OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 4/14/2017 4/7/2017 4/13/2017 G6002 STEREOSCOPIC X -RAY GUIDANCE C19 MALIGNANT NEOPLASM PROFESSIONAL OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 4/14/2017 4/7/2017 41312017 77338 Multi -Ieafcolllmator(MLC) device(s) for intensity C19 MALIGNANT NEOPLASM PROFESSIONAL modulated radiation them py IMRT), design and OF RECTOSIGMOID OUTPATIENT /HOSPITAL construction per IMRTpIan JUNCTION 4/17/2017 3/10/2017 4/13/2017- - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF RECTUM 4/17/2017 3/13/2017 4/13/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 4/17/2017 3114/2017 4/13/2017- - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF RECTUM $19.80 $300.00 FEMALE SUBSCRIBER R01 BCC $19.80 $300.00 FEMALE SUBSCRIBER R01 BCC $19.80 $300.00 FEMALE SUBSCRIBER R01 BCC $20194 $567.00 FEMALE SUBSCRIBER R01 BCC $197.27 $500.00 FEMALE SUBSCRIBER R01 BCC $19.80 $1,8001 FEMALE SUBSCRIBER R01 BCC $19.80 $300.00 FEMALE SUBSCRIBER R01 BCC $19.80 $300.00 FEMALE SUBSCRIBER R01 BCC $19.80 $300.00 FEMALE SUBSCRIBER R01 BCC $0.00 $200.00 FEMALE SUBSCRIBER R01 BCC $19.80 $300.00 FEMALE SUBSCRIBER R01 BCC $226.52 $900.00 FEMALE SUBSCRIBER R01 BCC $2,992.00 $4,749.50 FEMALE SUBSCRIBER R01 BCC $2,021.00 $6,918.92 FEMALE SUBSCRIBER R01 BCC $1,250.00 $1,250.00 FEMALE SUBSCRIBER RO1 BCC C.7.f 4/1]/201] 3/15/2017 4/13/2017- - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,142.00 $1,142.00 FEMALE SUBSCRIBER R01 BCC 3559 OF RECTUM W 4/17/2017 3/16/2017 4/13/2017- - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $0.00 $1,353.00 FEMALE SUBSCRIBER R01 BCC 3559 N OF RECTUM QN 4/17/2017 3/16/2017 4/13/2017- - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,353.00 $1,353.00 FEMALE SUBSCRIBER RO1 BCC 3559 OF RECTUM i 4/1]/201] 3/1]/201] 4/13/2017 - - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,144.68 $1,144.68 FEMALE SUBSCRIBER R01 BCC 3559 OF RECTUM 4/17/2017 3/20/2017 4113/2017- - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,142.00 $1,142.00 FEMALE SUBSCRIBER R01 BCC 3559 OF RECTUM } fl 4/1]/201] 3/21/2017 4/13/2017- - C20 MALIGNANTNEOPLASM HOSPITAL OUTPATIENT $1,142.00 $1,142.00 FEMALE SUBSCRIBER R01 BCC 3559 N. CL OF RECTUM Q, Q 4/17/2017 3/22/2017 4/13/2017- - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,142.00 $1,142.00 FEMALE SUBSCRIBER R01 BCC 3559 v OF RECTUM 4/1]/201] 3/23/2017 4/13/2017- - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,443.00 $1,443.00 FEMALE SUBSCRIBER R01 BCC 3559 OF RECTUM W 4/17/2017 3/24/2017 4/13/2017- - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,142.00 $1,142.00 FEMALE SUBSCRIBER R01 BCC 3559 OF RECTUM 4/17/2017 3/27/2017 4/13/2017- - C20 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,142.00 $1,142.00 FEMALE SUBSCRIBER R01 BCC 3559 OF RECTUM 4/20/2017 1/16/2017 4/18/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C20 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $18.00 FEMALE SUBSCRIBER R01 BCC 3559 HOT BBC, WED AND PLATELET COUNT) AND AUTOMATED OF RECTUM OUTPATIENT /HOSPITAL 0. DIFFERENTIAL WEE COUNT uj 4/21/2017 3/7/2017 4120/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION K6289 OTHER SPECIFIED PROFESSIONAL $210.44 $430.00 FEMALE SUBSCRIBER R01 BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES DISEASES OF ANUS AND INPATIENT /HOSPITAL UJ THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; RECTUM A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER LLJ PROVIDERS OR AGEN 4/24/2017 2/9/2017 4/20/2017 99245 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED C211 MALIGNANT NEOPLASM PROFESSIONAL $246.63 $559.00 FEMALE SUBSCRIBER R01 BCC 3559 PATIENT,WHICH REQUIRES THESE 3 KEY COMPONENTS: A OFANALCANAL OUTPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE v EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE uJ PROVIDED CONSISTE 4/26/2017 2/23/2017 4125/2017 * *' *" * * » »* ** * ** » * * ** * * * *» $108.23 $370.00 FEMALE SUBSCRIBER RO1 BCC 3559 (' 4/26/2017 3/6/2017 4/25/2017 45341 SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC K6289 OTHER SPECIFIED PROFESSIONAL $177.15 $278.00 FEMALE SUBSCRIBER 301 BCC 3559 ULTRASOUND EXAMINATION DISEASES OF ANUS AND OUTPATIENT /HOSPITAL RECTUM 4/28/2017 4/17/2017 4/27/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C19 MALIGNANT NEOPLASM PROFESSIONAL $36.38 $900.00 FEMALE SUBSCRIBER R01 BCC 3559 N OF RADIATION THERAPY FIELDS OF RECTOSIGMOID OUTPATIENT /HOSPITAL N JUNCTION C 4/28/2017 4117/2017 4/2]/201] 77427 RADIATION TREATMENT MANAGEMENT, FIVE C19 MALIGNANT NEOPLASM PROFESSIONAL $197.27 $500.00 FEMALE SUBSCRIBER ROl BCC 3559 Oj TREATMENTS OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 4/28/2017 4/18/2017 4/27/2017 77014 COMPUTED TOM OG RAP HYGU I DANCE FOR PLACE ME NT C19 MALIGNANT NEOPLASM PROFESSIONAL $36.38 $150.00 FEMALE SUBSCRIBER R01 BCC OF RADIATION THERAPY FIELDS OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 4/28/2017 4/19/2017 4/27/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C19 MALIGNANT NEOPLASM PROFESSIONAL $36.38 $150.00 FEMALE SUBSCRIBER R01 BCC OF RADIATION THERAPY FIELDS OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 4/28/2017 4/20/2017 4/27/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C19 MALIGNANT NEOPLASM PROFESSIONAL $3638 $150.00 FEMALE SUBSCRIBER R01 BCC OF RADIATION THERAPY FIELDS OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 4/28/2017 4/21/2017 4/27/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C19 MALIGNANT NEOPLASM PROFESSIONAL $3638 $150.00 FEMALE SUBSCRIBER R01 BCC OF RADIATION THERAPY FIELDS OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 5/1/2017 31712017 4/27/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R5383 OTHER FATIGUE PROFESSIONAL $7.78 $60.00 FEMALE SUBSCRIBER R01 BCC LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL 5/4/2017 4/7/2017 5/2/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $189.00 $643.80 FEMALE SUBSCRIBER RO1 BCC ANTINEOPLASTIC CHEMOTHERAPY 5/4/2017 4/14/2017 5/2/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $189.00 $442.55 FEMALE SUBSCRIBER RO1 BCC ANTINEOPLASTIC CHEMOTHERAPY 5/4/2017 4/14/2017 5/2/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $0.00 $442.55 FEMALE SUBSCRIBER RO1 BCC ANTINEOPLASTIC CHEMOTHERAPY 5/4/2017 4/21/2017 5/2/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $3.15 $3.15 FEMALE SUBSCRIBER RO1 BCC ANTINEOPLASTIC CHEMOTHERAPY 5/5/2017 4/17 /2017 5/3/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $2,273.75 $6,145.26 FEMALE SUBSCRIBER R01 BCC ANTINEOPLASTIC CHEMOTHERAPY 5/8/2017 4/24/2017 5/5/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C19 MALIGNANT NEOPLASM PROFESSIONAL $19717 $500.00 FEMALE SUBSCRIBER RO1 BCC TREATMENTS OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 5/8/2017 4/24/2017 5/5/2017 G6002 STEREOSCOPIC X -RAY GUIDANCE C19 MALIGNANT NEOPLASM PROFESSIONAL $19.80 $1,800.00 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 5/8/2017 4/25/2017 5/5/2017 G6002 STEREOSCOPICX -RAY GUIDANCE C19 MALIGNANT NEOPLASM PROFESSIONAL $19.80 $300.00 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 5/8/2017 4/26/2017 5/5/2017 G6002 STEREOSCOPIC X -RAY GUIDANCE C19 MALIGNANT NEOPLASM PROFESSIONAL $19.80 $300.00 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 5/8/2017 4/27/2017 5/5/201766002 STEREOSCOPICX -RAY GUIDANCE C19 MALIGNANT NEOPLASM PROFESSIONAL $19.80 $300.00 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 5/8/2017 4/28/2017 5/5/201766002 STEREOSCOPIC X -RAY GUIDANCE C19 MALIGNANT NEOPLASM PROFESSIONAL $19.80 $300.00 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 5/11/2017 4/3/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,907.14 $1,907.14 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/11/2017 4/4/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,907.14 $1,907.14 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/11/2017 4/5/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,907.14 $1,907.14 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/11/2017 4/10/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,907.14 $1,907.14 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/11/2017 4/17/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,907.14 $1,907.14 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/11/2017 4/18/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,907.14 $1,907.14 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/11/2017 4/19/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,907.14 $1,907.14 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/11/2017 4/21/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,907.14 $1,907.14 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/11/2017 4/24/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,243.00 $2,284.56 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 511112017 4/25/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,907.14 $1,907.14 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/11/2017 4126/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,907.14 $1,907.14 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/11/2017 4/27/2017 5/9/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,243.00 $2,259.51 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/12/2017 4/28/2017 5/11/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $1,907.14 $1,907.14 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/15/2017 4/6/2017 5/11/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,243.00 $2,636.93 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/15/2017 4/7/2017 5/11/2017- - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,243.00 $3,088.67 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID JUNCTION 5/15/2017 5/1/2017 5/12/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FORPLACEMENT C19 MALIGNANT NEOPLASM PROFESSIONAL $36.38 $600.00 FEMALE SUBSCRIBER R01 BCC OF RADIATION THERAPY FIELDS OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION C.7.f 5/15/2017 5/1/2017 5/12/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C19 MALIGNANT NEOPLASM PROFESSIONAL $197.27 $500.00 FEMALE SUBSCRIBER R01 BCC 3559 TREATMENTS OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION U) N 5/15/2017 5/2/2017 5/12/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C19 MALIGNANT NEOPLASM PROFESSIONAL $36.38 $150.00 FEMALE SUBSCRIBER R01 BCC 3559 OF RADIATION THERAPY FIELDS OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 5/15/2017 5/3/2017 5/12/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C19 MALIGNANT NEOPLASM PROFESSIONAL $3638 $150.00 FEMALE SUBSCRIBER R01 BCC 3559 7 OF RADIATION THERAPY FIELDS OF RECTOSIGMOID OUTPATIENT /HOSPITAL JUNCTION 5/16/2017 12/22/2016 1/3/2017 45380 COLONOSC OPY , FLEXIBLE; WITH BIOPSY, SINGLE OR 21211 ENCOUNTER FOR PROFESSIONAL ($269..i0I $737.00 FEMALE SUBSCRIBER R01 BCC 3559 MULTIPLE SCREENING FOR OUTPATIENT /HOSPITAL } MALIGNANT NEOPLASM OFCOLON CL 5/25/2017 12/22/2016 5/24/2017 88305 LEVEL IV- SURGICAL PATHOLOGY, GROSS AND C44520 SQUAMOUS CELL PROFESSIONAL $0.00 $510.00 FEMALE SUBSCRIBER 1 BCC 3559 Q, MICROSCOPIC EXAMINATION ABORTION- CARCINOMAOFANAL OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE SKIN v MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, rf NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION W 5/25/2017 12/22/2016 5/24/2017 88313 SPECIAL STAI N I NCEO D I N G I NEE R P R ETATI O N AN D R EPORT; C44520 SQUAMOUS CELL PROFESSIONAL $13.87 $158.00 FEMALE SUBSCRIBER 1BCC 3559 h GROUP II,ALLOTHER(EG, IRDN,TRICHROME), EXCEPT CARCINOMAOFANAL OUTPATIENT /HOSPITAL STAIN FOR MICROORGANISMS, STAINS FOR ENZYME SKIN CONSTITUENTS, OR IM MUNOCYTOCH EMISTRY AND IMMUNOHISTOCH EMISTRY 512512017 12/22/2016 5/24/2017 88341 IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, C44520 SQUAMOUS CELL PROFESSIONAL $0.00 $66.00 FEMALE SUBSCRIBER 1 BCC 3559 PERSPECIMEN; EACH ADDITIONAL SINGLE ANTIBODY CARCINOMAOFANAL OUTPATIENT /HOSPITAL Q STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO SKIN {i CODE FOR PRIMARY PROCEDURE) 5/25/2017 12/22/2016 5/24/2017 88342 IMMUNOHISTOCHEMISTRYOR IMMUNO CYTOCHEMISTRY, C44520 SQUAMOUS CELL PROFESSIONAL $0.00 $180.00 FEMALE SUBSCRIBER 1 BCC 3559 PERSPECIMEN; INITIAL SINGLE ANTIBODY STAIN CARCINOMAOFANAL OUTPATIENT /HOSPITAL PROCEDURE SKIN 5/26/2017 5/17/2017 5/24/2017 * *' "* * *' ** *' " ** ` * * ** *" ** $97.40 $298.00 FEMALE SUBSCRIBER RO1 BCC 3559 LLj 6/1/2017 2/22/2017 5/31/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C763 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $210.83 $566.00 FEMALE SUBSCRIBER RO1 BCC 3559 EVALUATION AND MANAGEMENT OF ANEW PATIENT, OF PELVIS WHICH REQUIRES THESE 3 KEY COMPONENTS: A J COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH v COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE W 6/1/2017 2/23/2017 5/31/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C763 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $71.49 $312.00 FEMALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PELVIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED Q HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOR❑ {hj 6/1/2017 2/28/2017 5/31/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C763 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $106.77 $370.00 FEMALE SUBSCRIBER RO1 BCC 3559 Cy EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PELVIS = PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY y COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER C.7.f 6/1/2017 3/6/2017 3/14/2017 910 ANESTHESIA FORTRAN SUR ETHRAL PROCEDURES C763 MALIGNANT NEOPLASM OTHER MEDICAL $733.03 $1,408.00 FEMALE SUBSCRIBER R01 BCC 3559 (INCLUDING URETHROCY5TOS COPY); NOT OTHERWISE OF PELVIS W SPECIFIED 6/1/2017 3/9/2017 5/31/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C763 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $106.77 $370.00 FEMALE SUBSCRIBER R01 BCC 3559 N EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PELVIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED A EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 7 COORDINATION OF CARE WITH OTHER "a 6/1/2017 3/16/2017 5/31/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C763 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $106.77 $370.00 FEMALE SUBSCRIBER BUT BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PELVIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY } COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF iL CL MODERATE COMPLEXITY. COUNSELING AND /OR Q, COORDINATION OF CARE WITH OTHER 6/1/2017 3/23/2017 5/31/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C210 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $7149 $312.00 FEMALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF ANUS, UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED h EXAMINATION; MEDICAL DECISION MAKING OF LOW D COMPLEXITY. COUNSELING AND COORD 6/1/2017 4/10/2017 5/31/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C210 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $106.77 $370.00 FEMALE SUBSCRIBER R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF ANUS, UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF Q MODERATE COMPLEXITY. COUNSELING AND /OR ui COORDINATION OF CARE WITH OTHER 6/1/2017 4/17/2017 5/31/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C210 MALIGNANT NEOPLASM PROFE55IONAL OFFICE $106.77 $370.00 FEMALE SUBSCRIBER R01 BCC 3559 U EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF ANUS, UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED LLJ U EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR �q COORDINATION OF CARE WITH OTHER J 6/6/2017 3/6/2017 6/5/2017 910 AN ESTH ESIA FO R TRA N S U R ETH RAIL P ROCEDU R ES C763 VATIC NAST N EOPLASM OTHER MEDICAL $0.00 $1,408.00 FEMALE SUBSCRIBER R01 BCC 3559 U (INCLUDING URETHROCYSTOSCOPY ); NOT OTHERWISE OF PELVIS SPECIFIED 6/9/2017 3/6/2017 6/8/2017 99218 INITIAL OBSERVATION CARE, PER DAY, FOR THE C218 MALIGNANT NEOPLASM PROFESSIONAL $69.81 $212.00 FEMALE SUBSCRIBER R01 BCC 3559 uj EVALUATION AND MANAGEMENT OF A PATIENT WHICH OF OVERLAPPING SITES INPATIENT / HDSPITAL REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR O F RECTU M, AN US AND COMPREHENSIVE HISTORY; A DETAILED OR ANAL CANAL U COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKI NG THAT IS STRAIGHTFORWARD OR OF LOW ` p COMPLEXITY. COUNSELING AND / Q N 6/9/2017 3/7/2017 6/8/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C218 MALIG NANT N EOPLASM PROFESSIONAL $75.14 $153,00 FEMALE SUBSCRIBER R01 EGG 3559 Cy EVALUATION AND MANAGEMENTOFA PATIENT ,WHICH OF OVERLAPPING SITES INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN OF RECTUM, ANUS AND = EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN ANALCANAL y EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. .G COUNSELING AND /OR m 6/9/2017 3/8/2017 6/8/2017 6/9/2017 5/1/2017 6/7/2017 - 6/9/2017 5/2/2017 6/7/2017 - 6/9/2017 5/3/2017 6/7/2017 - 6/19/2017 6/9/2017 6/16/2017 `` "" 6126/2017 4/20/2017 6/23/2017 - 6/30/2017 3/28/2017 612812017 - 6/30/2017 3/29/2017 6/28/2017 - 6/30/2017 3/30/2017 6/28/2017 - 7/7/2017 5/3/2017 7/6/2017 7/19/2017 7111/2017 7/15/2017 7/19/2017 7/11/2017 7/15/2017 7/19/2017 7/11/2017 7/15/2017 Q9967 8/30/2017 3/6/2017 3/14/2017 8/30/2017 3/6/2017 3/14/2017 8/30/2017 7 /28/2017 812812017 - 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE K6289 OTHER SPECIFIED PROFESSIONAL THAN 3D MINUTES SUBSCRIBER RO1 BCC DISEASES OF ANUS AND INPATIENT /HOSPITAL SUBSCRIBER RO1 BCC $2,243.00 RECTUM SUBSCRIBER R01 BCC - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,259.51 FEMALE SUBSCRIBER R01 BCC OF RECTOSIGMOID $1,849.50 FEMALE SUBSCRIBER R01 BCC $1,142.00 JUNCTION SUBSCRIBER R01 BCC - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $312.00 FEMALE SUBSCRIBER 301 BCC OF RECTOSIGMOID JUNCTION - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF RECTOSIGMOID JUNCTION - C19 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF RECTOSIGMOID JUNCTION - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C210 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF ANUS, UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST C44520 SQUAMOUS CELL OTHER MEDICAL MATERIALS) CARCINOMA. OF ANAL SKIN 74178 COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; C44520 SQUAMOUS CELL OTHER MEDICAL WITHOUT CONTRAST MATERIAL IN I OR BOTH BODY CARCINOMA OF ANAL REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND SKIN FURTHER SECTIONS IN 1 OR BOTH BODY REGIONS LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG /ML C44520 SQUAMOUS CELL OTHER MEDICAL IODINE CONCENTRATION, PER ML CARCINOMA OF ANAL SKIN 910 ANESTHESIA FO R TRA N S U R ETH RAE P ROCEDU R ES C763 VATIC NANT N EOPLASM OTHER MEDICAL (INCLUDING URETHROCYSTOSCOPY ); NOT OTHERWISE OF PELVIS SPECIFIED 910 ANESTHESIA FOR TRANSURETHRAL PROCEDURES C763 MALIGNANT NEOPLASM OTHER MEDICAL (INCLUDING URETHRDCYSTOSCOPY); NOT OTHERWISE OF PELVIS SPECIFIED - Z139 ENCOUNTER FOR HOSPITAL OUTPATIENT SCREENING, UNSPECIFIED $108.12 $227.00 FEMALE SUBSCRIBER R01 BCC $1,907.14 $1,907.14 FEMALE SUBSCRIBER RO1 BCC $1,907.14 $1,907.14 FEMALE SUBSCRIBER RO1 BCC $2,243.00 $2,259.51 FEMALE SUBSCRIBER R01 BCC $871.50 $1,162.00 FEMALE SUBSCRIBER RO1 BCC $2,243.00 $2,259.51 FEMALE SUBSCRIBER R01 BCC $1,849.50 $1,849.50 FEMALE SUBSCRIBER R01 BCC $1,142.00 $1,14100 FEMALE SUBSCRIBER R01 BCC $1,353.00 $1,353.00 FEMALE SUBSCRIBER RO1 BCC $7149 $312.00 FEMALE SUBSCRIBER 301 BCC $222.99 $829.00 FEMALE SUBSCRIBER R01 BCC $515.00 $1,278.00 FEMALE SUBSCRIBER RO1 BCC $10.40 $240.00 FEMALE SUBSCRIBER R01 BCC $733.03 $1,408.00 FEMALE SUBSCRIBER R01 BCC ($733, C31I ($1,403, 00 FEMALE SUBSCRIBER RO1 BCC $26735 $357.00 FEMALE SUBSCRIBER R01 BCC C.7.f 3559 w Z 3559 N 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 rl 9/1/2017 7/13/2017 81 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 0210 $91.85 FEMALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED BCC 3559 PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY BCC 3559 COMPONENTS: A DETAILED HISTORY; A DETAILED $52.00 FEMALE OF ANUS, UNSPECIFIED EXAMINATION; MEDICAL DECISION MAKING OF MALIGNANT NEOPLASM OTHER MEDICAL MODERATE COMPLEXITY. COUNSELING AND /OR $58.45 FEMALE SUBSCRIBER R01 COORDINATION OF CARE WITH OTHER 3559 1011012017 10/5/2017 10/9/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C210 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED ADJUSTMENT AND DEPENDENT PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY OTHER MEDICAL $165.72 COMPONENTS: A DETAILED HISTORY; A DETAILED SUBSCRIBER R01 BCC EXAMINATION; MEDICAL DECISION MAKING OF OF ANUS, UNSPECIFIED $5,712.00 MALE MODERATE COMPLEXITY. COUNSELING AND /OR 1 BCC 3559 COORDINATION OF CARE WITH OTHER $5,712.00 MALE 1011212017 10/2/2017 1011012017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C210 $1,278.00 FEMALE INCLUDE THE FOLLOWING; ALBUMIN (82040), BILIRUBIN, BCC 3559 TOTAL (82247), CALCIUM, TOTAL (82310), CARBON $492.41 $5,712.00 MALE DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), 1 BCC OF ANUS, UNSPECIFIED CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, Sub Total DEPENDENT ALKALINE (84075), POTASSIUM (84132), PROTEIN, 3559 10/12/2017 10/2/2017 10/10/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C210 1.875E +10 9/19/2017 HCT, BBC, W BC AND PLATELET COUNT) AND AUTOMATED 9118/2017 DIFFERENTIAL W BC COUNT 10/12/2017 10/3/2017 10/6/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST C210 9/18/2017 * * * ** MATERIALS) 10/12/2017 10/3/2017 10/6/2017 74178 COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; C210 8/22/2017 WITHOUT CONTRAST MATERIAL IN 1 OR BOTH BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S)AND 9/19/2017 FURTHER SECTIONS IN I OR BOTH BODY REGIONS 9/18/2017 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF ANUS, UNSPECIFIED MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF ANUS, UNSPECIFIED $106.77 $370.00 FEMALE SUBSCRIBER R01 BCC $10637 $370.00 FEMALE SUBSCRIBER R01 BCC C.7.f 3559 III MALIGNANT NEOPLASM OTHER MEDICAL $8.27 $91.85 FEMALE SUBSCRIBER R01 BCC 3559 OF ANUS, UNSPECIFIED BCC 3559 IODINE CONCENTRATION, PER ML $52.00 FEMALE OF ANUS, UNSPECIFIED BCC MALIGNANT NEOPLASM OTHER MEDICAL $6.08 $58.45 FEMALE SUBSCRIBER R01 BCC 3559 OF ANUS, UNSPECIFIED DEPENDENT 1 BCC 3559 $492.41 ADJUSTMENT AND DEPENDENT MALIGNANT NEOPLASM OTHER MEDICAL $165.72 $829.00 FEMALE SUBSCRIBER R01 BCC 3559 OF ANUS, UNSPECIFIED $5,712.00 MALE DEPENDENT 1 BCC 3559 VASCULAR ACCESS DEVICE $5,712.00 MALE MALIGNANT NEOPLASM OTHER MEDICAL $399.77 $1,278.00 FEMALE SUBSCRIBER R01 BCC 3559 OF ANUS, UNSPECIFIED $492.41 $5,712.00 MALE DRUG DELIVERY SYSTEMS 1 BCC OF ANUS, UNSPECIFIED $492.41 10/12/2017 10/3/2017 10/6/201]Q996] LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG /ML C210 MALIGNANT NEOPLASM OTHER MEDICAL SUBSCRIBER RO1 BCC 3559 IODINE CONCENTRATION, PER ML $52.00 FEMALE OF ANUS, UNSPECIFIED BCC 12/6/2017 1112712017 12/4/2017 - - Z452 ENCOUNTER FOR HOSPITAL OUTPATIENT $9,576.00 MALE DEPENDENT 1 BCC 3559 $492.41 ADJUSTMENT AND DEPENDENT 1 BCC 3559 $492.41 $5,712.00 MALE DEPENDENT MANAGEMENT OF 3559 $492.41 $5,712.00 MALE DEPENDENT 1 BCC 3559 VASCULAR ACCESS DEVICE $5,712.00 MALE 12/29/2017 10/3/2017 12128/2017 96523 IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR C210 MALIGNANT NEOPLASM PROFESSIONAL OFFICE 3559 $492.41 $5,712.00 MALE DRUG DELIVERY SYSTEMS 1 BCC OF ANUS, UNSPECIFIED $492.41 Sub Total DEPENDENT 1 BCC 3559 $492.41 $5,712.00 MALE DEPENDENT 1.875E +10 9/19/2017 8/20/2017 9118/2017 9/19/2017 8/21/2017 9/18/2017 * * * ** 9/19/2017 8/22/2017 9/18/2017 * * » 9/19/2017 8/23/2017 9/18/2017 9/19/2017 8/24/2017 9/18/201] * *ar* * * * ** *xr ** * *... *. *.. 9/19/2017 8/25/2017 9/18/201] 9/19/2017 8/26/2017 9/18/2017 9/19/2017 8/27/2017 9/18/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A SYNDROME OF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 9/19/2017 8/28/2017 9/18/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A SYNDROME OF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS $9.60 $240.00 FEMALE SUBSCRIBER R01 BCC 3559 $281.25 $375.00 FEMALE SUBSCRIBER RO1 BCC 3559 $26.28 $52.00 FEMALE SUBSCRIBER R01 BCC 3559 $115,203.83 $200,693.82 $1,352.11 $9,576.00 MALE DEPENDENT 1 BCC 3559 $492.41 $5,712.00 MALE DEPENDENT 1 BCC 3559 $492.41 $5,712.00 MALE DEPENDENT 1 BCC 3559 $492.41 $5,712.00 MALE DEPENDENT 1 BCC 3559 $492.41 $5,712.00 MALE DEPENDENT 1 BCC 3559 $492.41 $5,712.00 MALE DEPENDENT 1 BCC 3559 $492.41 $5,712.00 MALE DEPENDENT 1 BCC 3559 $492.41 $5,712.00 MALE DEPENDENT 1 BCC 3559 $492.41 $5,712.00 MALE DEPENDENT 1 BCC 3559 9/19/2017 8/29/2017 9/18/2017 99469 SUBS EQU ENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $492.41 $5,712.00 MALE DEPENDENT 1 BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 9/19/2017 8/30/2017 9/18/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $492.41 $5,712.00 MALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 9/19/2017 8/31/2017 9/18/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $492.41 $5,712.00 MALE DEPENDENT 1 BCC DAY, FORTHE EVALUATIDNAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HDSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 9/19/2017 9/1/2017 9/18/2017 99479 SUBSEQUENT INTENSIVE CARE, PER DAY, FDRTHE P220 RESPIRATORY DISTRESS PROFESSIONAL $15348 $2,983.00 MALE DEPENDENT 1 BCC EVALUATION AND MANAGEMENTOFTHE RECOVERING SYNDROMEOF NEWBORN INPATIENT /HOSPITAL LOW BIRTH WEIGHT INFANT (PRESENT BODY WEIGHT OF 1500 -25DD GRAMS) 9/19/2017 9/2/2017 9/18/2017 99479 SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE P220 RESPIRATORY DISTRESS PROFESSIONAL $153.48 $2,983.00 MALE DEPENDENT 1BCC EVALUATION AND MANAGEMENTOFTHE RECOVERING SYNDROMEOF NEWBORN INPATIENT/HOSPITAL LOW BIRTH WEIGHT INFANT (PRESENT BODY WEIGHT OF 1500 -250D GRAMS) 9/19/2017 9/3/2017 9/18/2017 99479 SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE P284 OTHER APNEA OF PROFESSIONAL $0.00 $2,983.00 MALE DEPENDENT 1BCD EVALUATION AND MANAGEMENTOFTHE RECOVERING NEWBORN INPATIENT /HOSPITAL LOW BIRTH WEIGHT INFANT (PRESENT BODY WEIGHT OF 1500 -25DD GRAMS) 9/19/2017 9/4/2017 9/18/2017 99480 SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE P284 OTHER APNEA OF PROFESSIONAL $2.09 $2,713.00 MALE DEPENDENT 1BCC EVALUATION AND MANAGEMENTOFTHE RE COVERING NEWBORN INPATIENT /HDSPITAL INFANT (PRESENT BODY WEIGHT OF 2501 -5000 GRAMS) 9/19/2017 9/5/2017 9/18/2017 99480 SUBSEQUENT INTENSIVE CARE, PER DAY, FDRTHE P294 OTHERAPNEAOF PROFESSIONAL $148.61 $2,713.00 MALE DEPENDENT 1BCC EVALUATION AND MANAGEMENTOFTHE RECOVERING NEWBORN INPATIENT /HOSPITAL INFANT (PRESENT BODY WEIGHT OF 2501 -5000 GRAMS) 9/19/2017 9/6/2017 9/1S/2017 99480 SUBSEQUENT INTENSIVE CARE, PERDAY, FDRTHE P284 OTHERAPNEAOF PROFESSIONAL $145.61 $2,713.00 MALE DEPENDENT 1BCC EVALUATION AND MANAGEMENTOFTHE RE COVERING NEWBORN INPATIENT /HOSPITAL INFANT (PRESENT BODY WEIGHT OF 2501 -5000 GRAMS) 9/19/2017 917/2017 9/18/2017 92586 AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE P284 OTHER APNEA OF PROFESSIONAL $137.04 $714.00 MALE DEPENDENT 1 BCC AUDIOMETRY AND /OR TESTING OFTHECENTRAL NEWBORN INPATIENT /HOSPITAL NERVOUS SYSTEM; LIMITED 9/19/2017 9/7/2017 9/18/2017 99480 SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE P284 OTHER APNEA OF PROFESSIONAL $148.61 $2,713.00 MALE DEPENDENT 1BCC EVALUATION AND MANAGEMENTOFTHE RECOVERING NEWBORN INPATIENT /HOSPITAL INFANT (PRESENT BODY WEIGHT OF 2501 -5000 GRAMS) 9/19/2017 9/8/2017 9/18/2017 99480 SUBSEQUENT INTENSIVE CARE, PER DAY, FORTHE P284 OTHERAPNEAOF PROFESSIONAL $148.61 $2,713.00 MALE DEPENDENT 1BCC EVALUATION AND MANAGEMENTOFTHE RECOVERING NEWBORN INPATIENT /HOSPITAL INFANT (PRESENT BODY W EIGHT OF 2501 -5000 GRAMS) 9/19/2017 9/9/2017 9/18/2017 99480 SUBSEQU ENT I NTENSIVE CARE, PERDAY, FORTHE P284 OTHERAPNEAOF PROFESSIONAL $148.61 $2,713.00 MALE DEPENDENT 1BCD EVALUATION AND MANAGEMENTOFTHE RE COVERING NEWBORN INPATIENT /HDSPITAL INFANT (PRESENT BODY WEIGHT OF 2501 -5000 GRAMS) 9/19/2017 9/10/2017 9/18/2017 99480 SUBSEQUENT INTENSIVE CARE, PER DAY, FORTHE P284 OTHERAPNEAOF PROFESSIONAL $148.61 $2,713.00 MALE DEPENDENT 1DEC EVALUATION AND MANAGEMENTOFTHE RECOVERING NEWBORN INPATIENT /HOSPITAL INFANT (PRESENT BODY WEIGHT OF 2501 -50DO GRAMS) 9/19/2017 9/11/2017 9/18/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE P284 OTHER APNEA OF PROFESSIONAL $131.42 $967.00 MALE DEPENDENT 1 BCC THAN 3D MINUTES NEWBORN INPATIENT /HOSPITAL 9128/2017 9/21/2017 9/26/2017 54150 CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH Z412 ENCOUNTER FOR PROFESSIONAL OFFICE $538.41 $750.00 MALE DEPENDENT 1BCD REGIONAL DORSAL PENILE OR RING BLOCK ROUTINE AND RITUAL MALE CIRCUMCISION C.7.f 9/28/2017 9/21/2017 9/26/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z412 ENCOUNTER FOR PROFESSIONAL OFFICE $155.80 $250.00 MALE DEPENDENT 1BCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED ROUTINE AND RITUAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY MALE CIRCUMCISION COMPONENTS: A DETAILED HISTORY; A DETAILED N EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER t 10/12/2017 9/13/2017 10/11/2017 99381 INITIAL COMPREHENSIVE PREVENTIVE MEDICINE 200111 HEALTH EXAMINATION PROFESSIONAL OFFICE $96.53 $200.00 MALE DEPENDENT 1 BCC 3559 7 EVALUATION AND MANAGEMENT OF AN INDIVIDUAL FOR NEWBORN 8 TO 28 INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, DAYS OLD EXAMINATION, COUNSELING /ANTICIPATORY GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC } PROCEDURES, NEW PATIENT; INFANT (AGE YOUNGER THAN 11'EAR) G. CL 10116/2017 8/20/2017 10/5/2017 * * * "* " "* * * * ** ' *' *' " "* 8/20/2017 4####Pg# $112,719.87 $179,607.00 MALE DEPENDENT 1 BCC 3559 10/17/2017 9/20/2017 10/16/2017 99391 PERIODICCOMPREHENSIVE PREVENTIVE MEDICINE 200111 HEALTH EXAMINATION PROFESSIONAL OFFICE $81.17 $125.00 MALE DEPENDENT 1 BCC 3559 v REEVALUATIONAND MANAGEMENTOFAN INDIVIDUAL FOR NEWBORN 8 TO 28 INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, DAYS OLD rf EXAMINATION, COUNSELING /ANTICIPATORY GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABDRATORY /DIAGNOSTIC F PROCEDURES, ESTABLISHED PATIENT; INFANT (AGE YOUNGER THAN I YEAR) 11/7/2017 11/3/2017 11/6/2017 99391 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $81.17 $125.00 MALE DEPENDENT 1 BCC 3559 _ REEVALUATIONAND MANAGEMENTOFAN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, IL ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC Lli PROCEDURES, ESTABLISHED PATIENT; INFANT (AGE YOUNGER THAN 1 YEAR) UJ 11/8/2017 10/4/2017 11/7/2017 99391 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $81.17 $125.00 MALE DEPENDENT 1 BCC 3559 REEVALUATIONAND MANAGEMENTOFAN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT LLJ EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; INFANT (AGE YOUNGER THAN I YEAR) v 11/28/2017 812012017 11/27/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, P0730 PRETERM NEWBORN, PROFESSIONAL $16.29 $41.00 MALE DEPENDENT 1 BCC 3559 FRONTAL UNSPECIFIED WEEKS OF INPATIENT /HOSPITAL LLJ GESTATION 11/28/2017 8/20/2017 11/27/2017 74000 RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE P0730 PRETERM NEWBORN, PROFESSIONAL $16.29 $45.00 MALE DEPENDENT 1 BCC 3559 ANTEROPOSTERIDR VIEW UNSPECIFIED WEEKS OF INPATIENT / HDSPITAL (' GESTATION 1112812017 8/21/2017 11/27/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, P220 RESPIRATORY DISTRESS PROFESSIONAL $1619 $41.00 MALE DEPENDENT 1 BCC 3559 FRONTAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL {V 11/28/2017 8/22/2017 11127/2017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, Z4682 ENCOUNTER FOR FITTING PROFESSIONAL $32.58 $82.00 MALE DEPENDENT 1 BCC 3559 Cy FRONTAL ANDADIUSTMENTOF INPATIENT /HOSPITAL NON - VASCULAR C CATHETER 1112812017 8/22/2017 1112712017 74000 RADIOLOGICEXAMINATIDN , ABDOMEN; SINGLE Z4682 ENCOUNTER FOR FITTING PROFESSIONAL $16.29 $45.00 MALE DEPENDENT 1 BCC 3559 ANTEROPOSTERIOR VIEW ANDADIUSTMENTOF INPATIENT /HOSPITAL L NON- VASCUTAR CATHETER �, C.7.f 1112812017 8/24/2017 11/27/2017 71010 RADIO LOGIC EXAM I NATION, CHEST; SINGLE VIEW, P229 RESPIRATORY DISTRESS PROFESSIONAL $16.29 $41.00 MALE DEPENDENT 1 BCC 3559 FRONTAL OF NEWBORN, INPATIENT /HOSPITAL UNSPECIFIED 12/8/2017 8/20/2017 12/6/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, POE, P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $74.00 MALE DEPENDENT 1 BCC 3559 N CEO, HCO3 (INCLUDING CALCULATED O2 SATURATION); SYNDROME OF NEWBORN INPATIENT /HOSPITAL Q! 12/8/2017 8/20/2017 12/6/2017 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $30.00 MALE DEPENDENT 1 BCC 3559 A STRIP) SYNDROME OF NEW BORN INPATIENT /HDSPITAL i 12/8/2017 8/20/2017 12/6/2017 86880 ANTIHUMAN GLOBULIN TEST (COOMBSTEST); DIRECT, P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $7.00 MALE DEPENDENT 1BCC 3559 "a EACH ANTISERUM SYNDROME OF NEWBORN INPATIENT /HOSPITAL m O 12/8/2017 8/20/2017 12/6/2017 86900 BLOOD TYPING, SEROLOGIC; ABO P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $31.00 MALE DEPENDENT 1 BCC 3559 SYNDROME OF NEWBORN INPATIENT /HOSPITAL } fl 121812017 8/20/2017 12/6/2017 86901 BLOOD TYPING, SEROLOGIC; RH(0) P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $12.00 MALE DEPENDENT 1 BCC 3559 N. CL SYNDROME OF NEWBORN INPATIENT /HOSPITAL Q, Q 12/8/2017 8/21/2017 12/6/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $74.00 MALE DEPENDENT 1 BCC 3559 v MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL (82310)CARBON DIOXIDE (82374) CHLORIDE (82435) Q CREATI NINE (92565) GLUCOSE (92947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) �- W 12/8/2017 8/21/2017 12/6/2017 82247 BILIRUBIN; TOTAL P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 ~ SYNDROMEOF NEWBORN INPATIENT /HDSPITAL 12/8/2017 8/21/2017 12/6/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, POE, P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $74.00 MALE DEPENDENT 1 BCC 3559 _ CO2, HCO3 ( INCLUDING CALCULATED O2 SATURATION); SYNDROME OF NEWBORN INPATIENT /HOSPITAL 12/8/2017 8/21/2017 12/6/2017 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $30.00 MALE DEPENDENT 1 BCC 3559 STRIP) SYNDROME OF NEWBORN INPATIENT /HOSPITAL Q W 12/8/2017 8/21/2017 12/6/2017 83735 MAGNESIUM P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $10.00 MALE DEPENDENT 1 BCC 3559 SYNDROME OF NEWBORN INPATIENT /HOSPITAL UJ 12/8/2017 8121/2017 12/6/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $13.00 MALE DEPENDENT 1 BCC 3559 0 SYNDROME OF NEWBORN INPATIENT /HOSPITAL {JJ 121812017 8/21/2017 12/6/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $19.00 MALE DEPENDENT 1 BCC 3559 HU, FEE, WBC AND PLATELET COUNT) AND AUTOMATED SYNDROME OF NEWBORN INPATIENT /HOSPITAL �q DIFFERENTIAL W BC COUNT J 12/8/2017 8/22/2017 12/6/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $37.00 MALE DEPENDENT 1 BCC 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL v (82310)CARBON DIOXIDE (82374) CHLORIDE (82435) CREATI MINE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM 184295) UREA NITROGEN (BUN) (84520) LLJ 12/8/2017 8/22/2017 12/6/2017 82247 BILIRUBIN;TOTAL P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 12/8/2017 8/22/2017 12/6/2017 82248 BILIRUBIN; DIRECT P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 F SYNDROMEOF NEWBORN INPATIENT /HDSPITAL {V 12/8/2017 8/22/2017 12/6/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $148.00 MALE DEPENDENT 1 BCC 3559 N COE, HOOD (INCLUDING CALCULATED O2 SATURATION); SYNDROME OF NEWBORN INPATIENT /HOSPITAL C 12/8/2017 8/22/2017 12/6/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $60.00 MALE DEPENDENT 1 BCC 3559 y STRIP) SYNDROME OF NEWBORN INPATIENT /HOSPITAL C.7.f 12/8/2017 8/22/2017 12/6/2917 12/8/2017 8/22/2017 12/6/2017 12/8/2017 8/22/2017 12/6/2017 12/8/2017 8/22/2017 12/6/2017 12/8/2017 8/22/2017 12/6/2017 121812017 8/23/2017 12/6/2017 12/8/2017 8/23/2017 12/6/2017 121812017 8/23/2017 12/6/2017 12/8/2017 8/23/2017 12/6/2017 12/8/2017 8/23/2017 12/6/2017 12/8/2017 8/23/2017 12/6/2017 12/8/2017 8/23/2017 12/6/2017 121812017 8/23/2017 12/6/2017 12/8/2017 8/23/2017 12/6/2017 121812017 8/23/2017 12/6/2017 12/8/2017 8/23/2017 12/6/2017 12/8/2017 8/23/2017 12/6/2017 12/8/2017 8/23/2017 12/6/2017 12/8/2017 8/24/2017 12/6/2017 121812017 8/24/2017 12/6/2017 83735 MAGNESIUM P220 84100 PHOSPHORUS INORGANIC (PHOSPHATE); P220 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, P220 HOT, BBC, NBC AND PLATELET COUNT) AND AUTOMATED DEPENDENT DIFFERENTIAL W BC COUNT 3559 86140 C- REACTIVE PROTEIN; P220 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION P220 AND PRESUMPTIVE IDENTIFICATION OF ISOLATES $0.00 (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) DEPENDENT 88106 SIMPLE FILTER METHOD WITH INTERPRETATION P220 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PDX, P220 CO2, HCO3 (INCLUDING CALCULATED 02 SATURATION); 1 BCC 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT P220 STRIP) DEPENDENT 82247 BILIRUBIN; TOTAL P220 82248 BILIRUBIN; DIRECT P220 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) P220 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE $0.00 84157 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER P220 SOURCE (EG, SYMOVIAL FLUID, CEREBROSPINAL FLUID) 3559 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, P220 HOT, BBC, W BC AND PLATELET COUNT) AND AUTOMATED 1 BCC DIFFERENTIAL W BC COUNT $0.00 86140 C- REACTIVE PROTEIN; P220 87070 CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, P220 BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND $19.00 MALE PRESUMPTIVE IDENTIFICATION OF ISOLATES 1 BCC 87205 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM P220 OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELLTYPES DEPENDENT 89051 CELL COUNT, MISCELLANEOUS BODY FLUIDS(EG, P220 CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; $19.00 MALE WITH DIFFERENTIAL COUNT 1 BCC 82945 GLUCOSE, BODY FLUID, OTHER THAN BLOOD P220 80170 GENTAMICIN P220 82247 BILIRUBIN; TOTAL P220 RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEW BORN INPATIENT /HDSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HDSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HDSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL $0.00 $10.00 MALE DEPENDENT 1 BCC 3559 $0.00 $13.00 MALE DEPENDENT 1 BCC 3559 $0.00 $19.00 MALE DEPENDENT 1 BCC 3559 $0.00 $19.00 MALE DEPENDENT 1 BCC 3559 $0.00 $24.00 MALE DEPENDENT 1 BCC 3559 $70.01 $197.00 MALE DEPENDENT 1 BCC 3559 $0.00 $74.00 MALE DEPENDENT 1 BCC 3559 $0.00 $30.00 MALE DEPENDENT 1 BCC 3559 $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 $0CD $19.00 MALE DEPENDENT 1 BCC 3559 $0.00 $10.00 MALE DEPENDENT 1 BCC 3559 $0.00 $19.00 MALE DEPENDENT 1 BCC 3559 $0.00 $19.00 MALE DEPENDENT 1 BCC 3559 $0.00 $24.00 MALE DEPENDENT 1 BCC 3559 $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 $0.00 $29.00 MALE DEPENDENT 1 BCC 3559 $0.00 $12.00 MALE DEPENDENT 1 BCC 3559 $0.00 $30.00 MALE DEPENDENT 1 BCC 3559 $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 C.7.f 12/8/2017 8/24/2017 12/6/2017 82248 BILIRUBIN; DIRECT P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 12/8/2017 8/24/2017 12/6/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $37.00 MALE DEPENDENT 1 BCC 3559 CO2,HCO3(INCLUDING CALCULATED O2 SATURATION); SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 12/8/2017 8/24/2017 12/6/2017 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $15.00 MALE DEPENDENT 1 BCC 3559 STRIP) SYNDROMEOF NEWBORN INPATIENT /HDSPITAL 12/8/2017 8/25/2017 12/6/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $37.00 MALE DEPENDENT 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL SYNDROMEOF NEWBORN INPATIENT /HOSPITAL (82310)CARBON DIOXIDE(82374) CHLORIDE(82435) CREATI NINE (82565) GLUCOSE(82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN( (84520) 12/8/2017 8125/2017 12/6/2017 82247 BILIRUBIN; TOTAL P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 121812017 8/25/2017 12/6/2017 82248 BILIRUBIN; DIRECT P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 12/8/2017 8/25/2017 12/6/2017 83735 MAGNESIUM P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $10.00 MALE DEPENDENT 1 BCC 3559 SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 12/8/2017 8/25/2017 12/6/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $13.00 MALE DEPENDENT 1 BCC 3559 SYNDROMEOF NEWBORN INPATIENT /HDSPITAL 12/8/2017 8/25/2017 12/6/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $19.00 MALE DEPENDENT 1 BCC 3559 HOT RBC,WBCAND PLATELET COUNT) AND AUTOMATED SYNDROMEOF NEWBORN INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 12/8/2017 8/2S/2017 12/6/2017 86140 C- REACTIVE PROTEIN; P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $19.00 MALE DEPENDENT 1 BCC 3559 SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 12/8/2017 8/26/2017 12/6/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $37.00 MALE DEPENDENT 1 BCC 3559 CO2, HCO3 (INCLUDING CALCULATED D2 SATURATION); SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 12/8/2017 8126/2017 12/6/2017 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $15.00 MALE DEPENDENT 1 BCC 3559 STRIP) SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 121812017 8/27/2017 12/6/2017 82247 BILIRUBIN; TOTAL P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 12/8/2017 8/27/2017 12/6/2017 82248 BILIRUBIN; DIRECT P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $7.00 MALE DEPENDENT 1 BCC 3559 SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 12/8/2017 8/27/2017 12/6/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $37.00 MALE DEPENDENT 1 BCC 3559 CO2, HCD3( INCLUDING CALCULATED D2 SATURATION); SYNDROMEOF NEWBORN INPATIENT /HDSPITAL 12/8/2017 812712017 12/6/2017 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $15.00 MALE DEPENDENT 1 BCC 3559 STRIP) SYNDROMEOF NEWBORN INPATIENT /HOSPITAL 12/8/2017 8/28/2017 12/6/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL P220 RESPIRATORY DISTRESS PROFESSIONAL $0.00 $37.00 MALE DEPENDENT 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL SYNDROMEOF NEWBORN INPATIENT /HOSPITAL (82310)CARBON DIOXIDE(82374) CHLORIDE(82435) CREATI NINE (82565) GLUCOSE(82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 12/8/2017 8/28/2017 12/6/2017 12/8/2017 8/28/2017 12/6/2017 12/8/2017 8/28/2017 12/6/2017 12/8/2017 8/28/2017 12/6/2017 121812017 8/31/2017 12/6/2017 12/8/2017 8/31/2017 12/6/2017 121812017 9/4/2017 12/6/2017 12/8/2017 91 12/6/2017 12/8/2017 9/4/2017 12/6/2017 12/8/2017 9/4/2017 12/6/2017 121812017 9/4/2017 12/6/2017 12/8/2017 9/4/2017 12/6/2017 Sub Total $7.00 MALE DEPENDENT 2.75E +10 1/30/2017 1/6/2017 1/10/2017 80076 HEPATIC FUNCTION PAN ELTH IS PANEL MUST INCLUDE P220 RESPIRATORY DISTRESS PROFESSIONAL THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL $0.00 SYNDROME OF NEWBORN INPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, 1 BCC $0.00 ALKALINE (84075), PROTEIN, TOTAL (84155), DEPENDENT 1 BCC TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460(, $7.00 MALE DEPENDENT TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) $0.00 $7.00 MALE 83735 MAGNESIUM P220 RESPIRATORY DISTRESS PROFESSIONAL $37.00 MALE DEPENDENT SYNDROME OF NEWBORN INPATIENT /HOSPITAL 84100 PHOSPHORUS INORGANIC (PHOSPHATE); P220 RESPIRATORY DISTRESS PROFESSIONAL 1 BCC SYNDROME OF NEWBORN INPATIENT /HOSPITAL 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, P220 RESPIRATORY DISTRESS PROFESSIONAL HCT,RBC, WBC AND PLATELET COUNT) AND AUTOMATED SYNDROME OF NEWBORN INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT 82247 BILIRUBIN; TOTAL P220 RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL 82248 BILIRUBIN; DIRECT P220 RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL P220 RESPIRATORY DISTRESS PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE P220 RESPIRATORY DISTRESS PROFESSIONAL THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SGDT) (84450) 83735 MAGNESIUM P220 RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL 84100 PHOSPHORUS INORGANIC (PHOSPHATE); P220 RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, P220 RESPIRATORY DISTRESS PROFESSIONAL HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED SYNDROME OF NEWBORN INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT 85045 BLOOD COUNT; RETICULOCYTE, AUTOMATED P220 RESPIRATORY DISTRESS PROFESSIONAL SYNDROME OF NEWBORN INPATIENT /HOSPITAL 99213 OFFICE DR OTHER OUTPATIENT VISIT FOR THE M25511 PAIN IN RIGHT SHOULDER PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD $0.00 $37.00 MALE DEPENDENT 1 BCC $0.00 $10.00 MALE DEPENDENT 1 BCC $0.00 $13.00 MALE DEPENDENT 1 BCC $0.00 $19.00 MALE DEPENDENT 1 BCC $0.00 $7.00 MALE DEPENDENT 1 BCC $0.00 $7.00 MALE DEPENDENT 1 BCC $0.00 $37.00 MALE DEPENDENT 1 BCC $0.00 $37.00 MALE DEPENDENT 1 BCC $0.00 $10.00 MALE DEPENDENT 1 BCC $0.00 $13.00 MALE DEPENDENT 1 BCC $0.00 $19.00 MALE DEPENDENT 1 BCC $0.00 $12.00 MALE DEPENDENT 1 BCC $122,175.95 $285,269.00 $44.57 $314.00 MALE SPOUSE 1 BCC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 H.SS: 1/30/2017 1/10/2017 111812017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE B349 VIRAL IN FECTI ON, OTHER MEDICAL $54.00 MALE SPOUSE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 3559 UNSPECIFIED $171.00 MALE SPOUSE 1 BCC PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $0.00 $54.00 MALE SPOUSE 1 BCC 3559 COMPONENTS: AN EXPANDED PROBLEM FOCUSED $171.00 MALE SPOUSE 1 BCC 3559 $0.00 HISTORY; AN EXPANDED PROBLEM FOCUSED SPOUSE 1 BCC 3559 $0.00 $57.00 MALE EXAMINATION; MEDICAL DECISION MAKING OF LOW 1 BCC 3559 $0.00 $54.00 MALE SPOUSE COMPLEXITY. COUNSELING AND COOED 3559 $0.00 $153.00 MALE 1/30/2017 1/20/2017 1/24/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M25311 OTHER INSTABILITY, OTHER MEDICAL 1 BCC 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP $54.00 MALE RIGHTSHOULDER 1 BCC 3559 $0.00 STRENGTH AND ENDURANCE, RANGE OF MOTION AND SPOUSE 1 BCC 3559 $0.00 $54.00 MALE FLEXIBILITY 1 BCC 3559 $0.00 1/30/2017 1/20/2017 1/24/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M25311 OTHER INSTABILITY, OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, RIGHTSHOULDER MANUAL TRACTION, 1 OR MORE REGIONS, EACH 15 MINUTES 113012017 1/23/2017 112412017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M25311 OTHER INSTABILITY, OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP RIGHTSHOULDER STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 1/30/2017 1/23/2017 1/24/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M25311 OTHER INSTABILITY, OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, RIGHTSHOULDER MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 1/31/2017 1/26/2017 1/27/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M25311 OTHER INSTABILITY, OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP RIGHTSHOULDER STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 1/31/2017 1/26/2017 1/27/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M25311 OTHER INSTABILITY, OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, RIGHT SHOULDER MANUAL TRACTION), 1 O MORE REGIONS, EACH 15 MINUTES 2/1/2017 1/11/2017 1/27/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M25311 OTHER INSTABILITY, OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP RIGHTSHOULDER STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 2/1/2017 1111/2017 1/27/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M25311 OTHER INSTABILITY, OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, RIGHTSHOULDER MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 21112017 1/11/2017 1/27/2017 97161 Physical therapy evaluation: low complexity, requiring N125311 OTHER INSTABILITY, OTHER MEDICAL theseComponents: A history with n o personal factors RIGHTSHOULDER and /or comorbidities that impact the plan of 2/1/2017 1/13/2017 1/27/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M25311 OTHER INSTABILITY, OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP RIGHT SHOULDER STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 2/1/2017 1/13/2017 1/27/2017 97140 MANUAL THERAPY TECH NIQUES (EG, MOBILIZATION/ M25311 OTHER INSTABILITY, OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, RIGHTSHOULDER MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 2/1/2017 1/16/2017 1/27/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M25311 OTHER INSTABILITY, OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP RIGHTSHOULDER STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 2/1/2017 1/16/2017 1/27/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M25311 OTHER INSTABILITY, OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, RIGHTSHOULDER MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 2/20/2017 1/25/2017 2/16/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF PROSTATE $175.00 $300.00 MALE SPOUSE 1 BCC C.7.f 3559 $0.00 $171.00 MALE SPOUSE 1 BCC 3559 $0.00 $54.00 MALE SPOUSE 1 BCC 3559 $0.00 $171.00 MALE SPOUSE 1 BCC 3559 $0.00 $54.00 MALE SPOUSE 1 BCC 3559 $0.00 $171.00 MALE SPOUSE 1 BCC 3559 $0.00 $54.00 MALE SPOUSE 1 BCC 3559 $0.00 $57.00 MALE SPOUSE 1 BCC 3559 $0.00 $54.00 MALE SPOUSE 1 BCC 3559 $0.00 $153.00 MALE SPOUSE 1 BCC 3559 $0.00 $171.00 MALE SPOUSE 1 BCC 3559 $0.00 $54.00 MALE SPOUSE 1 BCC 3559 $0.00 $114.00 MALE SPOUSE 1 BCC 3559 $0.00 $54.00 MALE SPOUSE 1 BCC 3559 $0.00 $15.00 MALE SPOUSE 1 BCC 3559 C.7.f 2/20/2017 2/2/2017 2/6/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M25311 OTHER INSTABILITY, OTHER MEDICAL $35.26 $171.00 MALE SPOUSE 1 BCC 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP RIGHTSHOULDER STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY N 2/20/2017 2/8/2017 2/14/2017 81002 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.57 $20.00 MALE SPOUSE 1 BCC 3559 OR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, OF PROSTATE LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINEI ANY NUMBER OF THESE CONSTITUENTS; NON AUTOMATED, WITHOUT MICROSCOPY } 2/20/2017 2/8/2017 2114/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $61.79 $240.00 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED > } HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW iL CL COMPLEXITY. COUNSELING AND COORD Q, Q 2/23/2017 1/30/2017 2/1/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M25311 OTHER INSTABILITY, OTHER MEDICAL $0.00 $114.00 MALE SPOUSE 1 BCC 3559 v MINUTES; THERAPEUTIC EXERCISES TO DEVELOP RIGHTSHOULDER STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 2/23/2017 1/30/2017 21112017 97140 MANUAL THERAPY TECHNIQUES )E6 , MOBILIZATION/ M25311 OTHER INSTABILITY, OTHER MEDICAL $5.54 $54.00 MALE SPOUSE 1 BCC 3559 MANIPULATION, MANUALLYMPHATIC DRAINAGE, RIGHTSHOULDER uj MANUAL TRACTION), LOS MORE REGIONS, EACH 15 3/2/2017 1/25/2017 2/15/2017 MINUTES 36415 COLLECTION DFVENOUS BLOOD BYVENIPUNCTURE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.80 $15.00 MALE SPOUSE 1 BCC 3559 OF PROSTATE _ 4/14/2017 4/10/2017 4/13/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K635 POLYP OF COLON PROFESSIONAL OFFICE $58.90 $350.00 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED ui EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY, COUNSELING AND /OR UJ COORDINATION OF CARE WITH OTHER 412812017 4/26/2017 4/27/2017 45382 COLONOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING, Z1211 ENCOUNTER FOR PROFESSIONAL $0.00 $1,300.00 MALE SPOUSE 1BCC 3559 ANY METHOD SCREENING FOR OUTPATIENT /HOSPITAL e LLJ MALIGNANT NEOPLASM °✓ OFCOLOA 4/28/2017 4/26/2017 4/27/2017 45384 COLONOSCOPY, FLEXIBLE; WITH REMOVALOF TUMOR(S), Z1211 ENCOUNTER FOR PROFESSIONAL $365.29 $1,450.00 MALE SPOUSE 1BCC 3559 J POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS SCREENING FOR OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM v OFCOLON 5/1/2017 4/26/2017 4/27/2017- - Z96010 PERSONAL HISTORY OF HOSPITAL OUTPATIENT $1,048.57 $5,800.00 MALE SPOUSE 1BCC 3559 COLONIC POLYPS IELJ 5/1/2017 4/26/2017 4/29/2017 810 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC Z1211 ENCOUNTERFOR PROFESSIONAL $0.00 $1,125.00 MALE SPOUSE 1 BCC 3559 PROCEDURES, ENDDSCOPE INTRODUCED DISTALTO SCREENING FOR OUTPATIENT /HOSPITAL DUODENUM MALIGNANT NEOPLASM (' OFCOLON 5/8/2017 4/26/2017 5/5/2017 88305 LEVELIV- SURGICAL PATHOLOGY, GROSS AND Z1211 ENCOUNTER FOR PROFESSIONAL $90.70 $528.00 MALE SPOUSE 1 BCC 3559 MICROSCOPIC EXAMINATION ABORTION- SCREENING FOR OUTPATIENT /HOSPITAL < SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE MALIGNANT NEOPLASM MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OFCOLON OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, fV NOT REQUIRING MICROSCOPIC EVALUATION OF = SURGICAL MARGINS, BREAST, REDUCTION E 5/25/2017 4126/2017 5/19/2017 810 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC Z1211 ENCOUNTER FOR PROFESSIONAL $0.00 $1,125.00 MALE SPOUSE 1 BCC 3559 PROCEDURES, ENDOSCOPE INTRODUCED DISTALTO SCREENING FOR OUTPATIENT /HOSPITAL DR DUODENUM MALIGNANT NEOPIASM OFCOLON C.7.f 6/2/2017 4/26/2017 4/29/2017 810 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC Z1211 ENCOUNTER FOR PROFESSIONAL $324.00 $1,125.00 MALE SPOUSE 1 BCC 3559 PROCEDURES, ENDOSCOPE INTRODUCED DISTALTO SCREENING FOR OUTPATIENT /HOSPITAL DUODENUM MALIGNANT NEOPLASM Z OFCOLON N 6/2/2017 4/26/2017 4/29/2017 810 ANESTHESIA FOR LOWER INTESTINAL ENDOSCDPIC Z1211 ENCOUNTER FOR PROFESSIONAL $0.00 f$1,125 00i MALE SPOUSE 1 BCC 3559 PROCEDURES, ENDOSCOPE INTRODUCED DISTALTO SCREENING FOR OUTPATIENT /HOSPITAL DUODENUM MALIGNANT NEOPLASM OFCOLON 6/12/2017 6/8/2017 6/9/2017 36415 COLLECTION OFVENOUS BLOOD BYVENIPUNCTURE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.80 $15.00 MALE SPOUSE 1 BCC 3559 7 OF PROSTATE 6/12/2017 6/8/2017 6/9/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $61.79 $240.00 MALE SPOUSE 1BCD 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY } COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED C EXAMINATION; MEDICAL DECISION MAKING OF LOW Q, COMPLEXITY. COUNSELING AND COORD ` `��. 6/30/2017 6/26/2017 6/29/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K635 POLYP OF COLON PROFESSIONAL OFFICE $58.90 $350.00 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF h MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 7/5/2017 6/29/2017 7/4/2017 83721 LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL E782 MIXED HYPERLIPIDEMIA OTHER MEDICAL $0.00 $52.00 MALE SPOUSE 1 BCC 3559 _ 7/12/2017 6/29/2017 7/11/2017 36415 COLLECTION OFVENOUS BLOOD BYVENIPUNCTURE E782 MIXED HYPERLIPIDEMIA PROFESSIONAL OFFICE $1.80 $12.00 MALE SPOUSE 1 BCC 3559 O 7/17/2017 7/13/2017 7/14/2017 82272 BLOOD, OCCULT, BY PEROXIDASE ACTIVITY(EG, GUAIAC), D509 IRON DEFICIENCY PROFESSIONAL OFFICE $2.10 $14.00 MALE SPOUSE 1 BCC 3559 Q QUALITATIVE, FECES, 1 -3 SIMULTANEOUS ANEMIA, UNSPECIFIED {li DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING Uy 7/24/2017 711112017 7/21/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE D509 IRON DEFICIENCY PROFE55IONAL OFFICE $1.80 $12.00 MALE SPOUSE 1 BCC 3559 ANEMIA, UNSPECIFIED 7/24/2017 711112017 712112017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D509 IRON DEFICIENCY PROFESSIONAL OFFICE $78.91 $461.00 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED ANEMIA, UNSPECIFIED e LLJ PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY °✓ COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF J MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER v 7/24/2017 711812017 712112017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D61819 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $252.72 $684.67 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF A NEW PATIENT, LLJ WHICH REQUIRES THESE 3 KEY CDMPDNENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH (' COMPLEXITY. COUNSELING AND /OR CDDRDINATION OF CARE WITH OTHER PROVIDERS OR AGE 8/2/2017 7/26/2017 8/1/2017 - - D61819 OTHER PANCYTOPENIA HOSPITAL OUTPATIENT $153.00 $204.00 MALE SPOUSE 1 BCC 3559 8/4/2017 7/24/2017 8/3/2017 88305 LEVEL IV- SURGICAL PATHOLOGY, GROSSAND D61818 OTHER PANCYTOPENIA PROFESSIONAL $77.46 $850.00 MALE SPOUSE 1 BCC 3559 N MICROSCOPIC EXAMINATION ABORTION - OUTPATIENT /HOSPITAL = SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE y MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, ._ NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION �, 6/4/2017 7/24/2017 8/3/2017 88311 DECALCIFICATION PROCEDURE (LISTS EPARATELY IN D61818 OTHER PANCYTOPENIA PROFESSIONAL $4.30 MALE SPOUSE ADDITION TO CODE FOR SURGICAL PATHOLOGY 3559 $0.00 OUTPATIENT /HOSPITAL SPOUSE 1 BCC EXAMINATION) $0.00 $26.00 MALE SPOUSE 8/4/2017 7/24/2017 8/3/2017 88313 SPECIALSTAIN INCLUDING INTERPRETATION AND REPORT; D61818 OTHER PANCYTOPENIA PROFESSIONAL 8/8/2017 8/1/2017 GROUP II, ALL OTHER LEG, IRON, TRICHROME), EXCEPT - C9200 OUTPATIENT /HOSPITAL HOSPITAL OUTPATIENT $417.74 STAIN FOR MICROORGANISMS, STAINS FOR ENZYME SPOUSE 1 BCC 3559 CONSTITUENTS, OR IM MUNOCYTOCH EMISTRY AND LEUKEMIA, NOT HAVING IMMUNOHISTOCH EMISTRY 8/4/2017 8/1/2017 8/3/2017 83615 LACTATE DEHYDROGENASE HD),(LDHK C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL 8/9/2017 7/19/2017 8/8/2017 81270 JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE ACHIEVED REMISSION QUALITATIVE PLATELET 8/4/2017 8/1/2017 8/3/2017 84550 URIC ACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL DISORDER( GENE ANALYSIS, P.VAL617PHE(V617F) LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION 8/4/2017 8/1/2017 8/3/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C9200 ACUTE MYELOBIS.STIC PROFESSIONAL EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL 8/9/2017 7/19/2017 8/8/2017 81403 MOLECULAR PATHOLOGY PROCEDURE, LEVEL4 (EG, ACHIEVED REMISSION QUALITATIVE PLATELET 8/4/2017 81112017 8/3/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, ANALYSIS OF SINGLE EXON BY DNA SEQUENCE ANALYSIS, LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), ANALYSIS OF > 10 AM PLICONS USING MULTIPLEX PCR IN 2 CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE 84D75), POTASSIUM (84132), PROTEIN, OR MORE INDEPENDENT REACTIONS, MUTATION $13.09 $95.00 MALE SPOUSE $86.78 $875.00 MALE SPOUSE C.7.f 1 BCC 3559 w 1 BCC 3559 N $0.00 $5.70 MALE SPOUSE 1 BCC 3559 $0.00 $4.30 MALE SPOUSE 1 BCC 3559 $0.00 $6.60 MALE SPOUSE 1 BCC 3559 $0.00 $26.00 MALE SPOUSE 1 BCC 3559 8/8/2017 7/27 /2017 8/2/2017 - - D539 NUTRITIONAL ANEMIA, HOSPITAL OUTPATIENT $4,620.97 $6,161.31 MALE SPOUSE 1 BCC 3559 UNSPECIFIED 8/8/2017 8/1/2017 8/7/2017 - - C9200 ACUTE MYELOBLASTIC HOSPITAL OUTPATIENT $417.74 $1,405.00 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING ACHIEVED REMISSION 8/9/2017 7/19/2017 8/8/2017 81270 JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE D691 QUALITATIVE PLATELET OTHER MEDICAL $0.00 $672.67 MALE SPOUSE 1 BCC 3559 DISORDER( GENE ANALYSIS, P.VAL617PHE(V617F) DEFECTS VARIANT 8/9/2017 7/19/2017 8/8/2017 81403 MOLECULAR PATHOLOGY PROCEDURE, LEVEL4 (EG, D691 QUALITATIVE PLATELET OTHER MEDICAL $0.00 $672.67 MALE SPOUSE 1 BCC 3559 ANALYSIS OF SINGLE EXON BY DNA SEQUENCE ANALYSIS, DEFECTS ANALYSIS OF > 10 AM PLICONS USING MULTIPLEX PCR IN 2 OR MORE INDEPENDENT REACTIONS, MUTATION SCANNING OR DUPLICATION /DELETION VARIANTS OF 2 -5 EXONS) ABLI (C- 8/10/2017 8/1/2017 8/9/2017 1036F CURRENTTDBACCO NON - USER(CAD, CAP,COPD, PV) C9200 ACUTE MYELOBIASTIC PROFESSIONAL $0.00 $0.01 MALE SPOUSE 1 BCC 3559 (DM) (IBD) LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION 811012017 8/1/2017 81912017 1126F INTERMEDIATE "DELAY" OFANY FLAP, PRIMARY "DELAY" C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $0.01 MALE SPOUSE 1 BCC 3559 OFSMALL FLAP, OR SECTIONING PEDICLE OFTUBEDOR LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, ACHIEVED REMISSION 8/10/2017 8/1/2017 8/9/2017 1220F PATIENTSCREENED FOR DEPRESSION (SUD) C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $0.01 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION rl 811012017 8/1/2017 8/9/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 EVALUATION AND MANAGEMENT OF A NEW PATIENT, SPOUSE LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL $0.00 WHICH REQUIRES THESE 3 KEY COMPONENTS:A SPOUSE ACHIEVED REMISSION 3559 $35.01 COMPREHENSIVE HISTORY; A COMPREH ENSIVE SPOUSE 1 BCC 3559 $89.46 EXAMINATION; MEDICAL DECISION MAKING OF HIGH SPOUSE 1 BCC 3559 $83.78 COMPLEXITY. COUNSELING AND /OR COORDINATION OF SPOUSE 1 BCC 3559 $0.00 CARE WITH OTHER PROVIDERS OR AGE SPOUSE 1 BCC 3559 8/10/2017 8/1/2017 8/9/2017 G8419 BMI DOCUMENTED OUTSIDE NORMAL PARAMETERS, NO C9200 ACUTE MYELOBLASTIC PROFESSIONAL FOLLOW -UP PLAN DOCUMENTED, NO REASON GIVEN LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION 8/10/2017 8/1/2017 8/9/2017 68427 ELIGIBLE PROFESSIDNALATTESTSTO DOCUMENTING IN C9200 ACUTE MYELOBLASTIC PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS ACHIEVED REMISSION 8/10/2017 8/1/2017 8/9/2017 G8731 PAIN ASSESSMENT USING A STANDARDIZED TOOL IS C9200 ACUTE MYELOBLASTIC PROFESSIONAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL REQUIRED ACHIEVED REMISSION 8/10/2017 8/2/2017 8/9/2017 38220 BONE MARROW ASPIRATION C9200 ACUTE MYELOBIA.STIC OTHER MEDICAL LEUKEMIA, NOT HAVING ACHIEVED REMISSION 8/10/2017 8/2/2017 8/9/2017 38221 BONE MARROW; BIOPSY, NEEDLE ORTROCAR C9200 ACUTE MYELOBLASTIC OTHER MEDICAL LEUKEMIA, NOT HAVING ACHIEVED REMISSION 8/10/2017 8/2/2017 8/9/2017 93306 ECHOCARDIOGRAPHY, TRANSTHDRACIC, REAL -TIME WITH Z5111 ENCOUNTER FOR PROFESSIONAL IMAGE DOCUMENTATION (2D), INCLUDES M -MODE ANTINEOPLASTIC OUTPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH CHEMOTHERAPY SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 8/10/2017 8/4/2017 8/9/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565(, GLUCOSE (82947), PH0SPHATASE, ALKALINE 184075), POTASSIUM (84132), PROTEIN, 8/10/2017 8/4/2017 8/9/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR C9200 ACUTE MYELOBIA.STIC PROFESSIONAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, ACHIEVED REMISSION UROBILINOGEN, ANY NUMBER DF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 8/10/2017 8/4/2017 8/9/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C9200 ACUTE MYELOBLASTIC PROFESSIONAL EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT LEUKEMIA, NOT HAVING INPATIENT / HDSPITAL ACHIEVED REMISSION 8/10/2017 8/4/2017 8/9/2017 85610 PROTHROMBIN TIME; C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/10/2017 8/4/2017 8/9/2017 85730 THROMBOPLASTIN TIME, PARTIAL(PTT(; PLASMA OR C9200 ACUTE MYELOBLASTIC PROFESSIONAL W HOLE BLOOD LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/10/2017 8/5/2017 8/9/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); C9200 ACUTE MYELOBIASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION $177.77 $660.00 MALE SPOUSE 1 BCC C.7.f 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $35.01 $251.00 MALE SPOUSE 1 BCC 3559 $89.46 $293.00 MALE SPOUSE 1 BCC 3559 $83.78 $235.00 MALE SPOUSE 1 BCC 3559 $0.00 $26.00 MALE SPOUSE 1 BCC 3559 $0.00 $6.00 MALE SPOUSE 1 BCC 3559 $0.00 $6.60 MALE SPOUSE 1 BCC 3559 $0.00 $4.30 MALE SPOUSE 1 BCC 3559 $0.00 $6,50 MALE SPOUSE 1 BCC 3559 $0.00 $5.70 MALE SPOUSE 1 BCC 3559 C.7.f 811012017 8/5/2017 8/9/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION Z N 8/10/2017 8/5/2017 8/9/2017 84100 PHOSPHORUS INORGANIC(PHDSPHATIQ C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 OR LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/10/2017 8/5/2017 8/9/2017 84550 URICACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 7 LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION 8/10/2017 8/5/2017 8/9/2017 85378 FIBRIN DEGRADATION PRODUCTS, D- DIMER; QUALITATIVE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $12.00 MALE SPOUSE 1 BCC 3559 ORSEMIOUANTITATIVE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL } ACHIEVED REMISSION L 8/10/2017 8/5/2017 8/9/2017 85384 FIBRINOGEN; ACTIVITY C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $9.20 MALE SPOUSE 1 BCC 3559 Q, LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL ACHIEVED REMISSION 8/10/2017 8/5/2017 8/9/2017 85610 PROTHROMBIN TIME; C9200 ACUTE MYELOBIASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION W 8/10/2017 8/5/2017 8/9/2017 85730 THROMBOPLASTIN TIME, PARTIAL(PTT); PLASMA OR C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $6.50 MALE SPOUSE 1BCC 3559 h WHOLE BLOOD LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION 8/10/2017 8/5/2017 8/9/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 INCLUDETHE FOLLOWING. ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (8231D), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), d CREATININE (82555), GLUCOSE (82947), PHOSPHATASE, ui ALKALINE )84075), POTASSIUM (84132), PROTEIN, 8/10/2017 8/5/2017 8/9/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $6.60 MALE SPOUSE 1 DEC 3559 EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION W 8/10/2017 8/6/2017 8/9/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 INCLUDE THE FOLLOWING; ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION J DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (82947), PHOSPHATASE, v ALKALINE (84075), POTASSIUM (84132), PROTEIN, 8/10/2017 8/6/2017 8/9/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $5.70 MALE SPOUSE 1 BCC 3559 LLJ LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION U 8/10/2017 8/6/2017 81912017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION „p N 8/10/2017 8/6/2017 8/9/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4,30 MALE SPOUSE 1 BCC 3559 Cy LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION C 8/10/2017 816/2017 8/9/2017 84550 URICACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ._ ACHIEVED REMISSION 811012017 8/6/2017 8/9/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL SPOUSE LET, RBC,WBC AND PLATELET COUNT) AND AUTOMATED $4.30 MALE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL $4.30 MALE DIFFERENTIAL WBC COUNT $0.00 ACHIEVED REMISSION SPOUSE 8/10/2017 8/7/2017 8/9/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL SPOUSE INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, $320.00 MALE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL $399.00 MALE TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 8/10/2017 8/712017 8/9/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); C9200 ACUTE MVELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/10/2017 8/7/2017 8/9/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/10/2017 8/7/2017 8/9/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); C9200 ACUTE MVELOBIASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/10/2017 8/7/2017 8/9/2017 84550 URIC ACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/10/2017 8/7/2017 8/9/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C9200 ACUTE MVELOBLASTIC PROFESSIONAL EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/10/2017 8/7/2017 8/9/2017 85610 PROTHROMBIN TIME; C9200 ACUTE MVELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/10/2017 81712017 8/9/2017 85730 THROMBOPIA5TIN TIME, PARTIAL(PTT); PLASMA OR C9200 ACUTE MVELOBLASTIC PROFESSIONAL WHOLE BLOOD LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/11/2017 8/1/2017 8/10/2017 88321 CONSULTATION AND REPORT ON REFERREDSLIDES C9200 ACUTE MYELOBLASTIC PROFESSIONAL PREPARED ELSEWHERE LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION 811112017 8/5/2017 8/10/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE C9200 ACUTE MVELOBIASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ETCH I R ES AT LEAST 20 F TH ESE 3 KEY COM PO N E NTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/11/2017 8/5/2017 8/10/2017 99235 OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE C9200 ACUTE MVELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME ACHIEVED REMISSION DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COON $0.00 $10.40 MALE SPOUSE $0.00 $26.00 MALE SPOUSE $0.00 $5.70 MALE SPOUSE $0.00 $10.80 MALE SPOUSE $0.00 $4.30 MALE SPOUSE $0.00 $4.30 MALE SPOUSE $0.00 $6.60 MALE SPOUSE $0.00 $4.30 MALE SPOUSE $0.00 $6.50 MALE SPOUSE $9173 $320.00 MALE SPOUSE $111.40 $399.00 MALE SPOUSE 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC $199.43 $648.00 MALE SPOUSE 1 DEC C.7.f 3559 w U) N 3559 OR 3559 3559 3559 3559 3559 3559 3559 3559 3559 m R C.7.f 811112017 8/6/2017 811012017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION Z DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; N MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM t 8/11/2017 8/6/2017 8/10/2017 99235 OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $199.43 $648.00 MALE SPOUSE 1BCC 3559 7 EVALUATION AND MANAGEMENTOFA PATIENT LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME ACHIEVED REMISSION DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A CDMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF } MODERATE COMPLEXITY. COUN s® 8/11/2017 8/7/2017 811012017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC 3559 Q, EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 20F THESE 3 KEY C0MPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. rf COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI W 8/11/2017 8/7/2017 8/10/2017 99235 OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $199.43 $648.00 MALE SPOUSE 1BCC 3559 h EVALUATION AND MANAGEMENT OF A PATIENT LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME ACHIEVED REMISSION DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A _ COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUN IL 8/11/2017 8/8/2017 8/10/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 {i INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION UJ DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565(, GLUCOSE (82947), PH0SPHATASE, f C f / Y a ALKALINE (84075), POTASSIUM (84132(, PROTEIN, J W 8/11/2017 8/8/2017 8/10/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $5.70 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL � ACHIEVED REMISSION w, J 811112017 8/8/2017 8/10/2017 83735 MAGNESIUM C9200 ACUTE MYELOBIASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 v LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL r ACHIEVED REMISSION Z W 8/11/2017 8/8/2017 8/10/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION (' 8/11/2017 8/812017 8/10/2017 84550 URIC ACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION {N 8/11/2017 8/8/2017 8/10/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $6.60 MALE SPOUSE 1 RCC 3559 N EXAMINATIDN WITH MANUAL DIFFERENTIAL WBC COUNT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL = ACHIEVED REMISSION ❑i 811112017 8/8/2017 811012017 99235 OBSERVATION OR INPATIENT HOSPITAL CARE, FORTH C9200 ACUTE MYELOBLASTIC PROFESSIONAL $10.80 EVALUATION AND MANAGEMENT OF A PATIENT SPOUSE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL MALE INCLUDING ADMISSION AND DISCHARGE ON THE SAME $0.00 ACHIEVED REMISSION MALE SPOUSE DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A $6,60 MALE SPOUSE $199.43 COMPREHENSIVE HISTORY; A COM PR EH ENSI VE MALE SPOUSE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUN 8/14/2017 8/4/2017 8/11/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION C9200 ACUTE MYELOBLASTIC PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LEUKEMIA, NOT HAVING INPATIENT / HDSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; ACHIEVED REMISSION A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITV. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 8/14/2017 8/5/2017 811212017 36569 INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS C9200 ACUTE MYELOBLASTIC PROFESSIONAL CATHETER)PICC), WITHOUT SUBCUTANEOUS PORT OR LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL PUMP; AGE 5 YEARS OR OLDER ACHIEVED REMISSION 8/14/2017 8/5/2017 8/12/2017 76937 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS C9200 ACUTE MYELOBIASTIC PROFESSIONAL REQUIRING ULTRASOUND EVALUATION OF POTENTIAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL ACHIEVED REMISSION PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION OF VASCULAR NEEDLE ENTRY, 8/14/2017 8/9/2017 8/11/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE )BICARBONATE)(82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE X84075), POTASSIUM (84132), PROTEIN, 8/14/2017 8/9/2017 8111/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 9/14/2017 81 811112017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/14/2017 8/9/2017 8/11/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); C9200 ACUTE MYELOBIASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/14/2017 8/9/2017 811112017 84550 URIC ACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/14/2017 8/9/2017 8111/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C9200 ACUTE MYELOBLASTIC PROFESSIONAL EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/14/2017 8/9/2017 8/11/2017 99235 OBSERVATION OR INPATIENT HOSPITALCARE, FORTHE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME ACHIEVED REMISSION DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUN $199.43 $648.00 MALE SPOUSE 1 BCC $144.85 $530.00 MALE SPOUSE 1 BCC $124.77 $369.00 MALE SPOUSE $20.24 $59.00 MALE SPOUSE $0.00 $26.00 MALE SPOUSE $0.00 $5.70 MALE SPOUSE $0.00 $10.80 MALE SPOUSE $0.00 $4.30 MALE SPOUSE $0.00 $4.30 MALE SPOUSE $0.00 $6,60 MALE SPOUSE $199.43 $648.00 MALE SPOUSE 1 BCC 1 BCC 0� 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC INHKII C.7.f 3559 Im 3559 3559 KAE 3559 3559 3559 3559 3559 WbS] 8/14/2017 8/10/2017 811212017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, SPOUSE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL $0.00 TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SPOUSE ACHIEVED REMISSION 3559 $0.00 DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), SPOUSE 1 BCC 3559 $0.00 CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, SPOUSE 1 BCC 3559 $5,731.09 ALKALINE (84075), POTASSIUM (84132), PROTEIN, SPOUSE 1 BCC 3559 8/14/2017 8/10/2017 8/12/2017 83615 LACTATE DEHVDROGENASE(ED),(LDH); C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION 8/14/2017 8/10/2017 8/12/2017 83735 MAGNESIUM C9200 ACUTE MVELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/14/2017 8/10/2017 8/12/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/14/2017 8/10 /2017 811212017 84550 URIC ACID; BLOOD C9200 ACUTE MVELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/14/2017 8/10/2017 8/12/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL HCT,RBC,WBC AND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 8/15/2017 7/24/2017 8/14/2017 ..... ..... .«r ++ ..... ... ». 8/16/2017 8/8/2017 8/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/16/2017 8/9/2017 8/15/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MVELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRESAT LEAST 2 OFTHESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/16/2017 8/11/2017 8/15/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE �BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84D75), POTASSIUM (84132), PROTEIN, 8/16/2017 8/11/2017 8/15/2017 83615 LACTATE DEHVDROGENASE(ED),(LDH); C9200 ACUTE MVELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION 8/16/2017 8/11/2017 8/15/2017 83735 MAGNESIUM C9200 ACUTE MVELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/16/2017 8/11/2017 8/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION $0.00 $26.00 MALE SPOUSE 1 BCC C.7.f 3559 $0.00 $5.70 MALE SPOUSE 1 BCC 3559 $0.00 $10.80 MALE SPOUSE 1 BCC 3559 $0.00 $4.30 MALE SPOUSE 1 BCC 3559 $0.00 $4.30 MALE SPOUSE 1 BCC 3559 $0.00 $10.40 MALE SPOUSE 1 BCC 3559 $5,731.09 $9,047.46 MALE SPOUSE 1 BCC 3559 $12134 $399.00 MALE SPOUSE 1 BCC 3559 $121.54 $399.00 MALE SPOUSE 1 BCC 3559 $0.00 $26.00 MALE SPOUSE 1 BCC 3559 $0.00 $5.70 MALE SPOUSE 1 BCC 3559 $0.00 $10.80 MALE SPOUSE 1 BCC 3559 $0.00 $4.30 MALE SPOUSE 1 BCC 3559 C.7.f 8/16/2017 8/11/2017 8/15/2017 84550 URIC ACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION Z N 8/16/2017 8/11/2017 8/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HER, C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 8/16/2017 8/12/2017 8/15/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 7 INCLUDE THE FOLLOWING ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), w CREATININE( 62565), GLUCOSE (82947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, } fl 8/16/2017 8/12/2017 8/15/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $5.70 MALE SPOUSE 1 BCC 3559 N. CL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL Q, ACHIEVED REMISSION Q 8/16/2017 8/12/2017 8/15/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL .� ACHIEVED REMISSION �+ F 8/16/2017 8/12/2017 8/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 uj LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL D ACHIEVED REMISSION Z 8/16/2017 8/12/2017 8/15/2017 84550 URIC ACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION O 8/16/2017 8/12/2017 8/15/2017 85025 BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 Q PUT, RBC, WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL {j DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 8/16/2017 8/13/2017 8/15/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $5.40 MALE SPOUSE 1 DEC 3559 cn LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION W 8/16/2017 8/13/2017 8/15/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 INCLUDE THE FOLLOWING; ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION J DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (82947), PHOSPHATASE, v ALKALINE )84075), POTASSIUM (84132), PROTEIN, 8/16/2017 8/13/2017 8/15/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $5.70 MALE SPOUSE 1 BCC 3559 Uj LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION U 8/16/2017 8/13/2017 8/15/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION „p N 8/16/2017 8/13/2017 8/15/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4,30 MALE SPOUSE 1 BCC 3559 Cy LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION C 8/16/2017 8113/2017 8/15/2017 84550 URIC ACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ._ ACHIEVED REMISSION 8/16/2017 8/13/2017 8/15/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL SPOUSE NET, RBC,NBC AND PLATELET COUNT) AND AUTOMATED $4.30 MALE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL $4.30 MALE DIFFERENTIAL WBC COUNT $0.00 ACHIEVED REMISSION SPOUSE 8/17/2017 8/14/2017 8/16/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL SPOUSE INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, $421.00 MALE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL $280.00 MALE TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALI(AUNE )84075), POTASSIUM (84132), PROTEIN, 8/17/2017 8/14/2017 8/16/2017 83615 LACTATE DEHYDROGENASE (ED), (LDH); C9200 ACUTE MVELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/17/2017 8/14/2017 8/16/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/17/2017 8/14/2017 8/16/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); C9200 ACUTE MVELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/17/2017 8/14/2017 8/16/2017 84550 URIC ACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/17/2017 8/14/2017 8/16/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C9200 ACUTE MVELOBLASTIC PROFESSIONAL HOT, RBC,NBC AND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL W BE COUNT ACHIEVED REMISSION 8/21/2017 8/2/2017 8/18/2017 85060 BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY C9200 ACUTE MVELOBLASTIC PROFESSIONAL PHYSICIAN WITH WRITTEN REPORT LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION 8/21/2017 8/2/2017 8/18/2017 85097 BONE MARROW, SMEAR INTERPRETATION C9200 ACUTE MVELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION 8/21/2017 8/2/2017 8/18/2017 88189 FLOWCYTOMETRY /READ, 16 & > C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION 812112017 8/2/2017 8/18/2017 88305 LEVELIV- SURGICAL PATHOLOGY, GROSS AND C9200 ACUTE MYELOBLASTIC PROFESSIONAL MICROSCOPIC EXAMINATION ABORTION- LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE ACHIEVED REMISSION MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHER THAN FORTUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION 8/21/2017 8/212017 8/18/2017 88311 DECALCIFICATION PROCEDURE)LISTSEPARATELY IN C9200 ACUTE MVELOBLASTIC PROFESSIONAL ADDITION TO CODE FOR SURGICAL PATHOLOGY LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL EXAMINATION) ACHIEVED REMISSION 8/21/2017 8/2/2017 8/18/2017 88313 SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT; C9200 ACUTE MYELOBLASTIC PROFESSIONAL GROUP II, ALL OTHER(EG, IRON, TRICHROME), EXCEPT LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL STAIN FOR MICROORGANISMS , STAINS FOR ENZYME ACHIEVED REMISSION CONSTITUENTS, OR IM MUNOCYTOCH EMISTRY AND IMMUNOHISTOCH EMISTRY $0.00 $10.40 MALE SPOUSE $0.00 $26.00 MALE SPOUSE $0.00 $5.70 MALE SPOUSE $0.00 $10.80 MALE SPOUSE $0.00 $4.30 MALE SPOUSE $0.00 $4.30 MALE SPOUSE $0.00 $10.40 MALE SPOUSE $26.60 $93.00 MALE SPOUSE $55.21 $184.00 MALE SPOUSE $112.54 $421.00 MALE SPOUSE $87.85 $280.00 MALE SPOUSE $14.11 $48.00 MALE SPOUSE $13.69 $46.00 MALE SPOUSE 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC lim.11M C.7.f 3559 w U) N 3559 OR 3559 3559 3559 3559 3559 3559 3559 3559 3559 m am R 812112017 8/2/2017 811812017 88360 MORPHOMETR I C ANALYSIS, TUMOR C9200 ACUTE MYELOBLASTIC PROFESSIONAL $129.75 $398.00 MALE SPOUSE 1 BCC IMMUNOHISTOCHEMISTRY )EG, HER- 2 /NEU, ESTROGEN LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL RECEPTOR /PROG ESTE RON E RECEPTOR), QUANTITATIVE ACHIEVED REMISSION OR SE M I QUANTITATIVE, PER SPECIMEN, EACH SINGLE ANTIBODY STAIN PROCEDURE; MANUAL 812112017 811012017 811812017 99235 OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $199.43 $648.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME ACHIEVED REMISSION DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COON 8/21/2017 8/11/2017 811812017 99235 OBSERVATION OR INPATIENT HOSPITALCARE, FORTHE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $199.43 $648.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME ACHIEVED REMISSION DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COON 812112017 8/12/2017 811812017 99235 OBSERVATION OR INPATIENT HOSPITALCARE, FORTHE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $199.43 $648.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME ACHIEVED REMISSION DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COON 812112017 8/13/2017 811812017 99235 OBSERVATION OR INPATIENT HOSPITALCARE, FORTHE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $19943 $648.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME ACHIEVED REMISSION DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COON 812112017 8/14/2017 811812017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 812112017 8/15/2017 811812017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (8231D), CARBON ACHIEVED REMISSION DIOXIDE )BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 8/21/2017 8/15/2017 8/18/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $5.70 MALE SPOUSE 1 BCC LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8121/2017 8/15/2017 8/18/2017 83735 MAGNESIUM C9200 ACUTE MYELOBIASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION C.7.f 812112017 8/15/2017 811812017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION Z N 8/21/2017 8/15/2017 8/18/2017 84550 URIC ACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/21/2017 8/15/2017 8 /18 /2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 7 LET, BBC, WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 8/21/2017 8/15/2017 8/18/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $11140 $399.00 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL W } REQUIRES AT LEAST 20F THESE 3 KEY C0MPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; CL MEDICAL DECISION MAKING OF HIGH COMPLEXITY. Q, COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/21/2017 8/16/2017 8/18/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED C9200 ACUTE MYELOBIASTIC PROFESSIONAL $0.00 $5.40 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION F W 8/21/2017 8/16/2017 8/18/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 F INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL (82247), CALCIUM, TOTAL (82310), CARBON LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), _ CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, F ALKALINE (84075), POTASSIUM (84132), PROTEIN, O 8/21/2017 8/16/2017 8/18/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $5.70 MALE SPOUSE 1 BCC 3559 Q LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL {j ACHIEVED REMISSION 8/21/2017 8/16/2017 8/18/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 cn LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION W 8/21/2017 8/16/2017 8/18/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL � ACHIEVED REMISSION w, J 812112017 8/16/2017 8/18/2017 84550 URIC ACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 DEC 3559 v LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL r ACHIEVED REMISSION Z W 8/21/2017 8/16/2017 8/18/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 LET, BBC, WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION (' 8/21/2017 8/16/2017 8/19/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MVELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1DEC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS :A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; {`Fl MEDICAL DECISION MAKING OF HIGH COMPLEXITY. N COUNSELING AND /OR COORDINATION OF CARE WITH = OTHER PROVI E 8/21/2017 8117 /2017 8/19/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED C9200 ACUTE MYELOBIASTIC PROFESSIONAL $0.00 $5.40 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION C.7.f 812112017 8/17/2017 8/19/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION Z DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), N CREATININE 1825651, GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 8/21/2017 8/17/2017 8/19/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL r ACHIEVED REMISSION "a 8/21/2017 811712017 8/19/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C9200 ACUTE MVELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 HCT RBC,WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION } fl 8/21/2017 8/17/2017 8/19/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC 3559 CL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL CL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENT&A ACHIEVED REMISSION Q DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH .� OTHER PROVI r 8/22/2017 7/27/2017 8/21/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $165.28 $469.12 MALE SPOUSE 1BCC 3559 uj r EVALUATION AND MANAGEMENTOFAN ESTABLISHED PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A — COMPREHENSIVE EXAMINATION; MEDICAL DECISION _ MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR r COORDINATION OF CARE WITH O 8/23/2017 7/26/2017 8/22/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HOD, D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $6.40 $33.88 MALE SPOUSE 1 BCC 3559 Q HUT, RBC, WBC AND PLATELET COUNT) AND AUTOMATED {li DIFFERENTIAL WBC COUNT 8/23/2017 8/18/2017 8/22/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C9200 ACUTE MVELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 UJ HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 0 8/23/2017 8/18/2017 8/22/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC 3559 LLJ EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL e °✓ REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; J MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH V OTHER PROVI r 8/23/2017 8/19/2017 8/22/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCD 3559 LLJ EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; (' MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI Q N 8/23/2017 8/20/2017 8/22/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399,00 MALE SPOUSE 1BCC 3559 Cy EVALUATION AND MANAGEMENTOFA PATIENT ,WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION = DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; y MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 2 C.7.f 8/24/2017 ]/24/201] 8/23/2017 38221 BONE MARROW; BIOPSY, NEEDLE OR TROCAR D61818 OTHER PANCYTOPENIA PROFESSIONAL $93.22 $292.00 MALE SPOUSE 1 BCC 3559 OUTPATIENT /HOSPITAL 8/24/2017 ]/24/201] 8/23/2017 ]]002 FLUOROSCOPIC GUIDANCE FORNEEDLE PLACEMENT(EG, D61818 OTHER PANCYTOPENIA PROFESSIONAL $35.04 $100.00 MALE SPOUSE 1 BCC 3559 N BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) OUTPATIENT /HOSPITAL Q! 8/24/2017 7/24/2017 81 99152 Moderate sedation ser 1— p—lded bythe same D61818 OTHER PANCYTOPENIA PROFESSIONAL $15.46 $48.00 MALE SPOUSE 1 BCC 3559 physician or other qualified health care professional OUTPATIENT /HOSPITAL performing the diagnostic or therapeutic service that 7 M 8/24/2017 7/24/2017 8/23/2017 60364 BONE MARROWASPIRATE &BIOPSY D61819 OTHER PANCYTOPENIA PROFESSIONAL $10.81 $48.00 MALE SPOUSE 1BCC 3559 OUTPATIENT /HOSPITAL 8/25/2017 8/18/2017 8124/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 } INCLUDE THE FOLLOWING, ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL Q TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION iL CL DIOXIDE (BILARBONATE)(823]4), CHLORIDE (82435), ¢, CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 8/25/2017 8/18/2017 8/24/2017 83735 MAGNESIUM C9200 ACUTE MYELOBIASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION W 8/25/2017 8/19/2017 8/24/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 h INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL K32310), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), _ CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (840]5), POTASSIUM (54132), PROTEIN, O 8/25/2017 8/19/2017 8/24/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL IJU ACHIEVED REMISSION 8/25/2017 8/19/2017 8/24/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C9200 ACUTE MYELOBLASTIC PROFE55IONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 HOT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL 0 DIFFERENTIAL WBC COUNT ACHIEVED REMISSION W 8/25/2017 8/20/2017 812412017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 INCLUDE THE FOLLOWING'. ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL Q . TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION J DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, v ALKALINE (84075), POTASSIUM (54132), PROTEIN, 8/25/2017 8/20/2017 8/24/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 LLJ LEUKEMIA, NOT HAVING INPATIENT / HDSPITAL ACHIEVED REMISSION U 8/25/2017 8/20/2017 8/24/2017 84550 URIC ACID; BLOOD C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $4.30 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION N 8/25/2017 8/20/2017 8/24/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED( HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 Cy LET, BBC, WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION n 8/25/2017 8/21/2017 812412017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, SPOUSE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL $121.54 TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SPOUSE ACHIEVED REMISSION 3559 DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565(, GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132(, PROTEIN, 8/25/2017 8/21/2017 8/24/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION 8/25/2017 8/21/2017 8/24/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C9200 ACUTE MVELOBLASTIC PROFESSIONAL HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 8/25/2017 8/21/2017 8/24/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENT&A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/25/2017 8/22/2017 8/24/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 8/25/2017 8/22/2017 8/24/2017 83735 MAGNESIUM C9200 ACUTE MVELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION 8/25/2017 8/22/2017 8/24/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C9200 ACUTE MVELOBLASTIC PROFESSIONAL HCF,RBC, WBC AND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 8/25/2017 8/22/2017 8/24/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/28/2017 8/23/2017 8/25/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION 8/28/2017 8/23/2017 8/25/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MVELOBLASTIC PROFESSIONAL INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (8231D), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 812812017 8/23/2017 8/25/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION C.7.f $0.00 $26.00 MALE SPOUSE 1 BCC 3559 W N m Q! $0.00 $10.80 MALE SPOUSE 1 BCC 3559 $0.00 $10.40 MALE SPOUSE 1 BCC 3559 W } fl $111.40 $399.00 MALE SPOUSE 1 BCC 3559 a. $0.00 $26.00 MALE SPOUSE 1 BCC 3559 $0.00 $10.80 MALE SPOUSE 1 BCC 3559 $0.00 $10.40 MALE SPOUSE 1 BCC 3559 $121.54 $399.00 MALE SPOUSE 1 BCC 3559 $0.00 $5.40 MALE SPOUSE 1 BCC 3559 $0.00 $26.00 MALE SPOUSE 1 BCC 3559 $0.00 $10.80 MALE SPOUSE 1 BCC III C.7.f 812812017 8/23/2017 8/25/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 LET, BBC, WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION N 8/28/2017 8/23/2017 8/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQU I R ES AT LEAST 20 F TH ESE 3 KEY COM PO N E NTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. } COUNSELING AND /OR COORDINATION OF CARE WITH "a OTHER PROVI 8/28/2017 8/24/2017 8/26/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE I BCC 3559 INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL } TOTAL (82247), GALLIUM, TOTAL (82310), CARBON ACHIEVED REMISSION Q DIOXIDE (BICARBONATE) (82374), CHLORIDE (92435), N. CL CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, Q, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 8/28/2017 8/24/2017 8/26/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL .� ACHIEVED REMISSION �+ F 8/28/2017 8/24/2017 8/26/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 lJj LET, BBC, WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 8/28/2017 8/24/2017 8/26/2017 85049 BLOOD COUNT; PLATELET, AUTOMATED C9200 ACUTE MVELOBLASTIC PROFESSIONAL $0.00 $5.40 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION O 8/29/2017 8/17/2017 8/24/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC 3559 Q EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL {i REQUIRES AT LEAST 2 OF THESE 3 KEY C0MPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; a) MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM Q W 8/29/2017 8/22/2017 8/24/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL � REQUIRES AT LEAST 2 OF THESE 3 KEY C0MPONENTS:A ACHIEVED REMISSION J DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. v COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI Z W 8/30/2017 8/25/2017 8/29/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT / HDSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION (' DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, Q N 8/30/2017 8/25/2017 8/29/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10,80 MALE SPOUSE 1 BCC 3559 Cy LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION C 8/30/2017 8125/2017 8/29/2017 85025 BLOOD COUNT; COMPLETE (CBC), AUTOMATED )HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ._ DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 8/30/2017 8/26/2017 8/29/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, SPOUSE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL $0.00 TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SPOUSE ACHIEVED REMISSION 3559 DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565(, GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132(, PROTEIN, 8/30/2017 8/26/2017 8/29/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION 8/30/2017 8/26/2017 8/29/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C9200 ACUTE MVELOBLASTIC PROFESSIONAL HCT, RBC,WBC AND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 8/30/2017 8/27/2017 8/29/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL INCLUDE THE FOLLOWING; ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 8/30/2017 8/27/2017 8/29/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/30/2017 8/27/2017 8/29/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C9200 ACUTE MVELOBLASTIC PROFESSIONAL EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 8/31/2017 8/10/2017 8/22/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE C9200 ACUTE MVELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/31/2017 8/11/2017 8/22/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/31/2017 8/12/2017 8/22/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/31/2017 8/13/2017 8/22/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $0.00 $26.00 MALE SPOUSE 1 BCC C.7.f 3559 $0.00 $10.80 MALE SPOUSE 1 BCC 3559 $0.00 $10.40 MALE SPOUSE 1 BCC 3559 $0.00 $26.00 MALE SPOUSE 1 BCC 3559 $0.00 $10.80 MALE SPOUSE 1 BCC 3559 $0.00 $6.60 MALE SPOUSE 1 BCC 3559 $121.54 $399.00 MALE SPOUSE 1 BCC 3559 $121.54 $399.00 MALE SPOUSE 1 BCC 3559 $121.54 $399.00 MALE SPOUSE 1 BCC 3559 $121.54 $399,00 MALE SPOUSE 1 BCC 3559 8/31/2017 8/14/2017 812212017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH $10.40 MALE LEUKEMIA, NOT HAVING 1 BCC REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A $121.54 ACHIEVED REMISSION SPOUSE DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; 3559 MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/31/2017 8/18/2017 8/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 8/31/2017 8/19/2017 812312017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/31/2017 8/20/2017 8/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 8/31/2017 8/23/2017 8/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 8/31/2017 8/28/2017 8/30/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL INCLUDE THE FOLLOWING; ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435(, CREATININE( 82565(, GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 8/31/2017 8/28/2017 8/30/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL ACHIEVED REMISSION 8/31/2017 8/28/2017 8/30/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HER, C9200 ACUTE MYELOBLASTIC PROFESSIONAL HCT, DEC, WBC AND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 8/31/2017 8/28/2017 8/30/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENT&A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM $121.54 $399.00 MALE SPOUSE 1 BCC $111.40 $399.00 MALE SPOUSE 1 BCC $111.40 $399.00 MALE SPOUSE 1 BCC $111.40 $399.00 MALE SPOUSE 1 BCC $121.54 $399.00 MALE SPOUSE 1 BCC $0.00 $26.00 MALE SPOUSE 1 BCC $0.00 $10.80 MALE SPOUSE 1 BCC 3559 $0.00 $10.40 MALE SPOUSE 1 BCC 3559 $121.54 $399.00 MALE SPOUSE 1 RCC 3559 C.7.f 9/1/2017 8/29/2017 8/31/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION Z DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), N CREATININE (82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 9/1/2017 8/29/2017 8/31/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL r ACHIEVED REMISSION "a 9/1/2017 8/29/2017 8/31/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, C9200 ACUTE MVELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION } fl 9/5/2017 8/15/2017 812612017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC 3559 D. CL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL Q, REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENT&A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH .� OTHER PROVI F 9/5/2017 8/16/2017 81 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC 3559 uj EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. — COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM O 9/5/2017 8/18/2017 9/1/2017 85060 BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY C9200 ACUTE MVELOBLASTIC PROFESSIONAL $26.60 $93.00 MALE SPOUSE 1 BCC 3559 Q PHYSICIAN WITH WRITTEN REPORT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL {li ACHIEVED REMISSION 9/5/2017 811812017 9/1/2017 85097 BONE MARROW, SMEAR INTERPRETATION C9200 ACUTE MVELOBLASTIC PROFESSIONAL $55.21 $184.00 MALE SPOUSE 1 BCC 3559 cn LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION W 9/5/2017 8/18/2017 9/1/2017 88188 FLOWCYTOMETRY /READ, 9 -15 C9200 ACUTE MYELOBLASTIC PROFESSIONAL $88.68 $343.00 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL � ACHIEVED REMISSION w, J 9/5/2017 8/18/2017 9/1/2017 88305 LEVELIV- SURGICAL PATHOLOGY, GROSS AND C9200 ACUTE MVELOBLASTIC PROFESSIONAL $87.85 $280.00 MALE SPOUSE 1 BCC 3559 v MICROSCOPIC EXAMINATION ABORTION- LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE ACHIEVED REMISSION MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, LLJ OTHERTHAN FORTUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION (' 9/5/2017 8/18/2017 9/1/2017 88311 DECALCIFICATION PROCEDURE)LISTSEPARATELV IN C9200 ACUTE MVELOBLASTIC PROFESSIONAL $14.11 $48.00 MALE SPOUSE 1 BCC 3559 ADDITION TO CODE FOR SURGICAL PATHOLOGY LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL < EXAMINATION) ACHIEVED REMISSION 9/5/2017 8/18/2017 9/1/2017 88313 SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT; C9200 ACUTE MVELOBLASTIC PROFESSIONAL $13.69 $46.00 MALE SPOUSE 1 BCC 3559 N GROUP II, ALL OTHER(EG, IRON, TRICHROME), EXCEPT LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL = STAIN FOR MICROORGANISMS , STAINS FOR ENZYME ACHIEVED REMISSION y CONSTITUENTS, OR IM MUNOCYTOCH EMISTRY AND IMMUNOHISTOCHEMISTRY .G C.7.f 9/5/2017 8/18/2017 9/1/2017 883421MMUNOHISTOC HEMISTRYOR IMMUNOCYTOCHEMISTRY , C9200 ACUTE MYELOBLASTIC PROFESSIONAL $48.30 $131.00 MALE SPOUSE 1BCC 3559 PERSPECIMEN; INITIAL SINGLE ANTIBODY STAIN LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL PROCEDURE ACHIEVED REMISSION N 9/5/2017 8/21/2017 8/26/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE C9200 ACUTE MYELOBIASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC 3559 OR EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 20 F TILL ESE 3 KEY COM PO N E NTS: A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. } COUNSELING AND /OR COORDINATION OF CARE WITH "a OTHER PROVI 9/5/2017 8/24/2017 8/29/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE IBCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL W } REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; CL MEDICAL DECISION MAKING OF HIGH COMPLEXITY. Q, COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 9/5/2017 8/25/2017 8/29/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBIASTIC PROFESSIONAL $111.40 $399.00 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 20 F TILL ESE 3 KEY COM PO N E NTS: A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; Ljj MEDICAL DECISION MAKING OF HIGH COMPLEXITY. h COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 9/5/2017 8/30/2017 9/1/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $26.00 MALE SPOUSE 1 BCC 3559 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (8231D), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), d CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, NJ ALKALINE (84075), POTASSIUM (84132), PROTEIN, 9/5/2017 8/30/2017 9/1/2017 83735 MAGNESIUM C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.80 MALE SPOUSE 1 BCC 3559 U LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION W 9/5/2017 8/30/2017 9/1/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED(HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $10.40 MALE SPOUSE 1 BCC 3559 U HCT, BBC, WBCAND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL � DIFFERENTIAL WBC COUNT ACHIEVED REMISSION J 9/7/2017 8/29/2017 9/6/2017 99255 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $240.43 $700.00 MALE SPOUSE 1FEE 3559 U PATIENT,WHICH REQUIRES THESE 3 KEY COMPONENTS: A LEUKEMIA, NOT HAVING COMPREHENSIVE HISTORY; A COMPREHENSIVE ACHIEVED REMISSION EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH uj COMPLEXITY, COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSI U 9/7/2017 8/29/2017 9/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MVELOBLASTIC PROFESSIONAL $148.53 $399.00 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL < REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS: A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. N COUNSELING AND /OR COORDINATION OF CARE WITH = OTHER PROVI ❑i 9/7/2017 8/30/2017 9/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $148.53 $399.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 9/7/2017 8/31/2017 9/6/2017 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $6.00 MALE SPOUSE 1 BCC BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKEMIA, NOT HAVING INPATIENT / HDSPITAL LEUIKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, ACHIEVED REMISSION UROBILINOGEN, ANY NUMBER DF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 9/7/2017 8/31/2017 9/6/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $54.60 MALE SPOUSE 1 BCC AND PRESUMPTIVE IDENTIFICATION OF ISOLATES LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) ACHIEVED REMISSION 9/7/2017 8/31/2017 9/6/2017 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, C9200 ACUTE MYELOBIASTIC PROFESSIONAL $0.00 $12.00 MALE SPOUSE 1 BCC URINE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 9/7/2017 8/31/2017 9/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $132.62 $399.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 9/7/2017 8/31/2017 9/6/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $103.51 $276.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN ACHIEVED REMISSION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 9/11/2017 7/24/2017 9/7/2017 88184 FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR 8898 OTHER ABNORMAL OTHER MEDICAL $44.36 $222.56 MALE SPOUSE 1BCC NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST FINDINGS IN SPECIMENS MARKER FROM OTHER ORGANS, SYSTEMS AND TISSUES 9/11/2017 7/24/2017 9/7/2017 88185 FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR 8898 OTHER ABNORMAL OTHER MEDICAL $783.58 $3,516.55 MALE SPOUSE 1 BCC NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH FINDINGS IN SPECIMENS ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO FROM OTHER ORGANS, CODE FOR FIRST MARKER) SYSTEMS AND TISSUES 9/11/2017 7/24/2017 9/7/2017 88189 FLOWCYTOMETRY /READ, 16 &> R898 OTHER ABNORMAL OTHER MEDICAL $69.22 $353.89 MALE SPOUSE 1 BCC FINDINGS IN SPECIMENS FROM OTHER ORGANS, SYSTEMS AND TISSUES 9/12/2017 8/24/2017 8129/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $162.05 $399.00 MALE SPOUSE 1 BCC EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LEUKEMIA, NOT HAVING REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 9/12/2017 8/25/2017 8/29/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $86.63 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH SPOUSE LEUKEMIA, NOT HAVING 3559 $85.49 REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A SPOUSE ACHIEVED REMISSION 3559 $19.86 DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; SPOUSE 1 BCC 3559 $165.30 MEDICAL DECISION MAKING OF HIGH COMPLEXITY. SPOUSE 1 BCC 3559 $116.79 COUNSELING AND /OR COORDINATION OF CARE WITH SPOUSE 1 BCC 3559 $0.00 OTHER PROVI SPOUSE 1 BCC 3559 9/12/2017 8/26/2017 8/29/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $0.00 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH SPOUSE LEUKEMIA, NOT HAVING 3559 $14.52 REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A SPOUSE ACHIEVED REMISSION 3559 $11639 DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; SPOUSE 1 BCC 3559 $0.00 MEDICAL DECISION MAKING OF HIGH COMPLEXITY. SPOUSE 1 BCC 3559 COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 9/12/2017 8/27/2017 8/29/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 9/20/2017 7/24/2017 9/18/2017 81310 NPMI(NUCLEOPHOSMIN)(EG, ACUTE MYELOID D649 ANEMIA, UNSPECIFIED OTHER MEDICAL LEUKEMIA( GENE ANALYSIS, EXON 12 VARIANTS 9/20/2017 7/24/2017 9/18/2017 88237 TISSUE CULTURE FOR NEDPWSTIC DISORDERS; BONE D649 ANEMIA, UNSPECIFIED OTHER MEDICAL MARROW, BLOOD CELLS 9/20/2017 7/24/2017 9/18/2017 88264 CHROMOSOME ANALYSIS; ANALYZE 20 -25 CELLS D649 ANEMIA, UNSPECIFIED OTHER MEDICAL 9/20/2017 7/24/2017 9/18/2017 88271 MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG, FISH) D649 ANEMIA, UNSPECIFIED OTHER MEDICAL 9/20/2017 7/24/2017 9/18/2017 88275 MOLECULAR CYTOGENETICS; INTERPHASE IN SITU D649 ANEMIA, UNSPECIFIED OTHER MEDICAL HYBRIDIZATION, ANALYZE 100 -300 CELLS 9/22/2017 8/18/2017 9114/2017 81245 FITTS(FMS- RELATED TYROSINE KINASE 3) (EG, ACUTE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL MYELOID LEUKEMIA), GENE ANALYSIS; INTERNALTANDEM LEUKEMIA, NOT HAVING DUPLICATION (ITD) VARIANTS HE, EXONS 14,15) ACHIEVED REMISSION 9/22/2017 811812017 9/14/2017 81246 PUTS (EMS RELATED TYROSINE KINASE 3) (EG, ACUTE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL MYELOID LEUKEMIA), GENE ANALYSIS; TYROSINE KINASE LEUKEMIA, NOT HAVING DOMAIN (TKD) VARIANTS (EG, D935,1836) ACHIEVED REMISSION 9/22/2017 8/18/2017 9/14/2017 81450 TARGETED GENOMI [SEQUENCE ANALY515 PANEL, C9200 ACUTE MYELOBIASTIC OTHER MEDICAL HEMATOLYMPHOID NEOPLASM OR DISORDER, DNA AND LEUKEMIA, NOT HAVING RNA ANALYSIS WHEN PERFORMED, 5 -50 GENES (EG, BRAF, ACHIEVED REMISSION CEB PA, D MT3A, EZH 2, FLT3, IDH 1, IDHE, JAKE, KRAS, KIT, BELL, IR A 1, 9/22/2017 8/18/2017 9/14/2017 81479 ON LI STIED MOLECULAR PATHOLOGY PROCEDURE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL LEUKEMIA, NOT HAVING ACHIEVED REMISSION 9/25/2017 8/31/2017 9/23/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, D709 NEUTROPENIA, PROFESSIONAL FRONTAL UNSPECIFIED INPATIENT /HOSPITAL 9/27/2017 8/2/2017 9/20/2017 81245 PUTS (EMS RELATEDTYROSINE KINASE 3) (EG, ACUTE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL MYELOID LEUKEMIA), GENE ANALYSIS; INTERNALTANDEM LEUKEMIA, NOT HAVING DUPLICATION (ITD) VARIANTS HE, EXONS 14,15) ACHIEVED REMISSION 9/27/2017 8/2/2017 9/20/2017 81246 FLT3 (FMS - RELATED TYROSINE KINASE 3) (EG, ACUTE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL MYELOID LEUKEMIA), GENE ANALYSIS; TYROSINE KINASE LEUKEMIA, NOT HAVING DOMAIN (TKD) VARIANTS (EG, D835,1836) ACHIEVED REMISSION $162.05 $399.00 MALE SPOUSE 1 BCC C.7.f 3559 $121.54 $399.00 MALE SPOUSE 1 BCC 3559 $121.54 $399.00 MALE SPOUSE 1 BCC 3559 $124.25 $449.00 MALE SPOUSE 1 BCC 3559 $86.63 $478.85 MALE SPOUSE 1 BCC 3559 $85.49 $807.15 MALE SPOUSE 1 BCC 3559 $19.86 $2,880.00 MALE SPOUSE 1 BCC 3559 $165.30 $1,224.00 MALE SPOUSE 1 BCC 3559 $116.79 $1,000.00 MALE SPOUSE 1 BCC 3559 $0.00 $1,000.00 MALE SPOUSE 1 BCC 3559 $0.00 $12,000.00 MALE SPOUSE 1 BCC 3559 $0.00 $1,500.00 MALE SPOUSE 1 BCC 3559 $14.52 $35.00 MALE SPOUSE 1 BCC 3559 $11639 $1,000.00 MALE SPOUSE 1 BCC 3559 $0.00 $1,000.00 MALE SPOUSE 1 BCC 3559 C.7.f 9/2]/201] 8/2/2017 9/20/2017 81450 TARGETED GE NO M I [SEQUENCE ANALYSIS PANEL, C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $0.00 $12,000.00 MALE SPOUSE 1BCC 3559 HEMATOLYMPHOID NEDPIASMOR DISORDER, DNAAND LEUKEMIA, NOT HAVING RNA ANALYSIS WHEN PERFORMED, 5 50 GENES (EG, BRAF, ACHIEVED REMISSION CEBPA, DNMI EZH2, FLT3, IDH1, IDH2,JAK2, KRAS, KIT, N MILL, NRAS, m 9/27/2017 8/2/2017 912012017 81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $0.00 $1,500.00 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING ACHIEVED REMISSION 10/19/2017 9/13/2017 101 81245 FLT3 (FMS - RELATED TYROSINE KINASE 3) (EG, ACUTE [9200 ACUTE MYELOBLASTIC OTHER MEDICAL $116.79 $1,000.00 MALE SPOUSE 1 DEC 3559 "a MYELOID LEUKEMIA), GENE ANALYSIS; INTERNALTANDEM LEUKEMIA, NOT HAVING m DUPLICATION (ITD) VARIANTS (IE, EXDNS 14,15) ACHIEVED REMISSION 10/19/2017 9/13/2017 10/4/2017 81246 FLT3 HEMS - RELATEDTYROSINE KINASE 3) (EG, ACUTE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $0.00 $1,000.00 MALE SPOUSE 1 BCC 3559 lu } > MYELOID LEUKEMIA ), GENE ANALYSIS; TYROSINE KINASE LEUKEMIA, NOT HAVING DOMAIN (TKD) VARIANTS (EG, D835,1836) ACHIEVED REMISSION iL CL CL 10119/2017 9/13/2017 10/4/2017 81450 TARGETED GENOMI [SEQUENCE ANALYSIS PANEL, C9200 ACUTE MYELOBIASTIC OTHER MEDICAL $0.00 $12,000.00 MALE SPOUSE 1BCC 3559 HEMATOLYMPHOID NEOPLASMOR DISORDER, DNAAND LEUKEMIA, NOT HAVING RNA ANALYSIS WHEN PERFORMED, 5 -50 GENES (EG, BRAF, ACHIEVED REMISSION CEBPA, DNMI EZH2, FLT3, IDH1, IDH2,JAK2, KRAS, KIT, rf w• ML L, NRAS, 10/19/2017 9/13/2017 10/4/2017 81479 UNLI STED MOLECULAR PATHOLOGY PROCEDURE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $0.00 $1,500.00 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING uLl ~ ACHIEVED REMISSION D 10/26/2017 8/18/2017 9/14/2017 81245 TILTS HFMS - RELATEDTYROSINE KINASE 3) (EG, ACUTE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $116.79 $1,000.00 MALE SPOUSE 1 BCC 3559 MYELOID LEUKEMIA), GENE ANALYSIS; INTERNALTANDEM LEUKEMIA, NOT HAVING _ DUPLICATION (ITD) VARIANTS HE, EXDNS 14,15) ACHIEVED REMISSION 10/26/2017 8/18/2017 9/14/2017 81246 FLT3 (FMS-RELATED TYROSINE KINASE 3)( E6, ACUTE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $0.00 $1,000.00 MALE SPOUSE 1 BCC 3559 MYELOID LEUKEMIA), GENE ANALYSIS; TYROSINE KINASE LEUKEMIA, NOT HAVING DOMAIN (TKD) VARIANTS (EG, D835,1836) ACHIEVED REMISSION uj IX 10/26/2017 8/18/2017 9/14/2017 81450 TARGETED GENOMICSEQUENCE ANALYSIS PANEL, C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $0.00 $12,000.00 MALE SPOUSE 1BCC 3559 UJ HEMATOLYMPHOID NEOPIASMOR DISORDER, DNAAND LEUKEMIA, NOT HAVING RNA ANALYSIS WHEN PERFORMED, 5 -50 GENES (EG, BRAF, ACHIEVED REMISSION 0 CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2,lAK2, KRAS, KIT, MLL, NRAS, W 10/26/2017 8/18/2017 9/14/2017 81419 FIN STIED MOLECULAR PATHOLOGY PROCEDURE C9200 ACUTE MYELOBIASTIC OTHER MEDICAL $0.00 $1,500.00 MALE SPOUSE 1 BCC 3559 LEUKEMIA, NOT HAVING ACHIEVED REMISSION J 10/26/2017 8/18/2017 9/14/2017 81245 FLT3 (FMS-RELATEDTYROSINE KINASE 3) (EG, ACUTE 09200 ACUTE MYELOBLASTIC OTHER MEDICAL ($116.79) ($1,000.0(U MALE SPOUSE 1 BCC 3559 V MYELOID LEUKEMIA), GENE ANALYSIS; INTERNALTANDEM LEUKEMIA, NOT HAVING r DUPLICATION (ITD) VARIANTS (IE, EXDNS 14,15) ACHIEVED REMISSION W 10/26/2017 8/18/2017 9/14/2017 81246 FLT3 (FMS- RELATEDTYROSINE KINASE 3) (EG, ACUTE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $0.00 1$1,001.00; MALE SPOUSE 1 BCC 3559 MYELOID LEUKEMIA), GENE ANALYSIS; TYROSINE KINASE LEUKEMIA, NOT HAVING DOMAIN (TKD) VARIANTS (EG, D935,1836) ACHIEVED REMISSION (' 10/26/2017 8/18/2017 9/14/2017 81450 TARGETED GENOMICSEQUENCE ANALYSIS PANEL, C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $0.00 ,$1,000.00; MALE SPOUSE 1 BCC 3559 HEMATOLYMPHOID NEOPIASMOR DISORDER, DNAAND LEUKEMIA, NOT HAVING „p < RNA ANALYSIS WHEN PERFORMED, 5 50 GENES (EG, BRAF, ACHIEVED REMISSION CEBPA, DNMI EZH2, FLT3, IDH1, IDH2,JAK2, KRAS, KIT, MLL, INK 1, N 10/26/2017 9/18/2017 9/14/2017 81479 UN LISTED MOLECULAR PATHOLOGY PROCEDURE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL $0.00 ($1,501.00) MALE SPOUSE 1 BCC 3559 = LEUKEMIA, NOT HAVING y ACHIEVED REMISSION L 10/31/2017 7/24/2017 8/14/2017 * *' "* " "* * " " ** '' *' *' " "* $5,731.09 $9,047.46 MALE SPOUSE 1 BCC 3559 10/31/2017 7/24/2017 8/14/2017 "' "* ` * " "" x ».. : * * ** " * " *" (55,7731.09) (53,047.46) MALE SPOUSE 1 BCC 3559 u 10/31/2017 7/24/2017 10/26/2017 k * * "" " " " ** ' * #p * * "' 11/1/2017 10/24/2017 10/31/2017 99220 INITIAL OBSERVATION CARE, PERDAY, FORTHE D61818 OTHER PANCYTOPENIA PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH OUTPATIENT /HOSPITAL REQUIRES THESE 3 KEY EOM PO N E NTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR A 11/1/2017 10/25/2017 10131/2017 99217 OBSERVATION CARE DISCHARGE DAY MANAGEMENT D61818 OTHER PANCYTOPENIA OTHER MEDICAL (THIS CODE ISTO BE UTILIZED BYTHE PHYSICIAN TO REPORT A.LL SERVICES PROVIDED TO A PATI ENT ON DISCHARGE FROM OBSERVATION STATUS IFTHE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF OBSERVATION STATUS. TO REPORT SERVICES TO A PATIENT DESIGNAT 11/1/2017 10/25/2017 10/31/2017- - C9200 ACUTE MYELOBI STIC HOSPITAL OUTPATIENT LEUKEMIA, NOT HAVING ACHIEVED REMISSION 111212017 10/24/2017 11/1/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R509 FEVER, UNSPECIFIED PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 11/3/2017 10/29/2017 11/2/2017- - A4189 OTHER SPECIFIED SEPSIS HOSPITAL OUTPATIENT 11/6/2017 91 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELORLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 11/6/2017 91 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LEUKEMIA, NOT HAVING REQU I R ES AT LEAST 2 O F TILL ESE 3 KEY COM PO N E NTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 9/13/2017 11/3/2017 85060 BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY 8897 ABNORMAL PROFESSIONAL PHYSICIAN WITH WRITTEN REPORT HISTOLOGICAL FINDINGS INPATIENT /HOSPITAL IN SPECIMENS FROM OTHER ORGANS, SYSTEMS AND TISSUES 11/6/2017 9/13/2017 11/3/2017 85097 BONE MARROW, SMEAR INTERPRETATION R897 ABNORMAL PROFESSIONAL HISTOLOGICAL FINDINGS INPATIENT /HOSPITAL IN SPECIMENS FROM OTHER ORGANS, SYSTEMS AND TISSUES 11/6/2017 9/13/2017 11/3/2017 88305 LEVEL IV- SURGICAL PATHOLOGY, GROSS AND R897 ABNORMAL PROFESSIONAL MICROSCOPIC EXAMINATION ABORTION- HISTOLOGICAL FINDINGS INPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE INSPECIMENSFROM MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHER ORGANS, SYSTEMS OTHER THAN FOR TUMOR RESECTIDN, BREAST, BIOPSY, ANDTISSUES NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION $0.00 $10,379.07 MALE SPOUSE 1 BCC $172.71 $813.00 MALE SPOUSE 1 BCC $67.69 $319.00 MALE SPOUSE 1 BCC $17,779.00 $19,04838 MALE SPOUSE 1 BCC $14.94 $36.00 MALE SPOUSE 1 BCC $7,679.00 $8,717.73 MALE SPOUSE 1 BCC $154.53 $399.00 MALE SPOUSE 1 BCC $15433 $399.00 MALE SPOUSE 1 BCC $33.46 $93.00 MALE SPOUSE 1 BCC $67.52 $184.00 MALE SPOUSE 1 BCC $103.02 $280,00 MALE SPOUSE 1 BCC 11/6/2017 9/13/2017 11/3/2017 88311 DECALCIFICATION PROCEDURE (LISTS EPARATELY IN R897 ABNORMAL PROFESSIONAL 3559 ADDITION TO CODE FOR SURGICAL PATHOLOGY $399.00 MALE HISTOLOGICAL FINDINGS INPATIENT /HOSPITAL 1 BCC EXAMINATION( IN SPECIMENS FROM OTHER ORGANS, SYSTEMS AND TISSUES 11/6/2017 9/13/2017 11/3/2017 88313 SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT; R897 ABNORMAL PROFESSIONAL GROUP II, ALL OTHER(EG, IRON, TRICHROME), EXCEPT HISTOLOGICAL FINDINGS INPATIENT /HOSPITAL STAIN FOR MICROORGANISMS, STAINS FOR ENZYME IN SPECIMENS FROM CONSTITUENTS, OR IMMUNOCYTOCHEMISTRY AND OTHER ORGANS, SYSTEMS IMMUNOHISTOCHEMISTRY AND TISSUES 11/6/2017 9/13/2017 11/3/2017 88360 MORPHOMETRIC ANALYSIS, TUMOR R897 ABNORMAL PROFESSIONAL IMMUNOHISTOCHEMISTRY (EG, HER- 2 /NEU, ESTROGEN HISTOLOGICAL FINDINGS INPATIENT /HOSPITAL RECEPTOR / FROG ESTE RON E RECEPTOR), QUANTITATIVE IN SPECIMENS FROM OR SEMIQUANTITATIVE , PER SPECIMEN, EACH SINGLE OTHER ORGANS, SYSTEMS ANTIBODY STAIN PROCEDURE; MANUAL AND TISSUES 11/6/2017 9/24/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBIASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 9/25/2017 11/3/2017 88189 FLOWCYTOMETRY /READ, 16 &> R897 ABNORMAL PROFESSIONAL HISTOLOGICAL FINDINGS INPATIENT /HOSPITAL IN SPECIMENS FROM OTHER ORGANS, SYSTEMS AND TISSUES 11/6/2017 9/25/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 9/26/2017 111312017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 9/27/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT / HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $17.40 $48.00 MALE SPOUSE 1 BCC $16.48 $46.00 MALE SPOUSE 1 BCC $14546 $398.00 MALE SPOUSE 1 BCC $154.53 $399.00 MALE SPOUSE 1 BCC C.7.f 3559 w Z N m Q! 3559 A 3559 fl } fl N. CL CL Q 3559 v $150.71 $421.00 MALE SPOUSE 1 BCC 3559 $15937 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $15937 $399.00 MALE SPOUSE 1 BCC 3559 11/6/2017 9/28/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $159.77 $399.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 9/29/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $15937 $399.00 MALE SPOUSE 1FCC EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 11/6/2017 9/30/2017 111312017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $159.77 $399.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 10/1/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $159.77 $399.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 10/2/2017 11/3/2017 70486 COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; D709 NEUTROPENIA, PROFESSIONAL $5841 $161.00 MALE SPOUSE 1 BCC WITHOUT CONTRAST MATERIAL UNSPECIFIED INPATIENT /HOSPITAL 11/6/2017 10/2/2017 11/3/2017 99221 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION D709 NEUTROPENIA, PROFESSIONAL $159.93 $400.00 MALE SPOUSE 1 BCC AND MANAGEMENTOFA PATIENT,WHICH REQUIRES UNSPECIFIED INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND /OR 11/6/2017 10/3/2017 11/3/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, R509 FEVER, UNSPECIFIED PROFESSIONAL $14.66 $41.00 MALE SPOUSE 1 BCC FRONTAL AND LATERAL; INPATIENT /HOSPITAL 11/6/2017 10/3/2017 11/3/2017 99223 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION C9200 ACUTE MYELOBIASTIC PROFESSIONAL $0.00 $783.00 MALE SPOUSE 1 BCC AND MANAGEMENTOFA PATIENT,WHICH REQUIRES LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; ACHIEVED REMISSION ACOMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS DR AGEN 11/6/2017 10/4/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $159.77 $399.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 10/5/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $235.75 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH SPOUSE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL $212.40 REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS:A SPOUSE ACHIEVED REMISSION 3559 DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 10/6/2017 11/3/2017 71250 COMPUTED TOMOGRAPHY, THORAX; WITHOUT R918 OTHER NONSPECIFIC OTHER MEDICAL CONTRAST MATERIAL ABNORMAL FINDING OF LUNG FIELD 11/6/2017 10/6/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MVELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 10/10/2017 11/3/2017 88108 CYTOPATHOLOGY, CONCENTRATION TECHNIQUE, SMEARS 1984 OTHER DISORDERS OF PROFESSIONAL AND INTERPRETATION)EG, SACCOMANNO TECHNIQUE) LUNG INPATIENT /HOSPITAL 11/6/2017 10/10/2017 11/3/2017 31624 BRONCHOSCOPY, RIGID OR FLEXIBLE; WITH BRONCHIAL C9200 ACUTE MYELOBLASTIC PROFESSIONAL ALVEOLAR LAVAGE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL ACHIEVED REMISSION 11/6/2017 10/10/2017 11/3/2017 99222 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION C9200 ACUTE MYELOBLASTIC PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; ACHIEVED REMISSION ACOMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXIN. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 11/6/2017 10/12/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MVELORLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQU I R ES AT LEAST 20 F TH ESE 3 KEY C0M PO N E NTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 10/13/2017 11/3/2017 70543 MAGNETIC RESONANCE(EG, PROTON) IMAGING, ORBIT, 1328 OTHER CHRONIC PROFESSIONAL FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), SINUSITIS INPATIENT /HOSPITAL FOLLOWED BY CONTRAST MATERIALS) AND FURTHER SEQUENCES 11/6/2017 10/13/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT / HDSPITAL REQUIRES AT LEAST 20F THESE 3 KEY C0MPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/6/2017 10/17/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 20F THESE 3 KEY C0MPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $159.77 $399.00 MALE SPOUSE 1 BCC C.7.f 3559 $6931 $193.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $30.52 $86.00 MALE SPOUSE 1 BCC 3559 $235.75 $590.00 MALE SPOUSE 1 BCC 3559 $212.40 $530.00 MALE SPOUSE 1 BCC 3559 $15937 $399.00 MALE SPOUSE 1 BCC $146.12 $407.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.51 $399,00 MALE SPOUSE 1 BCC 11/6/2017 1011712017 11/3/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FORTH EVALUATION C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES SPOUSE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL $0.00 THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; SPOUSE ACHIEVED REMISSION 3559 $0.00 A COMPREHENSIVE EXAMINATION; AND MEDICAL SPOUSE 1 BCC 3559 $0.00 DECISION MAKING OF HIGH COMPLEXITY. COUNSELING SPOUSE 1 BCC 3559 $0.00 AND /OR COORDINATION OF CARE WITH OTHER SPOUSE 1 BCC 3559 $0.00 PROVIDERS OR AGEN SPOUSE 1 BCC 3559 11/6/2017 10/18/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 11/6/2017 10/19/2017 111312017 99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES C9200 ACUTE MYELOBLASTIC OTHER MEDICAL OR LESS LEUKEMIA, NOT HAVING ACHIEVED REMISSION 11/6/2017 10/30/2017 11/3/2017 99222 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION A419 SEPSIS, UNSPECIFIED PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES ORGANISM INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; ACOMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 11/6/2017 10/30/2017 11/3/2017 99291 CRITICAL C ARE, EVALUATION AND MANAGEMENT OF THE D709 NEUTROPENIA, PROFESSIONAL CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- UNSPECIFIED OUTPATIENT /HOSPITAL 74 MIN UTES 11/6/2017 11/1/2017 11/3/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 11/6/2017 11/1/2017 11/3/2017 80202 VANCOMYCIN D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED I N PATI ENT /HOSPITAL 11/6/2017 11/1/2017 11/3/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL 11/6/2017 11/1/2017 11/3/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL 11/6/2017 11/1/2017 11/3/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC D709 NEUTROPENIA, PROFESSIONAL EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT UNSPECIFIED INPATIENT /HOSPITAL 11/6/2017 11/2/2017 11/4/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST D709 NEUTROPENIA, PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, UNSPECIFIED INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 11/6/2017 11/2/2017 11/4/2017 83735 MAGNESIUM D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL 11/6/2017 11/2/2017 11/4/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); D709 NEUTROPENIA, PROFESSIONAL UNSPECIFIED INPATIENT /HOSPITAL 11/6/2017 11/2/2017 11/4/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, PROFESSIONAL HUT, RBC,WBC AND PLATELET COUNT) AND AUTOMATED UNSPECIFIED INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT $312.68 $783.00 MALE SPOUSE 1 BCC $159.51 $399.00 MALE SPOUSE 1 BCC $109.96 $279.00 MALE SPOUSE $212.40 $530.00 MALE SPOUSE $310.51 $877.00 MALE SPOUSE $0.00 $26.00 MALE SPOUSE 1 BCC 1 BCC 1 BCC 1 BCC C.7.f 3559 Im 3559 3559 3559 3559 $0.00 $23.00 MALE SPOUSE 1 BCC 3559 $0.00 $10.80 MALE SPOUSE 1 BCC 3559 $0.00 $4.30 MALE SPOUSE 1 BCC 3559 $0.00 $6.60 MALE SPOUSE 1 BCC 3559 $0.00 $26.00 MALE SPOUSE 1 BCC 3559 $0.00 $10.80 MALE SPOUSE 1 BCC 3559 $0.00 $4.30 MALE SPOUSE 1 BCC 3559 $0.00 $10.40 MALE SPOUSE 1 BCC 3559 111812017 9/12/2017 11/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/8/2017 9/13/2017 11/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 111812017 9/13/2017 11/7/2017 99223 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION C9200 ACUTE MYELOBLASTIC PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL THESE KEY COMPONENTS: A COMPREHENSIVE HISTORY; ACHIEVED REMISSION ACOMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 11/8/2017 9/14/2017 11/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/8/2017 9/14/2017 11/7/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION C9200 ACUTE MYELOBLASTIC PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; ACHIEVED REMISSION A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 111812017 9/15/2017 11/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/8/2017 9/16/2017 11/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $312.68 $783.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $0.00 $783.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC 111812017 9/16/2017 11/7/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FORTH EVALUATION C9200 ACUTE MYELOBLASTIC PROFESSIONAL 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES $69.00 MALE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL 1 BCC THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; $266.40 ACHIEVED REMISSION SPOUSE ACOMPREHENSIVE EXAMINATION; AND MEDICAL 3559 DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 11/8/2017 9/17/2017 11/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 111812017 1011012017 11/7/2017 99223 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION C9200 ACUTE MYELOBLASTIC PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL THESE KEYCOMPONENT5: A COMPREHENSIVE HISTORY; ACHIEVED REMISSION ACOMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 11/8/2017 10/11/2017 11/7/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION C9200 ACUTE MYELOBLASTIC PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; ACHIEVED REMISSION ACOMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 11/8/2017 10/29/2017 11/7/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, C9200 ACUTE MYELOBLASTIC PROFESSIONAL FRONTAL LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION 11/8/2017 10129/2017 11/7/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 A4189 OTHER SPECIFIED SEPSIS OTHER MEDICAL LEADS; INTERPRETATION AND REPORT ONLY 11/8/2017 10/29/2017 11/7/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION A4189 OTHER SPECIFIED SEPSIS OTHER MEDICAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENTS CLINICAL CONDITION AND /DR MENTALSTATUS: ACOMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 11/9/2017 10/7/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/9/2017 10/8/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENT&A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM C.7.f $312.68 $783.00 MALE SPOUSE 1 BCC 3559 4) N Q! $141.64 $399.00 MALE SPOUSE 1 BCC 3559 7 fl } fl CL $0.00 $783.00 MALE SPOUSE 1 BCC 3559 CL R $0.00 $783.00 MALE SPOUSE 1 BCC 3559 $1434 $36.00 MALE SPOUSE 1 BCC 3559 $0.00 $69.00 MALE SPOUSE 1 BCC 3559 $266.40 $1,481.00 MALE SPOUSE 1 BCC 3559 $159.51 $399.00 MALE SPOUSE 1 BCC 3559 $159.51 $399.00 MALE SPOUSE 1 BCC 3559 11/9/2017 10/9/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRESAT LEAST 2 OFTHESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/9/2017 10/10/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LEUKEMIA, NOT HAVING REQUIRESAT LEAST 2 OFTHESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 11/9/2017 10/31/2017 111812017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R9431 ABNORMAL OTHER MEDICAL LEADS; INTERPRETATION AND REPORT ONLY ELECTROCARDIOGRAM [ECG] [EKG[ 11/13/2017 8/28/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 8/29/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 8/30/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 9/1/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 9/2/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MVELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $159.51 $399.00 MALE SPOUSE 1 BCC $159.51 $399.00 MALE SPOUSE 1 BCC $12.97 $32.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC 11/13/2017 9/3/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 9/4/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 11/13/2017 9/5/2017 111312017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 9/6/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 9/7/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 9/8/2017 111312017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 9/9/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $148.53 $399.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC 11/13/2017 9/10/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 9/11/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 11/13/2017 9/18/2017 11/10/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 9/21/2017 11/10/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 9/22/2017 11/10/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 10/9/2017 111312017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/13/2017 10/10/2017 11/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $148.53 $399.00 MALE SPOUSE 1 BCC $148.53 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $159.77 $399.00 MALE SPOUSE 1 BCC $15937 $399.00 MALE SPOUSE 1 BCC 11/13/2017 10/11/2017 11/3/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENT&AN ACHIEVED REMISSION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 11/17/2017 9/1/2017 111812017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 11/17/2017 9/2/2017 111812017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/17/2017 9/3/2017 11/8/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/17/2017 9/4/2017 11/8 /2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/17/2017 9/23/2017 111812017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING DF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/17/2017 9/26/2017 11/8/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $110.17 $276.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC 11/17/2017 9/27/2017 111812017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/17/2017 9/28/2017 111812017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 11/17/2017 9/29/2017 111812017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/17/2017 9/30/2017 11/8/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/17/2017 10/1/2017 11/8 /2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/17/2017 10/13/2017 111812017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/17/2017 10/14/2017 11/8/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC 11/17/2017 10/15/2017 111812017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL $854.00 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH SPOUSE LEUKEMIA, NOT HAVING INPATIENT /HOSPITAL $0.00 REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A SPOUSE ACHIEVED REMISSION 3559 $0.00 DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; SPOUSE 1 BCC 3559 $0.00 MEDICAL DECISION MAKING OF HIGH COMPLEXITY. SPOUSE 1 BCC 3559 $170.75 COUNSELING AND /OR COORDINATION OF CARE WITH SPOUSE 1 BCC 3559 OTHER PROVI 11/17/2017 10/16/2017 1118 12017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LEUKEMIA, NOT HAVING INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A ACHIEVED REMISSION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 11/17/2017 10/30/2017 11/16/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT 6939 DISORDER OF BRAIN, PROFESSIONAL CONTRAST MATERIAL UNSPECIFIED INPATIENT/HOSPITAL 11/17/2017 10/31/2017 11/16/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R918 OTHER NONSPECIFIC PROFESSIONAL FRONTAL ABNORMAL FINDING OF INPATIENT /HOSPITAL LUNG FIELD 11/17/2017 11/14/2017 11/16/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE 84D75), POTASSIUM (84132), PROTEIN, 11/17/2017 11/14/2017 11/16/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HEEL C9200 ACUTE MYELOBLASTIC PROFESSIONAL HCT,RBC,WBC AND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 11/20/2017 10/29/2017 11110/2017 - - C9200 ACUTE MYELOBLASTIC HOSPITAL OUTPATIENT LEUKEMIA, NOT HAVING ACHIEVED REMISSION 1112012017 11/15/2017 11/18/2017 1036F CURRENTTOBACCO NON - USER (CAD, CAP, CORD, PV) Z7682 AWAITING ORGAN OTHER MEDICAL (DMf(IBD) TRANSPLANT STATUS 11/20/2017 11/15/2017 11/18/2017 1126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" Z7682 AWAITING ORGAN OTHER MEDICAL OF SMALL FLAP, OR SECTIONING PEDICLE OFTUBED OR TRANSPLANT STATUS DIRECT FLAP, AT EYELIDS NOSE, 1112012017 11/15/2017 11/18/2017 1220F PATIENTSCREENED FOR DEPRESSION (SUD) Z7682 AWAITING ORGAN OTHER MEDICAL TRANSPLANT STATUS 1112012017 11/15/2017 11/18/2017 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE Z7682 AWAITING ORGAN OTHER MEDICAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED TRANSPLANT STATUS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 1112012017 11/15/2017 11/18/2017 68420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS Z7682 AWAITING ORGAN OTHER MEDICAL AND NO FOLLOW -UP PLAN IS REQUIRED TRANSPLANT STATUS 11/20/2017 11/15/2017 11/18/2017 68427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN Z7682 AWAITING ORGAN OTHER MEDICAL THE MEDICAL RECORD THEYOBTAINED, UPDATED, OR TRANSPLANT STATUS REVIEWED THE PATIENT'S CURRENT MEDICATIONS 1112012017 11/15/2017 11/18/2017 G8484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, Z7682 AWAITING ORGAN OTHER MEDICAL REASON NOT GIVEN TRANSPLANT STATUS 11/20/2017 11/15/2017 11/18/2017 68731 PAIN ASSESSMENT USING ASTANDARDIZED TOOL IS Z7682 AWAITING ORGAN OTHER MEDICAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN TRANSPLANT STATUS REQUIRED $141.64 $399.00 MALE SPOUSE 1 BCC $141.64 $399.00 MALE SPOUSE 1 BCC $58.41 $161.00 MALE SPOUSE $12.41 $35.00 MALE SPOUSE $0.00 $26.00 MALE SPOUSE 1 BCC 1 BCC 1 BCC C.7.f 3559 ®' 3559 3559 3559 $0.00 $10.40 MALE SPOUSE 1 BCC 3559 $854.00 $1,887.02 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $170.75 $429.00 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 C.7.f 11/21/2017 7/24/2017 9/18/2017 11/21/2017 7/24/2017 9/18/2017 11/21/2017 7/24/2017 9/18/2017 11/21/2017 7/24/2017 911812017 11/21/2017 7/24/2017 9/18/2017 11/21/2017 7/24/2017 11118/2017 11/21/2017 7/24/2017 11/18/2017 11/21/2017 7/24/2017 11/18/2017 11/21/2017 7/24/2017 11/18/2017 11121/2017 7/24/2017 11/18/2017 11/21/2017 7/24/2017 11/20/2017 11/21/2017 7/24/2017 1112012017 11/21/2017 7/24/2017 11/20/2017 11/21/2017 7/24/2017 11/20/2017 11/21/2017 7/24/2017 1112012017 11/22/2017 10/29/2017 11/2112017 A0425 11/22/2017 10/29/2017 11/21/2017 A0426 11/22/2017 10/30/2017 11/21/2017 11/22/2017 11/1/2017 11/21/2017 1112212017 11 /2/2017 11/21/2017 11/27/2017 8/2/2017 11/7/2017 " * *'* 1112712017 81212017 1112012017 ## - 11/27/2017 9/18/2017 11/14/2017 * ° "* 11/27/2017 9/19/2017 11/14/2017 * * * ** 1112712017 9/21/2017 11/14/2017 * * * 11/27/2017 9/22/2017 11/14/2017 * ** 11/27/2017 9/23/2017 11/14/2017 * * " ** 1112712017 9/24/2017 11/14/2017 * * * ** 11/27/2017 10/4/2017 11/14/2017 * 11/27/2017 10/5/2017 11/14/2017 11/27/2017 10/6/2017 11/14/2017 * * * ** 11/27 /2017 10/7 /2017 11/14/2017 11/27/2017 10/8/2017 11/14/2017 11/27/2017 11/14/2017 11/21/2017 81310 NPMl (NUCLEOPHOSMIN) (EG, ACUTE MYELOID D649 LEUKEMIA( GENE ANALYSIS, EXON 12 VARIANTS OTHER MEDICAL 88237 TISSUE CULTURE FOR NEDPLASTIC DISORDERS; BONE D649 MARROW, BLOOD CELLS OTHER MEDICAL 88264 CHROMOSOME ANALYSIS; ANALYZE 20 -25 CELLS D649 88271 MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG, FISH) D649 88275 MOLECULAR CYTOGENETICS; INTERPHASE IN SITU D649 HYBRIDIZATION, ANALYZE 100 -30D CELLS OTHER MEDICAL 81310 NEPAL NUCLEOPHOSMIN)(EG, ACUTE MYELOID D649 LEUKEMIA) GENE ANALYSIS, EXON 12 VARIANTS OTHER MEDICAL 88237 TISSUE CULTURE FOR NEOPLASTIC DISORDERS; BONE D649 MARROW, BLOOD CELLS OTHER MEDICAL 88264 CHROMOSOME ANALYSIS; ANALYZE 20 -25 CELLS D649 88271 MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG, FISH) D649 88275 MOLECULAR CYTOGENETICS; INTERPHASE IN SITU D649 HYBRIDIZATION, ANALYZE 100 -300 CELLS PROFE55IONAL 81310 NPM1 (NUCLEOPHOSMIN) (EG, ACUTE MYELOID D649 LEUKEMIA) GENE ANALYSIS, EXON 12 VARIANTS PROFESSIONAL 88237 TISSUE CULTURE FOR NEOPLASTIC DISORDERS; BONE D649 MARROW, BLOOD CELLS PROFESSIONAL 88264 CHROMOSOME ANALYSIS; ANALYZE 20 -25 CELLS D649 88271 MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG, FISH) D649 88275 MOLECULAR CYTOGENETICS; INTERPHASE IN SITU D649 HYBRIDIZATION, ANALYZE 100 -300 CELLS SPOUSE GROUND MILEAGE, PER STATUTE MILE 1498 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NOW 1498 EMERGENCY TRANSPORT, LEVEL 1(ALS 1) 1 BCC 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLEVIEW, A419 FRONTAL SPOUSE 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, R918 FRONTAL $807.15 MALE 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R918 FRONTAL $39.72 38221 BONE MARROW; BIOPSY, NEEDLE ORTROCAR C9200 ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL ANEMIA, UNSPECIFIED OTHER MEDICAL OTHER SPECIFIED PROFESSIONAL CARDIAC ARRHYFHMIAS OUTPATIENT /HOSPITAL OTHER SPECIFIED PROFE55IONAL CARDIAC ARRHYTHMIAS OUTPATIENT /HOSPITAL SEPSIS, UNSPECIFIED PROFESSIONAL ORGANISM INPATIENT /HOSPITAL OTHER NONSPECIFIC PROFESSIONAL ABNORMAL FINDING OF INPATIENT /HOSPITAL LUNG FIELD 1 BCC OTHER NONSPECIFIC OTHER MEDICAL ABNORMAL FINDING OF SPOUSE LUNG FIELD 3559 ACUTE MYELOBLASTIC OTHER MEDICAL LEUKEMIA, NOT HAVING ACHIEVED REMISSION ($12425; (.$449.00) MALE SPOUSE 1 BCC 3559 (586,63 (5478.8511 MALE SPOUSE 1 BCC 3559 685.4911 ($807.1511 MALE SPOUSE 1 BCC 3559 ($19.86) ($2,880.09) MALE SPOUSE 1 BCC 3559 ($165.30) (_$1,14.0011 MALE SPOUSE 1 BCC 3559 $0.00 $449.00 MALE SPOUSE 1 BCC 3559 $0.00 $478.85 MALE SPOUSE 1 BCC 3559 $0.00 $807.15 MALE SPOUSE 1 BCC 3559 $0.00 $2,880.00 MALE SPOUSE 1 BCC 3559 $0.00 $1,224.00 MALE SPOUSE 1 BCC 3559 $124.25 $449.00 MALE SPOUSE 1 BCC 3559 $86.63 $478.85 MALE SPOUSE 1 BCC 3559 $85.49 $807.15 MALE SPOUSE 1 BCC 3559 $39.72 $2,880.00 MALE SPOUSE 1 BCC 3559 $165.30 $1,224.00 MALE SPOUSE 1 BCC 3559 $1,590.00 $2,162.40 MALE SPOUSE 1 BCC 3559 $380.00 $850.00 MALE SPOUSE 1 BCC 3559 $12.41 $35.00 MALE SPOUSE 1 BCC 3559 $1241 $35.00 MALE SPOUSE 1 BCC 3559 $12.41 $35.00 MALE SPOUSE 1 BCC 3559 8/4/2017 4444#### $0.00 $1,345,565.00 MALE SPOUSE 1 BCC 3559 81212017 # # # # # # ## $0.00 $1,364,157.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $798.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $10314 $293.00 MALE SPOUSE 1 BCC 3559 sl 1112712017 11/20/2017 1112212017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL $95.38 INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, SPOUSE LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL $0.00 TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SPOUSE ACHIEVED REMISSION 3559 $0.00 DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), SPOUSE 1 BCC 3559 $524.58 CREATININE( 82565(, GLUCOSE (82947), PHOSPHATASE, SPOUSE 1 BCC 3559 $264.31 ALKALINE (84075), POTASSIUM (84132), PROTEIN, SPOUSE 1 BCC 3559 11/27/2017 11/20/2017 11/22/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, C9200 ACUTE MYELOBLASTIC PROFESSIONAL HUT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT ACHIEVED REMISSION 11/27/2017 11/21/2017 11/25/2017 93306 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL -TIME WITH Z7682 AWAITING ORGAN PROFESSIONAL IMAGE DOCUMENTATION (2D), INCLUDES M -MODE TRANSPLANT STATUS OUTPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 11129/2017 10/30/2017 11/28/2017 36430 TRANSFUSION, BLOOD OR BLOOD COMPONENTS D61818 OTHER PANCYTOPENIA OTHER MEDICAL 11/29/2017 10/30/2017 11/28/2017 99053 SERVICE(S) PROVIDED BETWEEN 10:00 PM AND 8:00 AM D61818 OTHER PANCYTOPENIA OTHER MEDICAL AT 24 -HOUR FACILITY, IN ADDITION TO BASIC SERVICE 11/29/2017 10/30/2017 11/28/2017 99291 CRITICALCARE, EVALUATION AND MANAGEMENT DELETE D61818 OTHER PANCYTOPENIA OTHER MEDICAL CRITICALLY ILLOR CRITICALLY INJURED PATIENT; FIRST30- 74 MINUTES 11/29/2017 10/30/2017 1112812017 99292 CRITICALCARE, EVALUATION AND MANAGEMENT OFTHE D61819 OTHER PANCYTOPENIA OTHER MEDICAL CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE) 11/29/2017 11/6/2017 1112812017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LEUKEMIA, NOT HAVING PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY ACHIEVED REMISSION COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY, COUNSELING AND /DR COORDINATION OF CARE WITH OTHER 11/29/2017 11/6/2017 11/28/2017 963651ntravenous infusion, for therapYprophylaxis, or diagnosis D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE (specify substance or drug); initial, up to 1 hour 11/29/2017 11/6/2017 11/28/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 11/29/2017 11/6/2017 11/28/2017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 11/29/2017 11/6/2017 11/28/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 NICE D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 11/29/2017 11/7/2017 11/28/2017 963651ntravenous infusion, forth em py, prophylaxis, or diagnosis CREW ACUTE LEUKEMIA OF PROFESSIONAL OFFICE (specify substance or drug); initial, up to l hour UNSPECIFIED CELLTYPE NOT HAVING ACHIEVED REMISSION 11/29/2017 11/7/2017 11/28/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C9500 ACUTE LEUKEMIAOF PROFESSIONAL OFFICE OR DIAGNOSIS (SPECIFY SUBSTANCE DR DRUG); UNSPECIFIED CELLTYPE ADDITIONAL SEQUENTIAL INFUSION OF A NEW NOT HAVING ACHIEVED DRUG / SUBSTANCE, UP TO I HOUR (LIST SEPARATELY IN REMISSION ADDITION TO CODE FOR PRIMARY PROCEDURE) $0.00 $26.00 MALE SPOUSE 1 BCC C.7.f 3559 $0.00 $10.40 MALE SPOUSE 1 BCC 3559 $95.38 $235.00 MALE SPOUSE 1 BCC 3559 $0.00 $244.00 MALE SPOUSE 1 BCC 3559 $0.00 $214.00 MALE SPOUSE 1 BCC 3559 $524.58 $1,973.00 MALE SPOUSE 1 BCC 3559 $264.31 $872.00 MALE SPOUSE 1 BCC 3559 $141.30 $348.35 MALE SPOUSE 1 BCC 3559 $9745 $240.24 MALE SPOUSE 1 BCC 3559 $44.62 $109.99 MALE SPOUSE 1 BCC 3559 $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 $14.90 $27.00 MALE SPOUSE 1 BCC 3559 $97.45 $240.24 MALE SPOUSE 1 BCC 3559 $44.62 $109.99 MALE SPOUSE 1 BCC 3559 11/29/2017 11/7/2017 1112812017 10894 INJECTION, DECITABINE, 1 MG C9500 ACUTE LEUIKEMIAOF PROFESSIONAL OFFICE 4) $23.00 MALE SPOUSE UNSPECIFIED CELLTYPE 3559 $97.45 M $14.90 NOT HAVING ACHIEVED SPOUSE 1 BCC 3559 SPOUSE REMISSION 3559 11/29/2017 11/7/2017 11/28/2017 J1626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG C9500 ACUTE LEUIKEMIAOF PROFESSIONAL DFFICE $14.90 $27.00 MALE SPOUSE UNSPECIFIED CELLTYPE 3559 $33.46 $93.00 MALE SPOUSE NOT HAVING ACHIEVED 3559 $51.51 $9745 $240.24 MALE REMISSION 1 BCC 11/29/2017 11/8/2017 1112812017 963651ntravenous infusion, for therapy, prophylaxis, or diagnosis D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE (specify substance or drug); initial, up to 1 hour 11/29/2017 11/8/2017 11/28/2017 96366 Intraven ousinfusion, for therapy,prophylaxis,ordiagnosis D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $72.85 MALE (specify substance or drug); each additional hour (List 1 BCC 3559 separately in addition to code for p,i—V Procedure) 11/29/2017 11/8/2017 1112812017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, D61819 OTHER PANCYTOPENIA PROFESSIONAL OFFICE OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW fl $44.62 $109.99 MALE SPOUSE DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN 3559 E. CL ADDITION TO CODE FOR PRIMARY PROCEDURE) 11/29/2017 111812017 1112812017 10894 INJECTION, DECITABINE, 1 MG D61819 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 11/29/2017 11/8/2017 11/28/2017 13480 INJECTION, POTASSIUM CHLORIDE, PER 2 VIED, D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 11/29/2017 11/9/2017 11/28/2017 96365 ntravenou s infusion, for th em py, p,,Rhylaxis, or diagnos i, C9500 ACUTE LEUKEMIA OF PROFESSIONAL OFFICE (specify substance or drug); initial, up to 1 hour UNSPECIFIED CELLTYPE NOT HAVING ACHIEVED REMISSION 11/29/2017 11/9/2017 1112812017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C9500 ACUTE LEUKEMIA OF PROFESSIONAL OFFICE OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); UNSPECIFIED CELLTYPE ADDITIONAL SEQUENTIAL INFUSION OF A NEW NOT HAVING ACHIEVED DRUG / SUBSTANCE, UP TO I HOUR (LIST SEPARATELY IN REMISSION ADDITION TO CODE FOR PRIMARY PROCEDURE) 11/29/2017 111912017 11/28/2017 J0894 INJECTION, DECITABINE, 1 MG C9500 ACUTE LEUKEMIAOF PROFESSIONAL OFFICE UNSPECIFIED CELLTYPE NOT HAVING ACHIEVED REMISSION 11/29/2017 11/9/2017 11/28/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCC C9500 ACUTE LEUKEMIAOF PROFESSIONAL OFFICE UNSPECIFIED CELLTYPE NOT HAVING ACHIEVED REMISSION 11/29/2017 11/14/2017 11/28/2017 85060 BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY C9200 ACUTE MYELOBLASTIC PROFESSIONAL PHYSICIAN WITH WRITTEN REPORT LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION 11/29/2017 11/14/2017 11/28/2017 88305 LEVEL IV- SURGICAL PATHOLOGY, GROSS AND C9200 ACUTE MYELOBLASTIC PROFESSIONAL MICROSCOPIC EXAMINATION ABORTION- LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE ACHIEVED REMISSION MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHERTHAN FOR TUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION 11/29/2017 11/14/2017 11/28/2017 88311 DECALCIFICATION PROCEDURE(LISTSEPARATELY IN C9200 ACUTE MYELOBLASTIC PROFESSIONAL ADDITION TO CODE FOR SURGICAL PATHOLOGY LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL EXAMINATION) ACHIEVED REMISSION C.7.f $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 4) $23.00 MALE SPOUSE 1 BCC 3559 $97.45 M $14.90 $27.00 MALE SPOUSE 1 BCC 3559 SPOUSE 1 BCC 3559 $1,022.50 $5,041.00 MALE SPOUSE Q! 3559 $14.90 $27.00 MALE SPOUSE 1 BCC 3559 $33.46 $93.00 MALE SPOUSE 1 BCC 3559 $51.51 $9745 $240.24 MALE SPOUSE 1 BCC 3559 7 $29.55 $72.85 MALE SPOUSE 1 BCC 3559 f0 } fl $44.62 $109.99 MALE SPOUSE 1 BCE 3559 E. CL $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 $16.20 $23.00 MALE SPOUSE 1 BCC 3559 $97.45 $240.24 MALE SPOUSE 1 BCC 3559 $44.62 $109.99 MALE SPOUSE 1 BCC 3559 $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 $14.90 $27.00 MALE SPOUSE 1 BCC 3559 $33.46 $93.00 MALE SPOUSE 1 BCC 3559 $51.51 $140.00 MALE SPOUSE 1 BCC 3559 $17.40 $48.00 MALE SPOUSE 1 BCC am C.7.f 11/29/2017 11/14/2017 1112812017 88313 SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT; C9200 ACUTE MYELOBLASTIC PROFESSIONAL $72.73 $199.00 MALE GROUP II, ALL OTHER IDS, IRON, TRICHROME), EXCEPT 1 BCC LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL $10.80 MALE SPOUSE STAIN FOR MICROORGANISMS , STAINS FOR ENZYME 3559 ACHIEVED REMISSION $11.30 MALE SPOUSE 1 BCC CONSTITUENTS, OR IM MUNOCYTOCH EMISTRY AND $0.00 $9.20 MALE SPOUSE 1 BCC 3559 IMMU NOHISTOCH EMISTRY $3.20 MALE SPOUSE 1 BCC 11/29/2017 11/14/2017 1112812017 88360 MORPHOMETRIC ANALYSIS, TUMOR C9200 ACUTE MYELOBLASTIC PROFESSIONAL $11.07 $70.00 MALE IMMUNOHISTOCHEMISTRY (EG, HER-2/NEU, ESTROGEN 1 BCC LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL $240.24 MALE SPOUSE RECEPTO R /PROG ESTE RONE RECEPTOR), QUANTITATIVE 3559 ACHIEVED REMISSION $109.99 MALE SPOUSE 1 BCC OR SEMIQUANTITATIVE, PER SPECIMEN, EACH SINGLE $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 ANTIBODYSTAIN PROCEDURE; MANUAL $27.00 MALE SPOUSE 1 BCC 11/29/2017 11/21/2017 11/28/2017 82375 CARBOXYHEMOGLDBIN; QUANTITATIVE 77682 AWAITING ORGAN PROFESSIONAL $0.00 $46.00 MALE SPOUSE 1 BCC TRANSPLANT STATUS OUTPATIENT /HOSPITAL 11/29/2017 11/21/2017 1112812017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, POE, Z7682 AWAITING ORGAN PROFESSIONAL SPOUSE 1 BCC C0E,HCD3(INCLUDING CALCULATED O2 SATURATION); $14130 TRANSPLANT STATUS OUTPATIENT /HOSPITAL 11/29/2017 11/21/2017 11/28/2017 83050 HEMOGLOBIN; METHEMOGLOBIN, QUANTITATIVE Z7682 AWAITING ORGAN PROFESSIONAL TRANSPLANT STATUS OUTPATIENT/HOSPITAL 11/29/2017 11/21/2017 11/28/2017 85014 BLOOD COUNT; HEMATOCRIT (HCT) Z7682 AWAITING ORGAN PROFESSIONAL TRANSPLANT STATUS OUTPATIENT /HOSPITAL 11/29/2017 11/22/2017 1112812017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R9431 ABNORMAL PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY ELECTROCARDIOGRAM OUTPATIENT /HOSPITAL [ECG] [EKG( 11/30/2017 10/29/2017 11/28/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 11/30/2017 11/10/2017 11/29/2017 963651ntravenous infusion, for therapy, prophylaxis, or diagnosis D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE (specify substance or drug); initial, up to 1 hour 11/30/2017 11/10/2017 11/29/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 11/30/2017 11/10/2017 11/29/2017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 11/30/2017 11/10/2017 11/29/2017 J1626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 11/30/2017 11/21/2017 1112912017 94010 SPIR0METRY, INCLUDING GRAPHIC RECORD, TOTAL AND Z7682 AWAITING ORGAN PROFESSIONAL TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE TRANSPLANT STATUS OUTPATIENT /HOSPITAL MEASUREMENT(S), W ITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION 11/30/2017 11/21/2017 11/29/2017 94726 PLETHYSMOGRAPHY FOR DETERMINATION OF LUNG Z7682 AWAITING ORGAN PROFESSIONAL VOLUMES AND, WHEN PERFORMED, AIRWAY RESISTANCE TRANSPLANT STATUS OUTPATIENT /HOSPITAL 11/30/2017 11/21/2017 1112912017 94729 DIFFUSING CAPACITY (EG, CARBON MONOXIDE, Z7682 AWAITING ORGAN PROFESSIONAL MEMBRANE) (LIST SEPARATELY IN ADDITION TO CODE TRANSPLANT STATUS OUTPATIENT /HOSPITAL FOR PRIMARY PROCEDURE) 12/5/2017 11/20/2017 12/1/2017 * * "* * * "''" * *` ** ' * * "" * * * »* 12/6/2017 11/27/2017 12/5/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C9200 ACUTE MYELOBLASTIC PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LEUKEMIA, NOT HAVING PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY ACHIEVED REMISSION COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER $49.44 $138.00 MALE SPOUSE 1 BCC 3559 $72.73 $199.00 MALE SPOUSE 1 BCC 3559 $0.00 $10.80 MALE SPOUSE 1 BCC 3559 $0.00 $11.30 MALE SPOUSE 1 BCC 3559 $0.00 $9.20 MALE SPOUSE 1 BCC 3559 $0.00 $3.20 MALE SPOUSE 1 BCC 3559 $12.97 $32.00 MALE SPOUSE 1 BCC 3559 $11.07 $70.00 MALE SPOUSE 1 BCC 3559 $9745 $240.24 MALE SPOUSE 1 BCC 3559 $44.62 $109.99 MALE SPOUSE 1 BCC 3559 $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 $14.90 $27.00 MALE SPOUSE 1 BCC 3559 $12.97 $32.00 MALE SPOUSE 1 BCC 3559 $0.00 $46.00 MALE SPOUSE 1 BCC 3559 $13.98 $35.00 MALE SPOUSE 1 BCC 3559 $234.OS $483.02 MALE SPOUSE 1 BCC 3559 $14130 $348.35 MALE SPOUSE 1 BCC 3559 12/6/2017 11/28/2017 12/5/2017 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $14.90 $27.00 MALE (specify substance or drug); initial, up to 1 hour 1 BCC 3559 $974S 12/6/2017 11/28/2017 12/5/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE SPOUSE 1 BCC OR DIAGNOSIS ISPECIFY SUBSTANCE OR DRUG); $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 ADDITIONAL SEQUENTIAL INFUSION OF A NEW $27.00 MALE SPOUSE 1 BCC 3559 $0.00 DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN SPOUSE 1 BCC 3559 $0.00 $90.00 MALE ADDITION TO CODE FOR PRIMARY PROCEDURE) 1 BCC 3559 $0.00 12/6/2017 11/28/2017 12/5/2017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 12/6/2017 11/28/2017 12/5/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 12/6/2017 11/29/2017 12/5/2017 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 3559 $44.62 (specify substance or drug); initial, up to 1 hour SPOUSE 1 BCC 3559 12/6/2017 11/29/2017 12/5/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $27.00 MALE SPOUSE OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); 3559 $97.45 $240,24 MALE SPOUSE 1 BCC ADDITIONAL SEQUENTIAL INFUSION OF A NEW $44.62 $109.99 MALE SPOUSE 1 BCC 3559 DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 12/6/2017 11/29/2017 12/5/2017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 12/6/2017 11/29/2017 12/5/2017 J1626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 12/7/2017 11/4/2017 12/6/2017 T1001 NURSING ASSESSMENT /EVALUATION A419 SEPSIS, UNSPECIFIED OTHER MEDICAL ORGANISM 12/7/2017 11/9/2017 12/6/2017 59131 PHYSICAL THERAPY; IN THE HOME, PER DIEM A419 SEPSIS, UNSPECIFIED OTHER MEDICAL ORGANISM 12/7/2017 11/24/2017 12/6/2017 59131 PHYSICAL THERAPY; IN THE HOME, PER DIEM A419 SEPSIS, UNSPECIFIED OTHER MEDICAL ORGANISM 12/7/2017 11/27/2017 12/6/2017 59131 PHYSICAL THERAPY; IN THE HOME, PER DIEM A419 SEPSIS, UNSPECIFIED OTHER MEDICAL ORGANISM 12/7/2017 11/29/2017 12/6/2017 59131 PHYSICAL THERAPY; IN THE HOME, PER DIEM A419 SEPSIS, UNSPECIFIED OTHER MEDICAL ORGANISM 121712017 11/30/2017 12/5/2017 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis C9500 ACUTE LEUKEMIA OF PROFESSIONAL OFFICE (specify substance or drug); initial, up to I hour UNSPECIFIED CELLTYPE NOT HAVING ACHIEVED REMISSION 12/7/2017 11/30/2017 12/5/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C9500 ACUTE LEUKEMIA OF PROFESSIONAL OFFICE OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); UNSPECIFIED CELLTYPE ADDITIONAL SEQUENTIAL INFUSION OF A NEW NOT HAVING ACHIEVED DRUG /SUBSTANCE, UP TO I HOUR (LIST SEPARATELY IN REMISSION ADDITION TO CODE FOR PRIMARY PROCEDURE) 12/7/2017 11/30/2017 12/5/2017 10894 INJECTION, DECITABINE, 1 MG C9500 ACUTE LEUIKEMIAOF PROFESSIONAL OFFICE UNSPECIFIED CELLTYPE NOT HAVING ACHIEVED REMISSION 12/7/2017 11/30/2017 12/5/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG C9500 ACUTE LEUKEMIAOF PROFESSIONAL OFFICE UNSPECIFIED CELLTYPE NOT HAVING ACHIEVED REMISSION 12/8/2017 12/1/2017 12/7/2017 963651ntravenous infusion, for therapy, prophylaxis, or diagnosis D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE (specify substance or drug); initial, up to 1 hour 121812017 121112017 12/7/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, D61318 OTHER PANCYTOPENIA PROFESSIONAL OFFICE OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $97.45 $240.24 MALE SPOUSE $44.62 $109.99 MALE SPOUSE C.7.f 1 BCC 3559 w C! 1 BCC 3559 N $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 $14.90 $27.00 MALE SPOUSE 1 BCC 3559 $974S $240.24 MALE SPOUSE 1 BCC 3559 $44.62 $109.99 MALE SPOUSE 1 BCC 3559 $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 $14.90 $27.00 MALE SPOUSE 1 BCC 3559 $0.00 $100.00 MALE SPOUSE 1 BCC 3559 $0.00 $90.00 MALE SPOUSE 1 BCC 3559 $0.00 $90.00 MALE SPOUSE 1 BCC 3559 $0.00 $90.00 MALE SPOUSE 1 BCC 3559 $0.00 $90.00 MALE SPOUSE 1 BCC 3559 $9745 $240.24 MALE SPOUSE 1 BCC 3559 $44.62 $109.99 MALE SPOUSE 1 BCC 3559 $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 $14.90 $27.00 MALE SPOUSE 1 BCC 3559 $97.45 $240,24 MALE SPOUSE 1 BCC 3559 $44.62 $109.99 MALE SPOUSE 1 BCC 3559 C.7.f 12/8/2017 12/1/2017 12/7/2017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 12/8/2017 12/1/2017 12/7/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $14.90 $27.00 MALE SPOUSE 1 BCC w 3559 N 12/11/2017 12/5/2017 12/8/2017 963651ntravenousinfuslon, forth era py, p rophylaxis, or diagnosis C9500 ACUTE LEUKEMIA OF PROFESSIONAL OFFICE $97.45 $240.24 MALE SPOUSE 1 BCC 3559 (specify substance or drug); initial, upto I hour UNSPECIFIED CELL TYPE NOT HAVING ACHIEVED REMISSION 12/11/2017 12/5/2017 12/8/2017 96367 INTRAVENOUS INFUSION, FORTHERAPY, PROPHYLAXIS, C9500 ACUTE LEUKEMIAOF PROFESSIONAL OFFICE $44.62 $109.99 MALE SPOUSE 1 BCC 3559 7 OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG; UNSPECIFIED CELL TYPE ADDITIONAL SEQUENTIAL INFUSION OF ANEW NOT HAVING ACHIEVED DRUG /SUBSTANCE, UP TO I HOUR (LIST SEPARATELY IN REMISSION ADDITION TO CODE FOR PRIMARY PROCEDURE) fl 12/11/2017 12/5/2017 12/8/2017 10894 INJECTION, DECITABINE, 1 MG C9500 ACUTE LEUKEMIA OF PROFESSIONAL OFFICE $1,022.50 $5,041.00 MALE SPOUSE 1 BCC } 3559 UNSPECIFIED CELLTYPE N. CL NOT HAVING ACHIEVED Q, REMISSION 12/11/2017 12/5/2017 12/8/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG C9500 ACUTE LEUKEMIAOF PROFESSIONAL OFFICE $14.90 $27.00 MALE SPOUSE 1 BCC 3559 UNSPECIFIED CELLTYPE NOT HAVING ACHIEVED REMISSION 1211212017 81 1112212017 *x« ++ * * *.* x« « +x . * *wr * * * *• 8/2/2017 # # # # # # ## $0.00 $1,393,899.00 MALE SPOUSE 1 BCC 3559 12/12/2017 11/30/2017 12/11/2017 - - D61818 OTHER PANCYTOPENIA HOSPITAL OUTPATIENT $10,999.50 $40,105.13 MALE SPOUSE 1 BCC 3559 UJ h J 12/13/2017 12/6/2017 12/12/2017 963651ntravenous nfusion, forth era py, prophylaxis, cr diagnos i, D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $97.45 $240.24 MALE SPOUSE 1 BCC 3559 (specify substance or drug); Initial, up to 1 hour 12/13/2017 12/6/2017 12/12/2017 96375 Therapeutic, prophylactic, or diagnostic injection (specify D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $31.17 $76.85 MALE SPOUSE 1 BCC 3559 substance or drug); each additional sequential intravenous push of a new substance /drug (List separately In addition O to code for primary procedure( Q W 12/13/2017 12/6/2017 12/12/2017 10894 INJECTION, DECITABINE, 1 MG D61819 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 12/13/2017 12/6/2017 12/12/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCC D61818 OTHER PANCYTOPENIA PROFE55IONAL OFFICE $14.90 $27.00 MALE SPOUSE 1 BCC 3559 12113/2017 12/7/2017 12/12/2017 963651ntravenous in fusion, for th em py, prophylaxis, Or diagnOSis D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $97.45 $240.24 MALE SPOUSE 1 BCC 3559 (specify substance or drug); initial, up to 1 hour LLJ 0 12/13/2017 121712017 1211212017 96375 Therapeutic, prophylactic, or diagnostic injection (specify D61819 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $31.17 $76.85 MALE SPOUSE 1 BCC 3559 � substance or drug); each additional sequential intravenous J push of a no, substance /drug (List separately In addition to code for primary procedure( V 12/13/2017 121712017 12/12/2017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 W 12/13/2017 12/]/201] 1211212017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCC D61819 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $14.90 $27.00 MALE SPOUSE 1 BCC 3559 12/13/2017 12/8/2017 12/12/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1302 OTHERSEASONAL PROFESSIONAL OFFICE $69.57 $314.00 MALE SPOUSE 1 BCC 3559 (' EVALUATION AND MANAGEMENT OF AN ESTABLISHED ALLERGIC RHINITIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED CIBI EXAMINATION; MEDICAL DECISION MAKING OF LOW" N COMPLEXITY. COUNSELING AND COORD 12/13/2017 12/8/2017 12/12/2017 96365 Intravenous in f,,I.r,for therapy, prophylaxis, or diagnos is D61819 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $97.45 $240,24 MALE SPOUSE 1 BCC 3559 iL (specify substance or drug); initial, up to 1 hour E s 12/13/2017 12/8/2017 1211212017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $1,022.50 $5,041.00 MALE SPOUSE 1 DEC 3559 2 C.7.f 12/18/2017 11/14/2017 1211212017 81245 FLT3(FMS- RELATED TYROSINE KINASE 3) (EG, ACUTE D47Z9 OTHER SPECIFIED OTHER MEDICAL $116.79 $1,000.00 MALE SPOUSE 1 BCC 3559 MYELOID LEUKEMIA), GENE ANALYSIS; INTERNALTANDEM NEOPLASMS OF DUPLICATION (LTD) VARIANTS (IE, EXONS 14,15) UNCERTAIN BEHAVIOR OF LYMPHOID, N HEMATOPOIETIC AND RELATED TISSUE 12/18/2017 11/14/2017 1211212017 81246 FLT3(FMS- RELATED TYROSINE KINASE 3) (EG, ACUTE D47Z9 OTHER SPECIFIED OTHER MEDICAL $0.00 $1,000.00 MALE SPOUSE 1 BCC 3559 MYELOID LEUKEMIA), GENE ANALYSIS; TYROSINE KINASE NEOPLASMS OF DOMAIN ITKD) VARIANTS (EG, D835,1836) UNCERTAIN BEHAVIOR OF } LYMPHOID, "a HEMATOPOIETIC AND RELATED TISSUE 12/18/2017 11/14/2017 12/12/2017 81450 TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, D4779 OTHER SPECIFIED OTHER MEDICAL $0.00 $12,000.00 MALE SPOUSE 1BCC 3559 HEMATOLYMPHOID NEOPLASMOR DISORDER, DNAAND NEOPLASMS OF } RNA ANALYSIS WHEN PERFORMED, 5 -50 GENES (EG, BRAF, UNCERTAIN BEHAVIOR OF PEBPA, DNMI EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, LYMPHOID, N. CL MILL, NRAS, HEMATOPOIETIC AND Q, RELATED TISSUE 12/18/2017 11/14/2017 12/12/2017 81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE D47Z9 OTHER SPECIFIED OTHER MEDICAL $0.00 $1,500.00 MALE SPOUSE 1 BCC 3559 NEOPLASMS OF UNCERTAIN BEHAVIOR OF LYMPHOID, HEMATOPOIETIC AND RELATED TISSUE h 12/18/2017 11/14/2017 12/16/2017 1036F CURRENTTOBACCO NON- USER(CAD, CAP,COPD, PV) C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $0.01 MALE SPOUSE 1 BCC 3559 (DM) (IBD) LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION 12/18/2017 11/14/2017 12/16/2017 1126F INTERMEDIATE "DELAY" DF ANY FLAP, PRIMARY "DELAY" C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $0.01 MALE SPOUSE 1 BCC 3559 OFSMALL FLAP, ORSECTIONING PEDICLE OFTUBEDOR LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, ACHIEVED REMISSION (L 12/18/2017 11/14/2017 12/16/2017 1220F PATIENTSCREENED FOR DEPRESSION (SUD) C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $0.01 MALE SPOUSE 1 BCC 3559 {j LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION UJ 12/18/2017 11114/2017 12/16/2017 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C9200 ACUTE MYELOBIASTIC PROFESSIONAL $170.75 $429.00 MALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY ACHIEVED REMISSION e LLJ COMPONENTS: A COMPREHENSIVE HISTORY; A °✓ COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR J COORDINATION OF CARE WITH v 12/18/2017 11/14/2017 12/16/2017 G8420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS C9200 ACUTE MYELOBIASTIC PROFESSIONAL $0.00 $0.01 MALE SPOUSE 1 BCC 3559 AND NO FOLLOW -UP PLAN IS REQUIRED LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION LLJ 12/18/2017 11/14/2017 12/16/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $0.01 MALE SPOUSE 1 BCC 3559 THE MEDIC AL RECORD THEY OBTAINED, UPDATED, OR LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL 0 REVIEWED THE PATIENT'S CURRENT MEDICATIONS ACHIEVED REMISSION 12/18/2017 11/14/2017 12/16/201768484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $0.01 MALE SPOUSE 1BCC 3559 REASON NOT GIVEN LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION CFJ f'V 12/18/2017 11/14/2017 12/16/2017 G8731 PAIN ASSESSMENT USING A STANDARDIZED TOOL IS C9200 ACUTE MYELOBLASTIC PROFESSIONAL $0.00 $0.01 MALE SPOUSE 1 BCC 3559 = DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL REQUIRED ACHIEVED REMISSION L 12/18/2017 12/4/2017 12/15/2017 963651nt— onousinfusion, for th em py, prophylaxis, or diagnos is D61818 OTHER PANC/TOPENIA PROFESSIONAL OFFICE $97.45 $240.24 MALE SPOUSE 1 BCC 3559 (specify substance or drug); initial, up to 1 hour 12/18/2017 12/4/2017 12/15/2017 96375 Therapeutic, prophylactic, or diagnostic injection (specify D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $10.40 MALE SPOUSE 1 BCC substance or drug); each additional sequential intravenous $116.79 $1,000.00 MALE SPOUSE 1 BCC 3559 $0.00 push of a new substance /drug (List separately In addition SPOUSE 1 BCC 3559 $0.00 $12,000.00 MALE SPOUSE to code for primary procedure) 3559 $0.00 $1,500.00 MALE 12/18/2017 12/4/2017 12/15/2017 10894 INJECTION, DECITABINE, 1 MG D61819 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 12/18/2017 12/4/2017 12/15/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCC D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE 12/18/2017 12/13/2017 12116/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST Z7682 AWAITING ORGAN PROFESSIONAL 1 BCC 3559 $159.77 INCLUDE THE FOLLOWING'. ALBUMIN (82040), BILIRUBIN, SPOUSE TRANSPLANT STATUS OUTPATIENT /HOSPITAL $159.77 $399.00 MALE SPOUSE TOTAL (82247), CALCIUM, TOTAL (82310), CARBON 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 DIOXIDE (BICARBONATE)(82374), CHLORIDE (92435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE X84075), POTASSIUM (84132), PROTEIN, 12118/2017 12/13/2017 12/16/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); Z7682 AWAITING ORGAN PROFESSIONAL TRANSPLANT STATUS OUTPATIENT /HOSPITAL 12/18/2017 12/13/2017 12/16/2017 85025 BLOOD COUNT; COMPLETE(CBQ, AU70MATED(HGB, Z7682 AWAITING ORGAN PROFESSIONAL HCT,RBC, WET AND PLATELET COUNT) AND AUTOMATED TRANSPLANT STATUS OUTPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT 1212012017 8/2/2017 9/20/2017 81245 FLT3( FMS - RELATED TYROSINE KINASE 3) (EG, ACUTE C9200 ACUTE MYELOBIASTIC OTHER MEDICAL MYELOID LEUKEMIA), GENE ANALYSIS; INTERNALTANDEM LEUKEMIA, NOT HAVING DUPLICATION (ITD) VARIANTS HE, EXDNS 14,15) ACHIEVED REMISSION 12/20/2017 8/2/2017 9/20/2017 81246 FLT3 (FMS- RELATEDTYROSINE KINASE 3) (EG, ACUTE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL MYELOID LEUKEMIA), GENE ANALYSIS; TYROSINE KINASE LEUKEMIA, NOT HAVING DOMAIN (TKD) VARIANTS (EG, D835,1836) ACHIEVED REMISSION 12/20/2017 8/2/2017 9/20/2017 81450 TARGETED GENOMICSEQUENCE ANALYSIS PANEL, C9200 ACUTE MYELOBLASTIC OTHER MEDICAL HEMATOLYMPHOID NEOPLASM OR DISORDER, DNAAND LEUKEMIA, NOT HAVING RNAANALYSIS WHEN PERFORMED, 5 -50 GENES (EG, BRAF, ACHIEVED REMISSION CEBPA, DNMi EZH2, FLT3, IDH1, IDH2,JAK2, KRAS, KIT, MLL, NRAS, 12/20/2017 8/2/2017 9/20/2017 81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL LEUKEMIA, NOT HAVING ACHIEVED REMISSION 1212012017 8/2/2017 9/20/2017 81245 FLT3(FMS- RELATEDTYROSINE KINASE 3) (EG, ACUTE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL MYELOID LEUKEMIA), GENE ANALYSIS; INTERNALTANDEM LEUKEMIA, NOT HAVING DUPLICATION( ITD) VARIANTS HE, EXDNS 14, 15) ACHIEVED REMISSION 12/20/2017 8/2/2017 9/20/2017 81246 FLT3(FMS- RELATEDTYRDSINE KINASE 3) (EG, ACUTE C9200 ACUTE MYELOBIASTIC OTHER MEDICAL MYELOID LEUKEMIA), GENE ANALYSIS; TYROSINE KINASE LEUKEMIA, NOT HAVING DOMAIN (TKD) VARIANTS (EG, D835,1836) ACHIEVED REMISSION 12/20/2017 8/2/2017 912012017 81450 TARGETED GENOMI [SEQUENCE ANALYSIS PANEL, C9200 ACUTE MYELOBLASTIC OTHER MEDICAL HEMATOLYMPHOID NEOPLASM OR DISORDER, DNA AND LEUKEMIA, NOT HAVING RNA ANALYSIS WHEN PERFORMED, 5 5D GENES (EG, BRAF, ACHIEVED REMISSION CEBPA, DNMT3A, EZH2, FLEE, DHl, IDH2,JAK2, KRAS, KIT, MILE, NRAS, 12/20/2017 8/2/2017 9/20/2017 81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE C9200 ACUTE MYELOBLASTIC OTHER MEDICAL LEUKEMIA, NOT HAVING ACHIEVED REMISSION 12/21/2017 9/20/2017 12/18/2017 *"" ** * * * ** *• * *_ * * *xx xxxxx 12/21/2017 10/2/2017 12/18/2017 "<:: 1212112017 10/3/2017 1211812017 * * *** ••••" *x* ** x.... ..x.. $31.17 $76.85 MALE SPOUSE 1 BCC C.7.f 3559 $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 $14.90 $27.00 MALE SPOUSE 1 BCC 3559 $0.00 $26.00 MALE SPOUSE 1 BCC 3559 $0.00 $5.70 MALE SPOUSE 1 BCC 3559 $0.00 $10.40 MALE SPOUSE 1 BCC 3559 $116.79 $1,000.00 MALE SPOUSE 1 BCC 3559 $0.00 $1,000.00 MALE SPOUSE 1 BCC 3559 $0.00 $12,000.00 MALE SPOUSE 1 BCC 3559 $0.00 $1,500.00 MALE SPOUSE 1 BCC 3559 (51,000.00) MALE SPOUSE 1 BCC 3559 $0.00 ($1,000.00% MALE SPOUSE 1 BCC 3559 $0.00 1$ MALE SPOUSE 1 BCC 3559 $0.00 ($1,500.001 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 $159.77 $399.00 MALE SPOUSE 1 BCC 3559 12/21/2017 10/31/2017 1211812017 99223 INITIAL HOSPITAL CARE, PER DAY, FORTH E EVALUATION D709 NEUTROPENIA, PROFESSIONAL $1,756.00 MALE SPOUSE AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 3559 UNSPECIFIED INPATIENT /HOSPITAL SPOUSE 1 BCC THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; $2,716.16 $7,902.00 MALE SPOUSE 1 BCC 3559 A COMPREHENSIVE EXAMINATION; AND MEDICAL $49.30 MALE SPOUSE 1 BCC 3559 $339.32 DECISION MAKING OF HIGH COMPLEXITY. COUNSELING SPOUSE 1 BCC 3559 $0.00 $26.00 MALE AND /OR COORDINATION OF CARE WITH OTHER 1 BCC 3559 PROVIDERS OR AGEN 12/21/2017 11/1/2017 12/18/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D61810 ANTINEOPLASTIC PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH CHEMOTHERAPY INPATIENT / HDSPITAL REQUIRESAT LEAST 2 OFTHESE 3 KEY COMPONENTS:A INDUCED PANCYTOPENIA DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 12/21/2017 11/14/2017 12/19/2017 - - C9200 ACUTE MYELOBLASTIC HOSPITAL OUTPATIENT LEUKEMIA, NOT HAVING ACHIEVED REMISSION 12/21/2017 11/15/2017 12/19/2017 - - C9200 ACUTE MYELOBIASTIC HOSPITAL OUTPATIENT LEUKEMIA, NOT HAVING ACHIEVED REMISSION 12/21/2017 11/20/2017 12/19/2017 - - C9200 ACUTE MYELOBLASTIC HOSPITAL OUTPATIENT LEUKEMIA, NOT HAVING ACHIEVED REMISSION 12/21/2017 11/21/2017 12/19/2017 - - C9200 ACUTE MYELOBLASTIC HOSPITAL OUTPATIENT LEUKEMIA, NOT HAVING ACHIEVED REMISSION 12/22/2017 10/29/2017 12/20/2017 A0425 GROUND MILEAGE, PERSTATUTE MILE R509 FEVER, UNSPECIFIED OTHER MEDICAL 12/22/2017 10/29/2017 12120/2017 A0429 AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY R509 FEVER, UNSPECIFIED OTHER MEDICAL TRANSPORT (SITE EMERGENCY) 1212212017 12/19/2017 1212112017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST C9200 ACUTE MYELOBLASTIC PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ACHIEVED REMISSION DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE )84075), POTASSIUM (84132), PROTEIN, 12/22/2017 12/19/2017 12/21/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC C9200 ACUTE MYELOBLASTIC PROFESSIONAL EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT LEUKEMIA, NOT HAVING OUTPATIENT /HOSPITAL ACHIEVED REMISSION 12/27/2017 10/20/2017 12/22/2017 963651ntavenous nfusion,fortherapy, prophylaxis, of diagnosis E860 DEHYDRATION PROFESSIONAL OFFICE (specify substance or drug); Initial, up to 1 hour 12/27/2017 10/20/2017 1212212017 12405 INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG E860 DEHYDRATION PROFESSIONAL OFFICE 12/27/2017 10/20/2017 12/22/2017 J7040 INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML =1 E860 DEHYDRATION PROFESSIONAL OFFICE UNIT) 12/27/2017 10/23/2017 12122/2017 963651ntavenous infusion, for therapy, prophylaxis, of diagnosis D61818 OTHER PANCYfOPENIA PROFESSIONAL OFFICE (specify substance or drug); initial, up to 1 hour 12/27/2017 101 12/22/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, D61818 OTHER PANCYFOPENIA PROFESSIONAL OFFICE OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $0.00 $783.00 MALE SPOUSE 1 BCC C.7.f 3559 $15937 $399.00 MALE SPOUSE 1 BCC 3559 $5,235.75 $14,075.00 MALE SPOUSE 1 BCC 3559 $684.84 $1,756.00 MALE SPOUSE 1 BCC 3559 $593.00 $1,179.00 MALE SPOUSE 1 BCC 3559 $2,716.16 $7,902.00 MALE SPOUSE 1 BCC 3559 $34.00 $49.30 MALE SPOUSE 1 BCC 3559 $339.32 $600.00 MALE SPOUSE 1 BCC 3559 $0.00 $26.00 MALE SPOUSE 1 BCC 3559 $0.00 $6.60 MALE SPOUSE 1 BCC 3559 $97.45 $240.24 MALE SPOUSE 1 BCC 3559 $10.96 $13.12 MALE SPOUSE 1 BCC 3559 $1.05 $1.80 MALE SPOUSE 1 BCC 3559 $97.45 $240.24 MALE SPOUSE 1 BCC 3559 $44.62 $109.99 MALE SPOUSE 1 BCC 3559 C.7.f 12/27/2017 10/23/2017 1212212017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 12/27/2017 10/23/2017 12/22/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $14.90 $27.00 MALE SPOUSE 1 BCC w 3559 N 12/27/2017 10/24/2017 12/22/2017 96365 Intravenousinfuslon, forth era py, p rophylaxis, or diagnos is D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $97.45 $240.24 MALE SPOUSE 1 BCC 3559 (specify substance or drug); initial, up to 1 hour 12/27/2017 10/24/2017 12/22/2017 96367 INTRAVENOUS INFUSION, FORTHERAPY, PROPHYLAXIS, D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $44.62 $109.99 MALE SPOUSE 1 BCC 3559 OR DIAGNOSIS (SPECIFY SUBSTANCE DR DRUG); r ADDITIONAL SEQUENTIAL INFUSION OF A N EW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 12/27/2017 10/24/2017 12/22/2017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3SS9 > } fl 12/27/2017 10/24/2017 1212212017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCC D61819 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $14.90 $27.00 MALE SPOUSE 1 BCC 3559 N. CL CL 12127/2017 10/25/2017 12/22/2017 96365 ITT s infusion, for th eca py, p rophylaxis, Or diag —is D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $97.45 $240.24 MALE SPOUSE 1 BCC 3559 (specify substance or drug); Initial, up to 1 hour v 12/27/2017 10/25/2017 1212212017 96367 INTRAVENOUS INFUSION, FORTHERAPY, PROPHYLAXIS, D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $44.62 $109.99 MALE SPOUSE 1 BCC 3559 Q OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN h ADDITION TO CODE FOR PRIMARY PROCEDURE) 12/27/2017 10/25/2017 12/22/2017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 12/27/2017 10/25/2017 12/22/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCC D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $14.90 $27.00 MALE SPOUSE 1 BCC 3559 12/27/2017 10/26/2017 12/22/2017 96365 Intravenousinfusion,fontherapy, prophylaxis,ordiagnosis D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $97.45 $240.24 MALE SPOUSE 1 BCC 3559 (specify substance or drug); initial, up to 1 hour Q ® W 12/27/2017 10/26/2017 1212212017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, D61819 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $44.62 $109.99 MALE SPOUSE 1 BCC 3559 OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG; Uy ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN 0 ADDITION TO CODE FOR PRIMARY PROCEDURE) ILLJ 12/27/2017 10/26/2017 12/22/2017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 1212712017 10/26/2017 1212212017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCC D61819 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $14.90 $27.00 MALE SPOUSE 1 BCC 3559 12/27/2017 10/27/2017 1212212017 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $97.45 $240.24 MALE SPOUSE 1 BCC 3559 v (specify substance or drug); initial, up to 1 hour 12/27/2017 1012712017 12/22/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, D61818 OTHER PANCYTOPENIA PROFE55IONAL OFFICE $44.62 $109.99 MALE SPOUSE 1 BCC 3559 OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADOITIDNAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN (' ADDITION TO CODE FOR PRIMARY PROCEDURE) 12/27/2017 10/27/2017 12122/2017 10894 INJECTION, DECITABINE, 1 MG D61818 OTHER PANCYTOPENIA PROFESSIONAL OFFICE $1,022.50 $5,041.00 MALE SPOUSE 1 BCC 3559 Q {V 12/27/2017 10/27/2017 12/22/2017 11626 INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCC D61818 OTHER PANCYTOPENIA PROFE55IONAL OFFICE $14.90 $27.00 MALE SPOUSE I BCC 3559 12/27/2017 11/1/2017 12/2112017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D61810 ANTINEOPLASTIC PROFESSIONAL $0.01 MALE SPOUSE EVALUATION AND MANAGEMENT OF A PATIENT, WH I CH 3559 CHEMOTHERAPY INPATIENT /HOSPITAL SPOUSE 1 BCC REQU I RES AT LEAST 20F THESE 3 KEY COMPONENTS: AN $0.00 INDUCED PANCYTOPENIA SPOUSE 1 BCC 3559 EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN $429.00 MALE SPOUSE 1 BCC 3559 $113,651.34 EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL $1,433.41 $6,77900 FEMALE DECISION MAKING OF MODERATE COMPLEXITY. 10CA 3559 $150.94 $703.00 FEMALE SUBSCRIBER COUNSELING AND /OR 3559 $287.99 $2,468.00 FEMALE 12/27/2017 11/2/2017 12/21/2017 99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES D61810 ANTINEOPLASTIC PROFESSIONAL DR LESS CHEMOTHERAPY INPATIENT /HOSPITAL INDUCED PANCYTOPENIA 12/27/2017 12/13/2017 12/22/2017 1036F CURRENTTDBACCO NON - USER (CAD, CAP, COPD, PV) 77682 AWAITING ORGAN OTHER MEDICAL (DM) (IBD) TRANSPLANT STATUS 12/27/2017 12/13/2017 12/22/2017 1126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" Z7682 AWAITING ORGAN OTHER MEDICAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR TRANSPLANT STATUS DIRECT FLAP, AT EYELIDS NOSE, 12/27/2017 12/13/2017 12/22/2017 1220F PATIENT SCREENED FOR DEPRESSION (SUD) Z7682 AWAITING ORGAN OTHER MEDICAL TRANSPLANT STATUS 12/27/2017 12/13/2017 1212212017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z7682 AWAITING ORGAN OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED TRANSPLANT STATUS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 12/27/2017 12/13/2017 12/22/2017 G8420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS Z7682 AWAITING ORGAN OTHER MEDICAL AND NO FOLLOW -UP PLAN IS REQUIRED TRANSPLANT STATUS 12/27/2017 12/13/2017 12/22/2017 G8427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN Z7682 AWAITING ORGAN OTHER MEDICAL THE MEDIC AL RECORD THEY OBTAINED, UPDATED, OR TRANSPLANT STATUS REVIEWED THE PATIENT'S CURRENT MEDICATIONS 12/27/2017 12/13/2017 12/22/2017 G9484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, Z7682 AWAITING ORGAN OTHER MEDICAL REASON NOT GIVEN TRANSPLANT STATUS 12/27/2017 12/13/2017 1212212017 G9731 PAIN ASSE55MENT USING ASTANDARDIZED TOOL IS Z7682 AWAITING ORGAN OTHER MEDICAL DOCUMENTED AS NEGATIVE, NO FOLLOW- UP PLAN TRANSPLANT STATUS REQUIRED 12/29/2017 12/19/2017 12/28/2017 38221 BONE MARROW; BIOPSY, NEEDLE OR TROCAR C9201 ACUTE MYELOBIASTIC OTHER MEDICAL LEUKEMIA, IN REMISSION Sub Total 2.875E +10 1/3/2017 12/19/2016 12131/2016 44207 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH K5730 DIVERTICULC515 OF PROFESSIONAL ANASTOMOSIS, WITH COLOPROCTOSTOMY (LOW PELVIC LARGE INTESTINE INPATIENT /HOSPITAL ANASTOMOSIS) WITHOUT PERFORATION OR ABSCESS WITHOUT BLEEDING 1/3/2017 12/19/2016 12/31/2016 44213 LAPAROSCOPY, SURGICAL, MOBILIZATION (TAKE-DOWN) K5730 DIVERTICULOSIS OF PROFESSIONAL OF SPLENIC FLEXURE PERFORMED IN CONJUNCTION WITH LARGE INTESTINE INPATIENT /HOSPITAL PARTIAL COLECTOMY (LISTSEPARATELY IN ADDITION TO WITHOUT PERFORATION PRIMARY PROCEDURE) OR ABSCESS WITHOUT BLEEDING 1/3/2017 12/19/2016 12/31/2016 47562 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY K5730 DIVERTICULOSIS OF PROFESSIONAL LARGE INTESTINE INPATIENT /HOSPITAL WITHOUT PERFORATION OR ABSCESS WITHOUT BLEEDING $97.67 $276.00 MALE SPOUSE 1 BCC C.7.f 3559 $97.64 $279.00 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $170.75 $429.00 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $0.00 $0.01 MALE SPOUSE 1 BCC 3559 $103.24 $293.00 MALE SPOUSE 1 BCC 3559 $113,651.34 $4,514,510.47 $1,433.41 $6,77900 FEMALE SUBSCRIBER 10CA 3559 $150.94 $703.00 FEMALE SUBSCRIBER 1 OCA 3559 $287.99 $2,468.00 FEMALE SUBSCRIBER 1 OCA 3559 C.7.f 1/5/2017 12/19/2016 12/30/2016- - K5732 DIVERTICULITISOF LARGE HOSPITAL INPATIENT 12/19/2016 # # # # # # ## $61,605.11 $97,455.00 FEMALE SUBSCRIBER 1LEA 3559 INTESTINE WITHOUT W PERFORATION OR ABSCESS WITHOUT N BLEEDING Q! 1/23/2017 12/19/2016 112012017 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR K5732 DIVERTICULIFISOF LARGE PROFESSIONAL $0.00 $12.00 FEMALE SUBSCRIBER 1 OCA 3559 a BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INTESTINE WITHOUT INPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, PERFORATION OR } UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; ABSCESS WITHOUT "a AUTOMATED, WITH MICROSCOPY BLEEDING m 1/23/2017 12/19/2016 1/20/2017 85610 PROTHRDMBIN TIME; K5732 DIVERTICULITISOF LARGE PROFESSIONAL $0.00 $14.00 FEMALE SUBSCRIBER I EGA 3559 INTESTINE WITHOUT INPATIENT /HOSPITAL } PERFORATION OR ABSCESS WITHOUT G. CL BLEEDING Q, Q 1/23/2017 12/19/2016 1/20/2017 85730 THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR K5732 DIVERTICULITISOF LARGE PROFESSIONAL $0.00 $18.00 FEMALE SUBSCRIBER 1EGA 3559 v WHOLE BLOOD INTESTINE WITHOUT INPATIENT /HOSPITAL PERFORATION OR ABSCESS WITHOUT BLEEDING F W 1/23/2017 12/19/2016 112012017 86850 ANTI BO DY SC RE EN, RBC, EAC H SE RU M TECH N I GO E K5732 DIVERTICULITISOF LARGE PROFESSIONAL $0.00 $29.00 FEMALE SUBSCRIBER 1LEA 3559 F INTESTINE WITHOUT INPATIENT / HDSPITAL PERFORATION OR ABSCESS WITHOUT BLEEDING F 1/23/2017 12/19/2016 1/20/2017 86900 BLOOD TYPING, SERDLOGIC;ABO K5732 DIVERTICULIFISOF LARGE PROFESSIONAL $0.00 $29.00 FEMALE SUBSCRIBER 1 OCA 3559 INTESTINE WITHOUT INPATIENT /HOSPITAL Q PERFORATION OR {i ABSCESS WITHOUT BLEEDING U`J 1/23/2017 12119/2016 1/20/2017 86901 BLOOD TYPING, SEROLOGIC; RH)D) K5732 DIVERTICULIFISOF LARGE PROFESSIONAL $0.00 $11.00 FEMALE SUBSCRIBER 1OCA 3559 INTESTINE WITHOUT INPATIENT /HOSPITAL PERFORATION OR LLJ e °✓ ABSCESS WITHOUT BLEEDING Q 1/23/2017 12/19/2016 1/20/2017 88302 LEVEL II- SURGICAL PATHOLOGY, GROSS AND K5732 DIVERTICULITIS OF LARGE PROFESSIONAL $26.85 $139.00 FEMALE SUBSCRIBER l OCA J 3559 MICROSCOPIC EXAMINATION APPENDIX, INCIDENTAL, INTESTINE WITHOUT INPATIENT /HOSPITAL v FALLOPIAN TUBE, STERILIZATION, FINGERS/TOES, PERFORATION OR F AMPUTATION, TRAUMATIC, FORESKIN, NEWBORN, ABSCESS WITHOUT HERNIA SAC, ANY LOCATION, HYDROCELE SAC, NERVE, BLEEDING uj SKIN, PLASTIC REPAIR, SYMPATHETIC GANGLION, TESTIS, CASTRATION, VA U 1/23/2017 12/19/2016 1120/2017 88304 LEVELIII- SURGICAL PATHOLOGY, GROSS AND K5732 DIVERTICULITISOF LARGE PROFESSIONAL $41.14 $203.00 FEMALE SUBSCRIBER IOCA 3559 MICROSCOPIC EXAMINATION ABORTION, INDUCED, INTESTINE WITHOUT INPATIENT /HOSPITAL ABSCESS, ANEURYSM ARTERIAL/VENTRICULAR, ANUS, PERFORATION OR < TAG, APPENDIX, OTHER THAN INCIDENTAL, ARTERY, ABSCESS WITHOUT ATHEROMATOUS PLAQUE, BARTHOLIN'S GLAND CYST, BLEEDING N DONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE, BURSA /SYNOVIAL n 1/23/2017 12/19/2016 112012017 88307 LEVELV - SURD I CAL PATH DUDDY, GROSS AND K5732 DIVERTICULITISOF LARGE PROFESSIONAL MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE INTESTINE WITHOUT INPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENT(S), PATHOLOGIC PERFORATION OR FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR ABSCESS WITHOUT RESECTION BREAST, EXCISION OF LESION, REQUIRING BLEEDING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT 1/23/2017 12/20/2016 112012017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL K5732 DIVERTICULITISOF LARGE PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL INTESTINE WITHOUT INPATIENT / HDSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) PERFORATION OR CREATININE(82565) GLUCOSE (82947) POTASSIUM ABSCESS WITHOUT (84132) SODIUM (84295) UREA NITROGEN (BUN)(84520) BLEEDING 1/23/2017 12/20/2016 1/20/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, K5732 DIVERTICULITISOF LARGE PROFESSIONAL HCT, BBC, WBC AND PLATELET COUNT) INTESTINE WITHOUT INPATIENT /HOSPITAL PERFORATION OR ABSCESS WITHOUT BLEEDING 1/23/2017 12/21/2016 1/20/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL K5732 DIVERTICULITISOF LARGE PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL INTESTINE WITHOUT INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) PERFORATION OR CREATININE(92565) GLUCOSE (92947) POTASSIUM ABSCESS WITHOUT (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) BLEEDING 1/23/2017 12/21/2016 1/20/2017 85027 BLOOD COUNT; COMPLETE (DEC), AUTOMATED (HER, K5732 DIVERTICULITISOF LARGE PROFESSIONAL HCT, RBC, WBC AND PLATELET COUNT) INTESTINE WITHOUT INPATIENT /HOSPITAL PERFORATION OR ABSCESS WITHOUT BLEEDING 1/23/2017 12/22/2016 1/20/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, K5732 DIVERTICULITIS OF LARGE PROFESSIONAL HUT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED INTESTINE WITHOUT INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT PERFORATION OR ABSCESS WITHOUT BLEEDING 1/26/2017 12/19/2016 1/25/2017 790 ANESTHESIA FOR INTRAPERITONEAL PROCEDURES IN K8020 CALCULUS OF OTHER MEDICAL UPPER ABDOMEN INCLUDING LAPAROSCOPY; NOT GALLBLADDER WITHOUT OTHERWISE SPECIFIED CHOLECYSTITIS WITHOUT OBSTRUCTION 1/26/2017 12/19/2016 1/25/2017 790 ANESTHESIA FOR INTRAPERITONEAL PROCEDURES IN K8020 CALCULUS OF PROFESSIONAL UPPER ABDOMEN INCLUDING LAPAROSCOPY; NOT GALLBLADDER WITHOUT INPATIENT /HOSPITAL OTHERWISE SPECIFIED CHOLECYSTITIS WITHOUT OBSTRUCTION 1/30/2017 1/5/2017 1/9/2017 99495 TRANSITNL CARE MGMT SVCS W/ FOLLOWING READ 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE ELEMENTS: COMMUNICATN(DIRECT CONTACT, HYPERTENSION TELEPHONE, ELECTRONIC) V✓/ PTNT & /OR CAREGIVER W /IN 2 BUS DAYS OF DISCHARGE MEDICAL DECISION MAKING OF AT LEAST MODERAT $298.50 $533.00 FEMALE SUBSCRIBER 1 REA $0.00 $35.00 FEMALE SUBSCRIBER 1 LEA $0.00 $18.00 FEMALE SUBSCRIBER l LEA $0.00 $35.00 FEMALE SUBSCRIBER 1 OCA $0.00 $18.00 FEMALE SUBSCRIBER 10CA $0.00 $18.00 FEMALE SUBSCRIBER 1 OCA $753.30 $2,200.00 FEMALE SUBSCRIBER 1 OCA $753.30 $2,420.00 FEMALE SUBSCRIBER 1 OCA $162.48 $525.48 FEMALE SUBSCRIBER l OCA 21112017 10/5/2016 1/30/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R1112 PROJECTILE VOMITING PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 2/1/2017 11/8/2016 1/30/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K8020 CALCULUS OF PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, GALLBLADDER WITHOUT WHICH REQUIRES THESE 3 KEY COMPONENTS:A CHOLECYSTITIS WITHOUT COMPREHENSIVE HISTORY; A COMPREHENSIVE OBSTRUCTION EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 3/8/2017 12/6/2016 3/6/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K8020 CALCULUS OF PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, GALLBLADDER WITHOUT WHICH REQUIRES THESE 3 KEYCOMPONENTS:A CHOLECYSTITIS WITHOUT COMPREHENSIVE HISTORY; ACOMPREHENSIVE OBSTRUCTION EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 3/13/2017 2/23/2017 3/7/2017 88305 LEVEL IV- SURGICAL PATHOLOGY, GROSS AND D1801 HEMANGIOMA OF SKIN OTHER MEDICAL MICROSCOPIC EXAMINATION ABORTION - AND SUBCUTANEOUS SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE TISSUE MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION 3/30/2017 10/11/2016 3/28/2017 * * * ** * * * ** '• * *+ * * * *' * * * ** 5/1/2017 12/6/2016 4128/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K8020 CALCULUS OF PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED GALLBLADDER WITHOUT PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY CHOLECYSTITIS WITHOUT COMPONENTS: A DETAI LED H ISTORY; A D ETAI LE D OBSTRUCTION EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/1/2017 2/23/2017 5/31/2017 11100 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND /OR D492 NEOPLASM OF PROFESSIONAL OFFICE MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNSPECIFIED BEHAVIOR UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); OF BONE, SOFT TISSUE, SINGLE LESION AND SKIN 6/1/2017 2/23/2017 5/31/2017 11101 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND /OR D492 NEOPLASM OF PROFESSIONAL OFFICE MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNSPECIFIED BEHAVIOR UNLESS OTHERWISE LISTED; EACH SEPARATE /ADDITIONAL OF BONE, SOFT TISSUE, LESION (LIST SEPARATELY IN ADDITION TO CODE FOR AND SKIN PRIMARY PROCEDURE) 6/1/2017 2/23/2017 5/31/2017 17000 DESTRUCTION(EG, LASER SURGERY, ELECTROSURGERY, D492 NEOPLASM OF PROFESSIONAL OFFICE CRYOSURGERY, CHEMOSURGERY, SURGICAL UNSPECIFIED BEHAVIOR CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC OF BONE, SOFT TISSUE, KERATOSES); FIRST LESION AND SKIN 6/1/2017 2/23/2017 5/31/2017 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D492 NEOPLASM OF PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, UNSPECIFIED BEHAVIOR WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OF BONE, SOFT TISSUE, HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION AND SKIN MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE P $63.86 $235.00 FEMALE SUBSCRIBER 1 OCA $151.80 $541.00 FEMALE SUBSCRIBER 1 BEA $0.00 $541.00 FEMALE SUBSCRIBER 1 OCA $219.12 $356.00 FEMALE SUBSCRIBER 1 BEA $17719 $511.00 FEMALE SUBSCRIBER 1 OCA $95.18 $346.00 FEMALE SUBSCRIBER l OCA $102.77 $177.00 FEMALE SUBSCRIBER l OCA $34.18 $99.00 FEMALE SUBSCRIBER 1 OCA $39.84 $135.00 FEMALE SUBSCRIBER 10CA $8110 $183.00 FEMALE SUBSCRIBER I OCA C.7.f 3559 w N Q! 3559 7 fl } fl G. CL 3559 Q, Q 4 F W 3559 O IL 3559 {j 3559 O J W 3559 v 3559 W U 3559 Q {hj 3559 N C.7.f 6/21/2017 6/12/2017 6/19/2017 k * * * ** * " * ** * * * ** * * * ** $70.18 $347.00 FEMALE SUBSCRIBER 1 OCA 3559 6/21/2017 6/12/2017 6/20/2017 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST I2 E039 HYPOTHYROIDISM, PROFESSIONAL OFFICE $0.00 $150.00 FEMALE SUBSCRIBER IOCA 3559 LEADS; WITH INTERPRETATION AND REPORT UNSPECIFIED N 6/21/2017 6/12/2017 6/20/2017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE E039 HYPOTHYROIDISM, PROFESSIONAL OFFICE $5943 $175.00 FEMALE SUBSCRIBER 1OCA 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED 7 EXAMINATION; MEDICAL DECISION MAKING OF LOW "a COMPLEXITY. COUNSELING AND COOED 6/21/2017 6/16/2017 6/20/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E8352 HYPERCALCEMIA PROFESSIONAL OFFICE $0.00 $25.00 FEMALE SUBSCRIBER 1 OCA 3559 W 6/21/2017 6/16/2017 6/20/2017 99211 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E8352 HYPERCALCEMIA PROFESSIONAL OFFICE $0.00 $100.00 FEMALE SUBSCRIBER lOCA } 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED L CL PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A Q, PHYSICIAN. USUALLY, THE PRESENTING PROBLEM(S) ARE MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING OR SUPERVISING THESE SERVICES. 7/7/2017 6/26/2017 7/5/2017 - - K5730 DIVERTICULOSIS OF HOSPITAL OUTPATIENT $2,617.12 $5,157.00 FEMALE SUBSCRIBER 1 OCA 3559 LARGE INTESTINE F WITHOUT PERFORATION LIJ h OR ABSCESS WITHOUT BLEEDING 7/14/2017 6/26/2017 7/12/2017 88305 LEVEL IV- SURGICAL PATHOLOGY, GROSS AND Z980 INTESTINAL BYPASS AND PROFESSIONAL $3833 $255.00 FEMALE SUBSCRIBER 1 OCA 3559 _ MICROSCOPIC EXAMINATION ABORTION- ANASTOMOSIS STATUS OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, Q NOT REQUIRING MICROSCOPIC EVALUATION OF uj SURGICAL M ^RGINS, BREAST, REDUCTION 711412017 6/26/2017 7/12/2017 88313 SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT; Z980 INTESTINAL BYPASS AND PROFESSIONAL $1240 $79.00 FEMALE SUBSCRIBER 1OCA 3559 GROUP II,ALLOTHER)EG, IRON, TRICHROME), EXCEPT ANASTOMOSIS STATUS OUTPATIENT /HOSPITAL 0 STAIN FOR MICROORGANISMS, STAINS FOR ENZYME CONSTITUENTS, OR IM MUNOCYTOCH EMISTRY AND een IMMUNOHISTOCHEMISTRY 712112017 7/18/2017 712012017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E8352 HYPERCALCEMIA PROFESSIONAL OFFICE $78.91 $347.00 FEMALE SUBSCRIBER 1OCA 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY v COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR LLJ COORDINATION OF CARE WITH OTHER 7/24/2017 6/26/2017 7/21/2017 45380 COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR Z1211 ENCOUNTER FOR PROFESSIONAL $269.77 $720.00 FEMALE SUBSCRIBER 10CA 3559 (' MULTIPLE SCREENING FOR OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM OFCOLON 8/2/2017 7/25/2017 7131/2017 - - E8352 HYPERCALCEMIA HOSPITAL OUTPATIENT $291.93 $519.00 FEMALE SUBSCRIBER 1 OCA 3559 N N 9/6/2017 8/31/2017 9/5/2017 29540 STRAPPING; ANKLE M722 PLANTAR FASCIAL PROFESSIONAL OFFICE $20.20 $85.00 FEMALE SUBSCRIBER 1 OCA 3559 FIBROMATOSIS = 9/6/2017 8/31/2017 91 73630 RADIOLOGIC EXAM I NATION, FOOT; COMPLETE, M722 PLANTAR FASCIAE PROFESSIONAL OFFICE $38.34 $200.00 FEMALE SUBSCRIBER 1 RICA 3559 y MINIMUM OF THREE VIEWS FIBROMATOSIS 9/6/2017 8/31/2017 91 9/6/2017 8/31/2017 91 L4397 10/23/2017 10/4/2017 10/20/2017 10/23/2017 10/4/2017 1012012017 10/23/2017 101 10/20/2017 10/23/2017 10/6/2017 10/20/2017 10/23/2017 101 10/20/2017 10/23/2017 10/6/2017 1012012017 10/23/2017 10/18/2017 10120/2017 10/23/2017 10/18 /2017 1012012017 10/23/2017 10/18/2017 10/20/2017 10/23/2017 10/18/2017 10/20/2017 10/24/2017 10/20/2017 10/23/2017 10/24/2017 10/20/2017 10/23/2017 10/24/2017 10/20/2017 10/23/2017 10/24/2017 10/20/2017 10/23/2017 10/31/2017 10/27/2017 10/30/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M722 PLANTAR FASCIAE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, $19.77 FEMALE FIBROMATOSIS 1 OCA WHICH REQUIRES THESE 3 KEY COMPONENTS: A $101.00 FEMALE SUBSCRIBER 1 OCA COMPREHENSIVE HISTORY; A COMPREHENSIVE $120.00 FEMALE SUBSCRIBER 1 REA EXAMINATION; MEDICAL DECISION MAKING OF $19.77 FEMALE SUBSCRIBER 1 BEA MODERATE COMPLEXITY. COUNSELING AND /OR $101.00 FEMALE SUBSCRIBER l OCA COORDINATION OF CARE WITH OTHER PROVIDERS OR $40.62 FEMALE SUBSCRIBER 10CA STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING M722 PLANTAR FASCIAE PROFESSIONAL OFFICE SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR $19.77 FEMALE FIBROMATOSIS 1 OCA POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, $101.00 FEMALE SUBSCRIBER 1 OCA PREFABRICATED, OFF - THE -SHELF $40.62 FEMALE SUBSCRIBER 1 OCA 97035 APPLICATION OF A MODALITY TO l OR MORE AREAS; M722 PLANTAR FASCIAE OTHER MEDICAL ULTRASOUND, EACH 15 MINUTES $101.00 FEMALE FIBROMATOSIS 1 OCA 97110 THERAPEUTIC PROCEDURE, 1 OR MOREAREAS, EACH 15 M722 PLANTAR FASCIAE OTHER MEDICAL MINUTES; THERAPEUTIC EXERC15ESTO DEVELOP $46.66 FEMALE FIBROMATOSIS l OCA STRENGTH AND ENDURANCE, RANGE OF MOTION AND $29.64 FEMALE SUBSCRIBER 1 OCA FLEXIBILITY 97162 Physical therapy evaluation: moderate complexity, M722 PLANTAR FASCIAE OTHER MEDICAL requiring these components: A history of present problem FIBROMATOSIS with 1 -2 personal factors and /or comorbldities 97035 APPLICATION OF A MODALITY TO I OR MORE AREAS; M722 PLANTAR FASCIAE OTHER MEDICAL ULTRASOUND, EACH 15 MINUTES FIBROMATOSIS 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M722 PLANTAR FASCIAE OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISESTO DEVELOP FIBROMATOSIS STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 97124 THERAPEUTIC PROCEDURE, LOB MOREAREAS, EACH 15 M722 PLANTAR FASCIAE OTHER MEDICAL MINUTES; MASSAGE, INCLUDING EFFLEURAGE, FIBROMATOSIS PETRISSAGE AN D /OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION) 97032 APPLICATION OFA MODALITYTO 1 OR MOREAREAS; M722 PLANTAR FASCIAE OTHER MEDICAL ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES FIBROMATOSIS 97035 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; M722 PLANTAR FASCIAE OTHER MEDICAL ULTRASOUND, EACH 15 MINUTES FIBROMATOSIS 97110 THERAPEUTIC PROCEDURE, 1 OR MOREAREAS, EACH 15 M722 PLANTAR FASCIAE OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISESTO DEVELOP FIBROMATOSIS STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 97124 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M722 PLANTAR FASCIAL OTHER MEDICAL MINUTES; MASSAGE, INCLUDING EFFLEURAGE, FIBROMATOSIS PETRISSAGE AN D /OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION) 97035 APPLICATION OFA MODALITY T010R MOREAREAS; M722 PLANTAR FASCIAE OTHER MEDICAL ULTRASOUND, EACH 15 MINUTES FIBROMATOSIS 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M722 PLANTAR FASCIAE OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISESTO DEVELOP FIBROMATOSIS STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 97124 THERAPEUTIC PROCEDURE, LOB MOREAREAS, EACH 15 M722 PLANTAR FASCIAE OTHER MEDICAL MINUTES; MASSAGE, INCLUDING EFFLEURAGE, FIBROMATOSIS PETRISSAGE AN D /OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION) 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M722 PLANTAR FASCIAE OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, FIBROMATOSIS MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 97032 APPLICATION OFA MODALITY TO l OR MOREAREAS; M722 PLANTAR FASCIAE OTHER MEDICAL ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES FIBROMATOSIS $83.33 $446.82 FEMALE SUBSCRIBER 1 OCA $71.61 $200.00 FEMALE SUBSCRIBER 1 BEA $337 $19.77 FEMALE SUBSCRIBER 1 OCA $17.16 $101.00 FEMALE SUBSCRIBER 1 OCA $29.03 $120.00 FEMALE SUBSCRIBER 1 REA $3.37 $19.77 FEMALE SUBSCRIBER 1 BEA $20.02 $101.00 FEMALE SUBSCRIBER l OCA $6.87 $40.62 FEMALE SUBSCRIBER 10CA $5.03 $29.64 FEMALE SUBSCRIBER l OCA $0.00 $19.77 FEMALE SUBSCRIBER 1 OCA $20.02 $101.00 FEMALE SUBSCRIBER 1 OCA $6.87 $40.62 FEMALE SUBSCRIBER 1 OCA $3.37 $19.77 FEMALE SUBSCRIBER l BEA $20.02 $101.00 FEMALE SUBSCRIBER 1 OCA $0.00 $40.62 FEMALE SUBSCRIBER 1 OCA $7.87 $46.66 FEMALE SUBSCRIBER l OCA $5.03 $29.64 FEMALE SUBSCRIBER 1 OCA C.7.f 3559 ®' 3559 3559 3559 3559 3559 WbSI 3559 3559 3559 3559 3559 3559 3559 3559 ti 10/31/2017 10/27/2017 10/30/2017 97035 APPLICATION OF A MODALITY T010R MORE AREAS; M722 PLANTAR FASCIAE OTHER MEDICAL SUBSCRIBER l OCA ULTRASOUND, EACH 15 MINUTES $40.62 FEMALE FIBROMATOSIS 10CA 10/31/2017 10/27/2017 10130/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M722 PLANTAR FASCIAL OTHER MEDICAL SUBSCRIBER 1 LOA MINUTES; THERAPEUTIC EXERCISES TO DEVELOP FIBROMATOSIS STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 10/31/2017 10/27/2017 10/30/2017 97124 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 N1722 PLANTAR FASCIAE OTHER MEDICAL MINUTES; MASSAGE, INCLUDING EFFLEURAGE, FIBROMATOSIS PETRISSAGE AND /OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION) 11/17/2017 11/14/2017 11/16/2017 17110 DESTRUCTION HE, LASER SURGERY, ELECTROSURGERY, L821 OTHER SEBORRHEIC PROFESSIONAL OFFICE CRYOSURGERY, CHEMOSURGERY, SURGICAL KERATOSIS CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS 11/17/2017 11/14/2017 11/16/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L821 OTHER SEBORRHEIC PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED KERATOSIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/6/2017 11/27/2017 12/4/2017 - - Z1231 ENCOUNTER FOR HOSPITAL OUTPATIENT SCREENING MAMMOGRAM FOR MALIGNANT NEOPLASM OF BREAST 12/15/2017 11/27/2017 12/13/2017 77063 SCREENING DIGITAL BREAST TOMOSYNTHESIS, BILATERAL Z1231 ENCOUNTERFOR PROFESSIONAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SCREENING OUTPATIENT /HOSPITAL PROCEDURE) MAMMOGRAM FOR MALIGNANT NEOPLASM OF BREAST 12/15/2017 11/27/2017 12/13/2017 77D67 Screening mammography, bilateral l(2-view study of each Z1231 ENCOUNTER FOR PROFESSIONAL breast), Including computer -aided detection (CAD) when SCREENING OUTPATIENT /HOSPITAL performed MAMMOGRAM FOR MALIGNANT NEOPLASM OF BREAST Sub Total 2.875E +10 5/8/2017 4/19/2017 5/5/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1069 ACUTE UPPER OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED RESPIRATORY INFECTION, PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY UNSPECIFIED COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 5/15/2017 4/28/2017 5/12/2017 87880 INFECTIOUS AGENT ANTIGEN DETECTION BY 1029 ACUTE PHARYNGITIS, OTHER MEDICAL IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; UNSPECIFIED STREPTOCDCCUS, GROUP 5/15/2017 4/28/2017 5/12/2017 99214 OFFICE DR OTHER OUTPATIENT VISIT FOR THE 1029 ACUTE PHARYNGITIS, OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER $0.00 $19.77 FEMALE SUBSCRIBER 1 OCA $20.02 $101.00 FEMALE SUBSCRIBER l OCA $6.87 $40.62 FEMALE SUBSCRIBER 10CA $82.35 $191.00 FEMALE SUBSCRIBER l OCA $106.31 $178.00 FEMALE SUBSCRIBER 1 LOA $294.00 $392.00 FEMALE SUBSCRIBER 1 OCA $0.00 $239.00 FEMALE SUBSCRIBER 10CA $65.84 $161.00 FEMALE SUBSCRIBER 1 OCA $70,854.53 $127,745.57 $175.00 $300.00 MALE SUBSCRIBER 1 BCC $0.00 $77.00 MALE SUBSCRIBER 1 BCC $175.00 $300.00 MALE SUBSCRIBER 1 BCC 5/18/2017 5/16/2017 5/17/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1158 OTHER SECONDARY PROFESSIONAL OFFICE $66.00 MALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC HYPERTENSION $1,000.00 MALE SUBSCRIBER PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 9/25/2017 9/19/2017 9/24/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1200 UNSTABLE ANGINA PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HDSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 9/25/2017 9/20/2017 9/24/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON -ST ELEVATION PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH (NSTEMI) MYOCARDIAL INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A INFARCTION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 9/26/2017 9/18/2017 9/25/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE 1214 NON -ST ELEVATION PROFESSIONAL CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- (NSTEMI) MYOCARDIAL OUTPATIENT /HOSPITAL 74 MIN UTES I NFARCHON 9/27/2017 9/21/2017 9/26/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON ST ELEVATION PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A INFARCTION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 9/27/2017 9/22/2017 9/26/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE 1214 NON ST ELEVATION PROFESSIONAL THAN 30 MINUTES (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL INFARCTION 9/28/2017 9/18/2017 9/27/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 9/28/2017 9/19/2017 9/27/2017 92941 PERCUTANEOUS TRANSLUMINAL REVASCULARIZATION OF 12102 ST ELEVATION(STEMI) PROFESSIONAL ACUTE TOTAL/SUBTOTAL OCCLUSION DURING ACUTE MYOCARDIAL INFARCTION INPATIENT /HOSPITAL MYOCARDIAL INFARCTION, CORONARY ARTERY OR INVOLVING LEFT CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION ANTERIOR DESCENDING OF INTRACORONARYSTEN CORONARYARTERY 9/28/2017 9/19/2017 9/27/2017 93458 Catheter placement in coronary artery)s)for coronary 12102 ST ELEVATION(STEMI) PROFESSIONAL angiagraphy, including intraprocedural injections ) for MYOCARDIAL INFARCTION INPATIENT /HOSPITAL coronary afgi.graphy, imagingsupervision and INVOLVING LEFT interpretation; with left heart catheterization including ANTERIOR DESCENDING intraprored ural njection)s) for left-i riculography, when CORONARYARTERY performed 9/28/2017 9/19/2017 9/27/2017 99152 Moderate sedation se rpecs provided by the same 12102 ST ELEVATION(STEMI) PROFESSIONAL physician or other qualified health care professional MYOCARDIAL INFARCTION INPATIENT /HOSPITAL performing the diagnostic or th era peutic service that INVOLVING LEFT ANTERIOR DESCENDING CORONARYARTERY $62.28 $190.00 MALE SUBSCRIBER 1 BCC $0.00 $620.00 MALE SUBSCRIBER 1 BCC $28.64 $319.00 MALE SUBSCRIBER 1 BCC $257.93 $1,630.00 MALE SUBSCRIBER 1 BCC $111.77 $319.00 MALE SUBSCRIBER 1 BCC $111.74 $327.00 MALE SUBSCRIBER 1 BCC $9.25 $66.00 MALE SUBSCRIBER 1 BCC $565.19 $1,000.00 MALE SUBSCRIBER 1 BCC $135.31 $550.00 MALE SUBSCRIBER 1 BCC $9.58 $75.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE 3559 3559 3559 3559 3559 ME III 9/28/2017 9/22/2017 9/27/2017 K0606 AUTOMATIC EXTERNAL DEFIBRILLATOR, WITH 1214 NON -ST ELEVATION OTHER MEDICAL $75.00 MALE INTEGRATED ELECTROCARDIOGRAM ANALYSIS, GARMENT 1 BCC (NSTEMI) MYOCARDIAL $140.00 MALE SUBSCRIBER TYPE INFARCHON 9/28/2017 9/26/2017 9/27/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1158 OTHER SECONDARY PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 10/2/2017 9/20/2017 9/29/2017 76770 ULTRASOUND, RETROPERITONEAL(EG, RENAL, AORTA, N179 ACUTE KIDNEY FAILURE, PROFESSIONAL NODES), REALTIME WITH IMAGE DOCUMENTATION; UNSPECIFIED INPATIENT /HOSPITAL COMPLETE 10/5/2017 9/19/2017 10/4/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 10/5/2017 9/19/2017 101 99254 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED C 10/5/2017 9/21/2017 10/4/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 10/5/2017 9/21/2017 10/4/2017 92928 PERCUTANEOUS TRANSCATHETER PLACEMENT OF 1214 NON -ST ELEVATION PROFESSIONAL INTRACORONARY STENT(S), WITH CORONARY (N5TEMI) MYOCARDIAL INPATIENT /HOSPITAL ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR INFARCTION CORONARY ARTERY OR BRANCH 10/5/2017 9/21/2017 10/4/2017 99152 Moderate sedation services provided by the same 1214 NON ST ELEVATION PROFESSIONAL physician or other qualified health care professional (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL performing the diagnostic or th era pectic service that INFARCTION 10/5/2017 9/22/2017 101 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 10/5/2017 9/27/2017 10/4/2017 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE LEADS; WITH INTERPRETATION AND REPORT DISEASE OF NATIVE CORONARY ARTERY W ITHOUT ANG I NA PECTORIS $2,479.29 $3,305.72 MALE SUBSCRIBER 1 BCC $93.05 $280.00 MALE SUBSCRIBER 1 BCC $49.82 $260.00 MALE SUBSCRIBER 1 BCC $0.00 $210.00 MALE SUBSCRIBER 1 BCC $172.92 $200.00 MALE SUBSCRIBER 1 BCC $102.08 $210.00 MALE SUBSCRIBER 1 BCC $1,008.63 $2,000.00 MALE SUBSCRIBER 1 BCC $12.77 $75.00 MALE SUBSCRIBER 1 BCC $70.93 $140.00 MALE SUBSCRIBER 1 BCC $33.01 $66,00 MALE SUBSCRIBER 1 BCC C.7.f 3559 w Z 3559 N 3559 3559 mg IRIIE 3559 3559 3559 IRIIE 10/5/2017 9/27/2017 101412017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE $298.09 $536.00 MALE SUBSCRIBER 1BICE EVALUATIONAND MANAGEMENTOFA NEW PATIENT, DISEASE OF NATIVE WHICH REQUIRESTHESE 3 KEYCOMPONENTS :A CORONARYARTERY COMPREHENSIVE HISTORY; ACOMPREHENSIVE WITHOUTANGINA EXAMINATION; MEDICAL DECISION MAKING OF PECTORIS MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 10/5/2017 9/29/2017 10/4/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR R7989 OTHER SPECIFIED PROFESSIONAL OFFICE $251 $10.00 MALE SUBSCRIBER 1 BCC BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, ABNORMAL FINDINGS OF LEUIKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, BLOODCHEMISTRY UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY 10/5/2017 9/29/2017 10/4/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R7989 OTHER SPECIFIED PROFE55IONAL OFFICE $194.93 $335.00 MALE SUBSCRIBER 1 BCC EVALUATIONAND MANAGEMENTOFA NEW PATIENT, ABNORMAL FINDINGS OF WHICH REQUIRESTHESE 3 KEYCOMPONENTS :A BLOODCHEMISTRY COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 10/6/2017 9/18/2017 9/28/2017 - - 1214 NON ST ELEVATION HOSPITAL INPATIENT 9/18/2017 # # # # # # ## $91,836.44 $217,885.28 MALE SUBSCRIBER 1 BCC (NSTEMI( MYOCARDIAL INFARCTION 10/6/2017 9/18/2017 10/5/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST 1214 NON ST ELEVATION PROFESSIONAL $0.00 $48.00 MALE SUBSCRIBER 1 BCC INCLUDETHE FOLLOWING: ALBUMIN (82040), BILIRUBIN, (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON INFARCTION DIOXIDE (BICARBONATE)(82374), CHLORIDE (82435), CREATININE( 82565(, GLUCOSE (82947), PHOSPHATASE, ALKALINE 184075), POTASSIUM (84132, PROTEIN, 10/6/2017 9/18/2017 10/5/2017 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR 1214 NON ST ELEVATION PROFESSIONAL $0.00 $15.00 MALE SUBSCRIBER 1 BCC BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, (NSTEMI( MYOCARDIAL INPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, INFARCTION UROBILINDGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 10/6/2017 9/18/2017 10/5/2017 83735 MAGNESIUM 1214 NON ST ELEVATION PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 1 BCC (NSTEMI( MYOCARDIAL INPATIENT /HOSPITAL INFARCTION 10/6/2017 9/18/2017 10/5/2017 84484 TROPONIN, QUANTITATIVE 1214 NON ST ELEVATION PROFESSIONAL $0.00 $52.00 MALE SUBSCRIBER 1 BCC (NSTEMI( MYOCARDIAL INPATIENT /HOSPITAL INFARCTION 10/6/2017 9/18/2017 10/5/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, 1214 NON ST ELEVATION PROFESSIONAL $0.00 $21.00 MALE SUBSCRIBER 1 BCC HCT, BBC, WBCAND PLATELET COUNT) AND AUTOMATED (NSTEMI( MYOCARDIAL INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT INFARCTION 10/6/2017 9/18/2017 10/5/2017 85610 PROTHROMBIN TIME; 1214 NON -ST ELEVATION PROFESSIONAL $0.00 $15.00 MALE SUBSCRIBER 1 BCC (NSTEMI( MYOCARDIAL INPATIENT / HDSPITAL INFARCHON 10/6/2017 9/18/2017 10/5/2017 85730 THROMBOPLASTIN TIME, PARTIAL (AFT); PLASMA OR 1214 NON ST ELEVATION PROFESSIONAL $0.00 $16.00 MALE SUBSCRIBER 1BCC WHOLE BLOOD (NSTEMI( MYOCARDIAL INPATIENT /HOSPITAL INFARCTION 10/6/2017 9/19/2017 10/5/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL( THIS PANEL 1214 NON -ST ELEVATION PROFESSIONAL $0.00 $46.00 MALE SUBSCRIBER 1 BCC MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL (NSTEMI( MYOCARDIAL INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) INFARCTION CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN( (84520) 101 9/19/2017 10/5/2017 80061 URIC PANEL 1214 NON ST ELEVATION PROFESSIONAL $0.00 $47.00 MALE SUBSCRIBER 1 BCC (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL INFARCTION C.7.f 3559 Im mm 3559 3559 mw 3559 3559 3559 3559 3559 3559 gm 10/6/2017 9/19/2017 101 83735 MAGNESIUM 1214 NON -ST ELEVATION PROFESSIONAL SUBSCRIBER $0.00 $26.00 MALE (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL $21.00 MALE SUBSCRIBER $0.00 INFARCTION SUBSCRIBER 10/6/2017 9/19/2017 101 84100 PHOSPHORUS INORGANIC (PHOSPHATE); 1214 NON -ST ELEVATION PROFESSIONAL SUBSCRIBER $147.00 MALE SUBSCRIBER (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL INFARCTION 10/6/2017 9/19/2017 101 84484 TROPONIN, QUANTITATIVE 1214 NON -ST ELEVATION PROFESSIONAL (NSTEMI) MYOCARDIAL INPATIENT / HDSPITAL INFARCTION 10/6/2017 9/19/2017 101 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, 1214 NON ST ELEVATION PROFESSIONAL HCT,RBC, WBC AND PLATELET COUNT) AND AUTOMATED (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT INFARCTION 10/6/2017 9/19/2017 10/5/2017 85347 COAGULATION TIME; ACTIVATED 1214 NON -ST ELEVATION PROFESSIONAL (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL INFARCTION 10/6/2017 9/19/2017 101 85730 THROMBOPLASTIN TIME, PARTIAL (PET); PLASMA OR 1214 NON 5T ELEVATION PROFESSIONAL WHOLE BLOOD (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL INFARCTION 10/6/2017 9/20/2017 10/5/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1214 NON ST ELEVATION PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; INFARCTION A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 10/6/2017 9/20/2017 101 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL 1214 NON -ST ELEVATION PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL (823101 CARBON DIOXIDE (82374) CHLORIDE (82435) INFARCTION CREATININE (92565) GLUCOSE (92947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 10/6/2017 9/20/2017 10/5/2017 83735 MAGNESIUM 1214 NON -ST ELEVATION PROFESSIONAL (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL INFARCTION 10/6/2017 9/20/2017 10/5/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); 1214 NON ST ELEVATION PROFESSIONAL (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL INFARCTION 10/6/2017 9/20/2017 10/5/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HER, 1214 NON ST ELEVATION PROFESSIONAL HCT,RBC, WBC AND PLATELET COUNT) AND AUTOMATED (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT INFARCTION 10/6/2017 9/21/2017 101 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1214 NON 5T ELEVATION PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS: AN INFARCTION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 18/6/2017 9/21/2017 101 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL 1214 NON ST ELEVATION PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) INFARCTION CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 10/6/2017 9/21/2017 10/5/2017 83735 MAGNESIUM 1214 NON -ST ELEVATION PROFESSIONAL (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL INFARCTION 10/6/2017 9/21/2017 10/5/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); 1214 NON ST ELEVATION PROFESSIONAL (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL INFARCTION $0.00 $18.00 MALE SUBSCRIBER $0.00 $15.00 MALE SUBSCRIBER $0.00 $26.00 MALE SUBSCRIBER $0.00 $21.00 MALE SUBSCRIBER $0.00 $68.00 MALE SUBSCRIBER $0.00 $16.00 MALE SUBSCRIBER $0.00 $413.00 MALE SUBSCRIBER 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC C.7.f 3559 w Z 3559 N OR IN, 3559 i 3559 3559 W } fl 3559 CL CL Q 3559 v $0.00 $46.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $18.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $15.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $21.00 MALE SUBSCRIBER 1 BCC 3559 $73.12 $147.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $46.00 MALE SUBSCRIBER 1 BCC 3559 50.00 518.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $15.00 MALE SUBSCRIBER 1 BCC 3559 C.7.f 10/6/2017 9/21/2017 10/5/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (LOSE 1214 NON -ST ELEVATION PROFESSIONAL $0.00 $21.00 MALE SUBSCRIBER 1 BCC 3559 LET, BBC, WBCAND PLATELET COUNT) AND AUTOMATED (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT INFARCTION Z 10/6/2017 9/22/2017 10/5/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL 1214 NON -ST ELEVATION PROFESSIONAL $0.00 $46.00 MALE SUBSCRIBER 1 BCC 3559 N MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL OR (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) INFARCTION CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM 184295) UREA NITROGEN (BUN) (84520) i 10/11/2017 9/19/2017 10110/2017 93306 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH 8079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $58.36 $100.00 MALE SUBSCRIBER 1 BCC 3559 "a IMAGE DOCUMENTATION (2D), INCLUDES M -MODE INPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY } fl 10/12/2017 9/19/2017 10/11/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1214 NON -ST ELEVATION PROFESSIONAL $0.00 $225.00 MALE SUBSCRIBER 1 BCC 3559 E. CL LEADS; INTERPRETATION AND REPORT ONLY (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL Q, INFARCTION 10/13/2017 10/11/2017 1011212017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 87989 OTHER SPECIFIED PROFESSIONAL OFFICE $2.34 $8.00 MALE SUBSCRIBER 1 BCC 3559 ABNORMAL FINDINGS OF BLOOD CHEMISTRY rf 10/19/2017 9/19/2017 10/4/2017 99254 INPATIENT CONSULTATION FOR ANEW OR ESTABLISHED R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $172.92 $200.00 MALE SUBSCRIBER 1BCC 3559 PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE uj h EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED C _ 10/19/2017 9/19/2017 10/4/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $0.00 ($210.007 MALE SUBSCRIBER 1 BCC 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL U' REQUI RES AT LEAST 2 OF TH ESE 3 KEY COM RD ENTS: A IL DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; ui MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH a) OTHER PROVI Q 10119/2017 9/19/2017 10/4/2017 99254 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL ($172.927 (,$200.00) MALE SUBSCRIBER 1 BCC 3559 PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT /HOSPITAL LLJ COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF � MODERATE COMPLEXITY. COUNSELING AND /OR J COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED C v 10/19/2017 9/19/2017 10/13/2017 99254 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $0.00 $200.00 MALE SUBSCRIBER 1BCC 3559 PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT /HOSPITAL LLJ COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR (' COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED C 10/19/2017 9/20/2017 10/4/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $102.08 $210.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL N REQUI RES AT LEAST 2 OF TH ESE 3 KEY COM PO IN ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; _ MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI C.7.f 10/19/2017 9/20/2017 10/1312017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $0.00 $210.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPON ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; N MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM t 10/26/2017 10/11/2017 10/24/2017 84156 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE R7989 OTHER SPECIFIED OTHER MEDICAL $0.00 $44.29 MALE SUBSCRIBER 1 BCC 3559 7 ABNORMAL FINDINGS OF BLOOD CHEMISTRY 10/26/2017 10/20/2017 10/24/2017 36415 COLLECTION OFVENOUS BLOOD BYVENIPUNCTURE R7989 OTHER SPECIFIED PROFESSIONAL OFFICE $2.34 $8.00 MALE SUBSCRIBER 1 BCC 3559 ABNORMAL FINDINGS OF BLOOD CHEMISTRY 10/26/2017 10/20/2017 10/24/2017 80053 COMPREHENSIVE METABOLIC PANELTHISPANEL MUST R7989 OTHER SPECIFIED PROFESSIONAL OFFICE $0.00 $30.00 MALE SUBSCRIBER 1 BCC 3559 INCLUDE THE FOLLOW ING; ALBUMIN (82040), BILIRUBIN, ABNORMAL FINDINGS OF N. CL TOTAL (82247), CALCIUM, TOTAL (32310), CARBON BLOOD CHEMISTRY Q, DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE(9 2565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 10/26/2017 10/20/2017 10/24/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R7989 OTHER SPECIFIED PROFESSIONAL OFFICE $122.22 $215.00 MALE SUBSCRIBER 1 BCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED ABNORMAL FINDINGS OF PATIENT,WHICH REQUIRES AT LEAST 20F THESE 3 KEY BLOODCHEMISTRY h COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER _ 11/20/2017 11/1/2017 11/19/2017 K0606 AUTOMATIC EXTERNAL DEFIBRILLATOR , WITH 1214 NON -ST ELEVATION OTHER MEDICAL $3,305.72 $3,305.72 MALE SUBSCRIBER 1 BCC 3559 INTEGRATED ELECTROCARDIOGRAM ANALYSIS, GARMENT (NSTEMI) MYOCARDIAL TYPE INFARCTION Q 12/11/2017 9/19/2017 12/7/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1214 NON ST ELEVATION PROFESSIONAL $2830 $225.00 MALE SUBSCRIBER 1 BCC 3559 {� LEADS; INTERPRETATION AND REPORT ONLY (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL INFARCTION UJ Sub Total $101,690.84 $237,105.01 cfnY 3E +10 111312017 11/18/2016 12/29/2016 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE $99.69 $461.00 FEMALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED HYPERTENSION PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY e LLJ COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR J COORDINATION OF CARE WITH OTHER v 1/30/2017 1/11/2017 111212017 11100 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND /OR D485 NEOPLASM OF PROFESSIONAL OFFICE $85.53 $110.53 FEMALE SUBSCRIBER l BCC 3559 r MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNCERTAIN BEHAVIOR OF UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); SKIN IFLJ SINGLE LESION 1/30/2017 1/11/2017 1/12/2017 17000 DESTRUCTION( EG, IASER SURGERY, ELECTROSURGERV, D485 NEOPLASM OF PROFESSIONAL OFFICE $42.85 $85.70 FEMALE SUBSCRIBER 1 BCC 3559 CRYOSURGERY, CHEMOSURGERY, SURGICAL UNCERTAIN BEHAVIOR OF 0 CURETTEMENT), PREMALIGNANT LESIONS(EG, ACTINIC SKIN KERATOSES); FIRST LESION 1/30/2017 1/11/2017 1/12/2017 88304 LEVEL III- SURGICAL PATHOLOGY, GROSS AND D485 NEOPLASM OF PROFESSIONAL OFFICE $6915 $69.25 FEMALE SUBSCRIBER 1 BCC 3559 MICROSCOPIC EXAMINATION ABORTION, INDUCED, UNCERTAIN BEHAVIOR OF N ABSCESS, ANEURYSM ARTERIAL/VENTRICULAR, ANUS, SKIN TAG, APPENDIX, OTHER THAN INCIDENTAL, ARTERY, _ ATHEROMATOUS PLAQUE, BARTHOLIN'S GLAND CYST, BONE FRAGMENT(S), OTHERTHAN PATHOLOGIC FRACTURE, BURSA /SYNOVIAL .G 2/6/2017 1/11/2017 1/17/2017 - - E039 HYPOTHYROIDISM, HOSPITAL OUTPATIENT UNSPECIFIED 2/20/2017 2/6/2017 2/8/2017 93000 ELECTRDCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 1739 PERT PH FEAT VASCULAR PROFESSIONAL OFFICE LEADS; WITH INTERPRETATION AND REPORT DISEASE, UNSPECIFIED 2/20/2017 2/6/2017 2/8/2017 99204 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 1739 PERIPHERAL VASCULAR PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, DISEASE, UNSPECIFIED WHICH REQUIRES THESE 3 KEYCDMPDNENTS:A COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 2/23/2017 2/8/2017 2/9/2017 11100 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND /OR D485 NEOPLASM OF PROFESSIONAL OFFICE MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNCERTAIN BEHAVIOR OF UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); SKIN SINGLE LESION 2123/2017 2/8/2017 2/9/2017 88304 LEVELIII- SURGICAL PATHOLOGY, GROSS AND D485 NEOPLASM OF PROFESSIONAL OFFICE MICROSCOPIC EXAMINATION ABORTION, INDUCED, UNCERTAIN BEHAVIOR OF ABSCESS, ANEURYSM - ARTERIAL/VENTRICULAR, ANUS, SKIN TAG, APPENDIX, OTHER THAN INCIDENTAL, ARTERY, ATHEROMATOUS PLAQUE, BARTHOLIN'S GLAND CYST, BONE FRAGMENTS), OTHER THAN PATHOLOGIC FRACTURE, BURSA /SYNOVIAL 3/7/2017 2/22/2017 2/23/2017 93306 ECHOCARDIOGRAPHY, TRANSTHDRACIC, REAL -TIME WITH 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE IMAGE DOCUMENTATION (213), INCLUDES M -MODE HYPERTENSION RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 3/22/2017 3/6/2017 3/7/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1739 PERIPHERAL VASCULAR PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISEASE, UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 3/29/2017 2/28/2017 3/15/2017 97602 REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S); 581812A LACERATION WITHOUT OTHER MEDICAL NON SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA FOREIGN BODY, LEFT (EG, WET -TO-MOIST DRESSINGS, ENZYMATIC, ABRASION), LOWER LEG, INITIAL INCLUDING TOPICAL APPLICATIONS ), WOUND ENCOUNTER ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION 3/29/2017 2/28/2017 3/15/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 581812A LACERATION WITHOUT OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED FOREIGN BODY, LEFT PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY LOWER LEG, INITIAL COMPONENTS: A DETAILED HISTORY; A DETAILED ENCOUNTER EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/11/2017 3/9/2017 3/24/2017 97602 REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S); 581812D LACERATION WITHOUT OTHER MEDICAL NON SELECTIVE DEBRIDEMENT, W ITHOUTANESTHESIA FOREIGN BODY, LEFT (EG, WET -TO-MOIST DRESSINGS, ENZYMATIC, ABRASION), LOWER LEG, SUBSEQUENT INCLUDING TOPICAL APPLICATION(SE WOUND ENCOUNTER ASSESSMENT, AND INSTRUCTIONS) FOR ONGOING CARE, PER SESSION $340.48 $1,529.43 FEMALE SUBSCRIBER 1 BCC $12.86 $65.00 FEMALE SUBSCRIBER 1 BCC $155.55 $638.00 FEMALE SUBSCRIBER 1 BCC $8533 $110.53 FEMALE SUBSCRIBER 1 BCC $69.25 $69.25 FEMALE SUBSCRIBER 1 BCC $148.77 $841.00 FEMALE SUBSCRIBER 1 BCC $89.30 $406.00 FEMALE SUBSCRIBER 1 BCC $0.00 $130.00 FEMALE SUBSCRIBER 1 BCC $175.00 $300.00 FEMALE SUBSCRIBER 1 BCC $0.00 $130,00 FEMALE SUBSCRIBER 1 BCC C.7.f 3559 w 3559 N m 3559 3559 3559 ME III mg 4/11/2017 3/9/2017 3/24/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 581812D LACERATION WITHOUT OTHER MEDICAL $312.32 FEMALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC FOREIGN BODY, LEFT $3,651.00 FEMALE SUBSCRIBER PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $498.93 LOWER LEG, SUBSEQUENT SUBSCRIBER 1 BCC COMPONENTS: A PROBLEM FOCUSED HISTORY; A $88.00 FEMALE ENCOUNTER 1 BCC PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 4/12/2017 3/13/2017 3/30/2017 97602 REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S); 581812D LACERATION WITHOUT OTHER MEDICAL NON SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA FOREIGN BODY, LEFT (EG, WET -TO-MOIST DRESSINGS, ENZYMATIC, ABRASION), LOWER LEG, SUBSEQUENT INCLUDING TOPICAL APPLICATION(S), WOUND ENCOUNTER ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION 4/12/2017 3/13/2017 3/30/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 581912D LACERATION WITHOUT OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED FOREIGN BODY, LEFT PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LOWER LEG, SUBSEQUENT COMPONENTS: A PROBLEM FOCUSED HISTORY; A ENCOUNTER PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING, COUNSELING AND /OR COORDINATION OF CARE WIT 4/12/2017 3/20/2017 3/24/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1739 PERIPHERAL VASCULAR PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISEASE, UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 4/26/2017 4/10/2017 4/13/2017 - - E039 HYPOTHYROIDISM, HOSPITAL OUTPATIENT UNSPECIFIED 4/26/2017 4/10/2017 4113/2017 - - E785 HYPERLIPIDEMIA, HOSPITAL OUTPATIENT UNSPECIFIED 5/1/2017 4/3/2017 4/10/2017 - - 1739 PERIPHERAL VASCULAR HOSPITAL OUTPATIENT DISEASE, UNSPECIFIED 5/3/2017 4/10/2017 4/17/2017 - - 110 ESSENTIAL (PRIMARY) HOSPITAL OUTPATIENT HYPERTENSION 5/4/2017 4/3/2017 4/18/2017 93924 NONINVASIVE PHYSIOLOGIC STUDIES OF LOWER 1743 EMBOLISM AND PROFESSIONAL EXTREMITY ARTERIES, AT REST AND FOLLOWING THROMBOSIS OF OUTPATIENT /HOSPITAL TREADMILL STRESS TESTING, HE, BIDIRECTIONAL DOPPLER ARTERIES OF THE LOWER WAVEFORM OR VOLUME PLETHYSMOGRAPHY EXTREMITIES RECORDING AND ANALYSIS AT REST WITH ANKLE /BRACHIAL INDICES IMMEDIATELY AFTER AND AT TIMED INTERVALS FOLLOWING PERFORM 5/4/2017 4/3/2017 4/18/2017 93925 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR 1743 EMBOLISM AND PROFESSIONAL ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY THROMBOSIS OF OUTPATIENT /HOSPITAL ARTERIES OF THE LOWER EXTREMITIES 5/4/2017 4/3/2017 4/18/2017 93979 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC 1743 EMBOLISM AND PROFESSIONAL VASCULATURE, OR BYPASS GRAFTS; UNILATERAL OR THROMBOSIS OF OUTPATIENT /HOSPITAL LIMITED STUDY ARTERIES OF THE LOWER EXTREMITIES 5/4/2017 4/22/2017 5/2/2017 - - 1739 P ERIPHERAL VASCULAR HOSPITAL OUTPATIENT DISEASE, UNSPECIFIED 5/9/2017 4/22/2017 5/2/2017 - - 1739 PERIPHERAL VASCULAR HOSPITAL OUTPATIENT DISEASE, UNSPECIFIED $175.00 $300.00 FEMALE SUBSCRIBER 1 BCC $0.00 $130.00 FEMALE SUBSCRIBER 1 BCC $175.00 $300.00 FEMALE SUBSCRIBER 1 BCC $51.53 $276.00 FEMALE SUBSCRIBER 1 BCC $444.52 $592.70 FEMALE SUBSCRIBER 1 BCC $234.24 $312.32 FEMALE SUBSCRIBER 1 BCC $1,642.95 $3,651.00 FEMALE SUBSCRIBER 1 BCC $498.93 $665.24 FEMALE SUBSCRIBER 1 BCC $26.62 $88.00 FEMALE SUBSCRIBER 1 BCC $41.04 $164.00 FEMALE SUBSCRIBER 1 BCC $27.13 $89.00 FEMALE SUBSCRIBER 1 BCC $0.00 $116,048.00 FEMALE SUBSCRIBER 1 BCC $64,475.07 $116,048.00 FEMALE SUBSCRIBER 1 BCC C.7.f 3559 ®' im 9m 3559 3559 3559 3559 3559 3559 3559 I 5/22/2017 4/3/2017 5/8/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1739 PERI PH ERAL VASCULAR PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISEASE, UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5/22/2017 4/21/2017 5/15/2017 37221 Revascularintion, endovascular, open or percutaneous, 170212 ATHEROSCLEROSIS OF PROFESSIONAL c artery, unilateral, initial vessel; with transluminal stent NATIVE ARTERIES OF OUTPATIENT /HOSPITAL placement(s), includes angioplasty within the same vessel, EXTREMITIES WITH when performed INTERMITTENT CLAUDICATION, LEFT LEG 5/22/2017 4/21/2017 511512017 37226 Revascularint ion, endovascular, open or percutaneous, 170212 ATHEROSCLEROSIS OF PROFESSIONAL femoral,poplltealartery(,), a nilateral; with transluminal NATIVE ARTERIES OF OUTPATIENT /HOSPITAL stmt placement(s), includes angioplasty within the same EXTREMITIES WITH vessel, when performed INTERMITTENT CLAUDICATION, LEFT LEG 5/22/2017 4/21/2017 5/15/2017 75625 AORTOGRAPHI, ABDOMINAL, BY SERIALOGRAPHY, 170212 ATHEROSCLEROSIS OF PROFESSIONAL RADIOLOGICAL SUPERVISION AND INTERPRETATION NATIVE ARTERIES OF OUTPATIENT /HOSPITAL EXTREMITIES WITH INTERMITTENT CLAUDICATION, LEFT LEG 5/22/2017 4/21/2017 5/15/2017 75774 ANGIOGRAPHY, SELECTIVE, EACH ADDITIONAL VESSEL 170212 ATHEROSCLEROSIS OF PROFESSIONAL STUDIED AFTER BASIC EXAMINATION, RADIOLOGICAL NATIVE ARTERIES OF OUTPATIENT /HOSPITAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN EXTREMITIES WITH ADDITION TO CODE FOR PRIMARY PROCEDURE) INTERMITTENT CLAUDICATION, LEFT LEG 5/22/2017 4/21/2017 5/15/2017 76937 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS 170212 ATHEROSCLEROSIS OF PROFESSIONAL REQUIRING ULTRASOUND EVALUATION OF POTENTIAL NATIVE ARTERIES OF OUTPATIENT /HOSPITAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL EXTREMITIES WITH PATENCY, CONCURRENT REALTIME ULTRASOUND INTERMITTENT VISUALIZATION OF VASCULAR NEEDLE ENTRY, CLAUDICATION, LEFT LEG 5/22/2017 4/21/2017 5/15/2017 99152 Moderate sedation services provided by the some 170212 ATHEROSCLEROSIS OF PROFESSIONAL physician or other qualified health care professional NATIVE ARTERIES OF OUTPATIENT /HOSPITAL performing the diagnostic or th era peutic service that EXTREM ITIES WITH INTERMITTENT CLAUDICATION, LEFT LEG 5/22/2017 4/22/2017 5/4/2017 93923 COMPLETE BILATERAL NONINVASIVE PHYSIOLOGIC 1739 PERIPHERAL VASCULAR PROFESSIONAL STUDIES OF UPPER OR LOWER EXTREM ITY ARTERIES, 3OR DISEASE, UNSPECIFIED OUTPATIENT /HOSPITAL MORE LEVELS (EG, FOR LOWER EXTREMITY: ANKLE /BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL /DORSALIS PEDIS ARTERIES PLUS 5/22/2017 4/22/2017 5/4/2017 93925 DUPLEXSCAN OF LOWER EXTREMITY ARTERIES OR 1739 PERIPHERAL VASCULAR PROFESSIONAL ARTERIAL BYPASS GRAFTS; COMPLETE BILATERALSTUDY DISEASE, UNSPECIFIED OUTPATIENT /HOSPITAL 5/22/2017 4/22/2017 5/4/2017 93916 DUPLEXSCAN OFARTERIAL INFLOWAND VENOUS 1739 PERIPHERAL VASCULAR PROFESSIONAL OUTFLOW OFABDOMINAL, PELVIC, SCROTALCONTENTS DISEASE, UNSPECIFIED OUTPATIENT /HOSPITAL AND /OR RETROPERITONEAL ORGANS; LIMITED STUDY $129.60 $248.00 FEMALE SUBSCRIBER 1 BCC $494.96 $2,335.00 FEMALE SUBSCRIBER 1 BCC $957.26 $2,200.00 FEMALE SUBSCRIBER 1 BCC $103.68 $235.00 FEMALE SUBSCRIBER 1 BCC $32.30 $104.00 FEMALE SUBSCRIBER 1 BCC $2747 $67.00 FEMALE SUBSCRIBER 1 BCC $21.46 $55.00 FEMALE SUBSCRIBER 1 BCC $32.33 $131.00 FEMALE SUBSCRIBER 1 BCC $54.72 $164.00 FEMALE SUBSCRIBER 1 BCC $54.97 $206.00 FEMALE SUBSCRIBER 1 BCC 6/2/2017 4/22/2017 5/22/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1739 PERI PH ERAL VASCULAR PROFESSIONAL $12.00 FEMALE SUBSCRIBER EVALUATION AND MANAGEMENT OF A PATIENT, WHICH 3559 DISEASE, UNSPECIFIED INPATIENT /HOSPITAL SUBSCRIBER 1 BCC REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN $76.53 $276.00 FEMALE SUBSCRIBER 1 BCC 3559 EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 6/2/2017 5/9/2017 5/19/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R197 DIARRHEA, UNSPECIFIED OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/2/2017 5/9/2017 5/19/2017 55001 PRESCRIPTION DRUG, BRAND NAME R197 DIARRHEA, UNSPECIFIED OTHER MEDICAL 6/2/2017 5/23/2017 5/31/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 590862A INSECT BITE OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED (NONVENOMOUS), LEFT PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY FOOT, INITIAL COMPONENTS: A DETAILED HISTORY; A DETAILED ENCOUNTER EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/19/2017 6/5/2017 6/6/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1739 PERIPHERAL VASCULAR PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISEASE, UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/19/2017 6/7/2017 6/9/2017 92014 OPHTHALMOLOGI CAL SERVICES: MEDICAL EXAMINATION H04203 UNSPECIFIED EPIPHORA, PROFESSIONAL OFFICE AND EVALUATION, WITH INITIATION OR CONTINUATION BILATERAL LACRIMAL OF DIAGNOSTIC AND TREATMENT PROGRAM; GLANDS COMPREHENSIVE, ESTABLISHED PATIENT, ONE OR MORE VISITS 7/7/2017 7/5/2017 7/6/2017 36416 COLLECTION OF CAPILLARY BLOOD SPECIMEN(EG, E785 HYPERLIPIDEMIA, PROFESSIONAL OFFICE FINGER, HEEL, EAR STICK) UNSPECIFIED 7/7/2017 7/5/2017 7/6/2017 80061 LIPID PANEL E785 HYPERLIPIDEMIA, PROFESSIONAL OFFICE UNSPECIFIED 711212017 7/7 /2017 7/10/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 7/26/2017 711712017 7/24/2017 - - 1739 PERIPHERAL VASCULAR HOSPITAL OUTPATIENT DISEASE, UNSPECIFIED 7/27/2017 711712017 7/24/2017 - - 1739 PERIPHERAL VASCULAR HOSPITAL OUTPATIENT DISEASE, UNSPECIFIED 8/1/2017 7/22/2017 7/28/2017 69209 Removal impacted ..rumen using Irrigation /lavage, H6123 IMPACTED CERUMEN, OTHER MEDICAL unilateral BILATERAL C.7.f $119.19 $228.00 FEMALE SUBSCRIBER 1 BCC 3559 41 N Q! $225.00 $300.00 FEMALE SUBSCRIBER 1 BCC 3559 7 fl } fl CL $0.00 $12.00 FEMALE SUBSCRIBER 1 BCC 3559 CL Q $225.00 $300.00 FEMALE SUBSCRIBER 1 BCC 3559 v $114.30 $406.00 FEMALE SUBSCRIBER 1 BCC 3559 $8526 $143.00 FEMALE SUBSCRIBER 1 BCC 3559 $0.00 $12.00 FEMALE SUBSCRIBER 1 BCC 3559 $0.00 $63.00 FEMALE SUBSCRIBER 1 BCC 3559 $76.53 $276.00 FEMALE SUBSCRIBER 1 BCC 3559 $0.00 $3,175.00 FEMALE SUBSCRIBER 1 BCC 3559 $1,905.00 $3,175.00 FEMALE SUBSCRIBER 1 BCC 3559 $0.00 $155.00 FEMALE SUBSCRIBER 1 BCC 3559 81112017 7/22/2017 7/2812017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H6123 IMPACTED CERUMEN, OTHER MEDICAL SUBSCRIBER 1 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED $126.00 MALE BILATERAL 1 BCC 3559 3/8/2017 4####44# $9,432.65 $42,986.38 MALE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY 1 BCC 3559 $235.06 $1,481.00 MALE SUBSCRIBER 1 BCC COMPONENTS: AN EXPANDED PROBLEM FOCUSED $50.68 $121.00 MALE SUBSCRIBER 1 BCC 3559 $63.94 HISTORY; AN EXPANDED PROBLEM FOCUSED SUBSCRIBER 1 BCC 3559 $112.00 $360.00 MALE SUBSCRIBER EXAMINATION; MEDICAL DECISION MAKING OF LOW 3559 $142.36 $893.00 MALE SUBSCRIBER 1 BCC 3559 COMPLEXITY. COUNSELING AND COORD $315.00 MALE SUBSCRIBER 1 BCC 8/7/2017 711712017 8/2/2017 93924 NONINVASIVE PHYSIOLOGIC STUDIES OF LOWER 1739 PERIPHERAL VASCULAR PROFESSIONAL $467.00 MALE SUBSCRIBER 1 BCC EXTREMITY ARTERIES, AT REST AND FOLLOWING $8.30 DISEASE, UNSPECIFIED OUTPATIENT /HOSPITAL 1 BCC 3559 $86.41 TREADMILL STRESS TESTING, HE, BIDIRECTIONAL DOPPLER SUBSCRIBER 1 BCC 3559 $262.74 $613.20 MALE SUBSCRIBER WAVEFORM ORVOLUME PLETHYSMOGRAPHY 3559 $79.80 $216.00 MALE SUBSCRIBER 1 BCC 3559 RECORDING AND ANALYSIS AT REST W ITH $54.00 MALE SUBSCRIBER 1 BCC 3559 ANKLE /BRACHIAL INDICES IMMEDIATELY AFTER AND AT TIMED INTERVALS FOLLOWING PERFORM 81712017 711712017 81212017 93925 DUPLEXSCAN OF LOWER EXTREMITY ARTERIES OR 1739 PERIPHERAL VASCULAR PROFESSIONAL ARTERIAL BYPASS GRAFTS; COMPLETE 3I1TATERALSTUDY DISEASE, UNSPECIFIED OUTPATIENT /HOSPITAL 8/25/2017 7/17 /2017 8/23/2017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 1739 PERIPHERAL VASCULAR PROFESSIONAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED DISEASE, UNSPECIFIED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 12/22/2017 121712017 12/8/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1739 PERIPHERAL VASCULAR PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISEASE, UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD Sub Total 3.25E +10 111712017 10/26/2016 1/13/2017 * * "x+ 1/19/2017 12/22/2016 1/18/2017 3/1]/201] 3/8/201] 3/16/201] 3/17/2017 3/8/201] 3/16/2017 3/22/2017 3/6/2017 3/21/2017 93880 DUPLEX SCAN OF EXTRACRANIALARTERIES ;COMPLETE R55 SYNCOPE AND COLLAPSE PROFESSIONAL BILATERAL STUDY INPATIENT /HOSPITAL 3/22/2017 3/8/2017 3/21/2017 * * * «* * * * ** *« « ** * * * ** * * * ** 312212017 319/2017 3/21/2017 74171 Computed tomography, abdomen and pelvis; with R55 SYNCOPE AND COLLAPSE PROFESSIONAL contrast materials) INPATIENT /HOSPITAL 3/23/2017 3/8/2017 3/22/2017 3/23/2017 3/9/2017 3/22/2017 3/23/2017 3/10/2017 3/22/2017 3/23/2017 3/11/2017 3/22/2017 * * " ** 3/29/2017 3/8/2017 3/28/2017 4/4/2017 3/15/2017 4/3/2017 4/10/2017 3/8/2017 4/7/2017 4/11/2017 3/8/2017 4/10/2017 93306 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL -TIME WITH G459 TRANSIENT CEREBRAL PROFESSIONAL IMAGE DOCUMENTATION (2D), INCLUDES M -MODE ISCHEMIC ATTACK, INPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH UNSPECIFIED SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 5/5/2017 4/30/2017 5/4/2017 A0425 GROUND MILEAGE, PER STATUTE MILE 86889 OTHER GENERAL OTHER MEDICAL SYMPTOMS AND SIGNS $225.00 $300.00 FEMALE SUBSCRIBER 1 BCC $35.50 $88.00 FEMALE SUBSCRIBER 1 BCC $54.72 $164.00 FEMALE SUBSCRIBER 1 BCC $90.89 $163.00 FEMALE SUBSCRIBER 1 BCC $76.53 $276.00 FEMALE SUBSCRIBER 1 BCC C.7.f 3559 ®' 3559 3559 $74,307.76 $256,59035 $8641 $185.00 MALE SUBSCRIBER 1 BCC 3559 $49.75 $126.00 MALE SUBSCRIBER 1 BCC 3559 3/8/2017 4####44# $9,432.65 $42,986.38 MALE SUBSCRIBER 1 BCC 3559 $235.06 $1,481.00 MALE SUBSCRIBER 1 BCC 3559 $50.68 $121.00 MALE SUBSCRIBER 1 BCC 3559 $63.94 $202.00 MALE SUBSCRIBER 1 BCC 3559 $112.00 $360.00 MALE SUBSCRIBER 1 BCC 3559 $142.36 $893.00 MALE SUBSCRIBER 1 BCC 3559 $50.22 $315.00 MALE SUBSCRIBER 1 BCC 3559 $50.22 $315.00 MALE SUBSCRIBER 1 BCC 3559 $7447 $467.00 MALE SUBSCRIBER 1 BCC 3559 $8.30 $70.00 MALE SUBSCRIBER 1 BCC 3559 $86.41 $185.00 MALE SUBSCRIBER 1 BCC 3559 $262.74 $613.20 MALE SUBSCRIBER 1 BCC 3559 $79.80 $216.00 MALE SUBSCRIBER 1 BCC 3559 $27.22 $54.00 MALE SUBSCRIBER 1 BCC 3559 5/5/2017 4/30/2017 5/4/2017 A0427 AM BU LANCE SERVICE, ADVANCED LIFE SUPPORT, R6889 OTHER GENERAL OTHER MEDICAL SUBSCRIBER 1 BCC $0.00 EMERGENCY TRANSPORT, LEVEL 1(AL51- EMERGENCY) SUBSCRIBER SYMPTOMS AND SIGNS 5/9/2017 4/30/2017 5/8/2017 + « *«x 1 BCC $0.00 $254.00 MALE 5/10/201] 4/30/2017 51912017 $254.00 MALE SUBSCRIBER 1 BCC 5/10/2017 5/1/2017 5/9/2017 * * * ** * * * ** * * * ** * * * *« * * * ** 511012017 51212017 5/9/201] $15,535.55 MALE SUBSCRIBER 1 BCC 5/10/2017 5/3/2017 5191201] 1 BCC $0.00 $190.00 MALE 5/10/2017 5/4/2017 5/9/2017 * * * ** * * * ** * * * ** * * * ** * * * ** S/10/2017 S/5/2017 5/9/2017 1 BCC $0.00 $190.00 MALE 5/12/2017 4/29/2017 5191201] $190.00 MALE SUBSCRIBER 1 BCC 5/17/2017 5/6/2017 5/16/2017 * * * ** * * * ** + « « *+ « + + ++ + + + +« 5/17/2017 5/8/2017 5/16/2017 $1,450.00 MALE SUBSCRIBER 1 BCC 5/17/2017 5/9/2017 5/16/201] 5/17/20 17 5/9/2017 5/16/2017 5/17/2017 5/10/2017 5/16/2017 5/1]/201] 5/11/2017 5/16/201] 5/17/2017 5/12/2017 5/16/2017 5/17/20 17 5/12/2017 5/16/2017 5/18/2017 4/30/2017 5/16/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 50990XA UNSPECIFIED INIURYOF PROFESSIONAL AND MANAGEMENTOFA PATIENT,WHICH REQUIRES HEAD, INITIAL OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS ENCOUNTER IMPOSED BY THE VRGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND ME DICAL DELIS 5/22/2017 4/30/2017 5/19/2017 80047 BASIC METABOLIC PANEL (CALCIUM, IONIZED) THIS PANEL S2242XA MULTIPLE FRACTURES OF PROFESSIONAL MUST INCLUDETHEF0LLOWIN6: CALCIUM,IONIZED RIBS, LEFT SIDE, INITIAL OUTPATIENT /HOSPITAL (82330) CARBON DIOXIDE (92374) CHLORIDE (92435) E NCOUNTER FOR CLOSED CREATININE(82565) GLUCOSE(82947) POTASSIUM FRACTURE )84132) SODIUM )84295) UREA NITROGEN (BUN) (84520) 5/22/2017 4/30/2017 5/19/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST S2242XA MULTIPLE FRACTURES OF PROFESSIONAL INCLUDE THE FOLLOWING. ALBUMIN (82040), BILIRUBIN, RIBS, LEFT SIDE, INITIAL OUTPATIENT/HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON ENCOUNTER FOR CLOSED DIOXIDE(BICARBO MATE) (92374), CHLORIDE (92435), FRACTURE CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 5/22/2017 4/30/2017 5/19/2017 80320 ALCOHOLS S2242XA MULTIPLE FRACTURESOF PROFESSIONAL RIBS, LEFT SIDE, INITIAL OUTPATIENT /HOSPITAL E NCOUNTER FOR CLOSED FRACTURE 5/22/2017 4/30/2017 5/19/2017 83690 LIPASE S2242XA MULTIPLE FRACTURES OF PROFESSIONAL RIBS, LEFT SI DE, INITIAL OUTPATIENT /HOSPITAL E NCOUNTER FOR CLOSED FRACTURE 5/22/2017 4/30/2017 5/19/2017 84484 TROPONIN, QUANTITATIVE S2242XA MULTIPLE FRACTURES OF PROFESSIONAL RIBS, LEFT SI DE, INITIAL OUTPATIENT /HOSPITAL E NCOUNTER FOR CLOSED FRACTURE 5/22/2017 4/30/2017 5/19/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, S2242XA MULTIPLE FRACTURES OF PROFESSIONAL HCF, RBC, VBC AND PLATELET COUNT) RIBS, LEFT SIDE, INITIAL OUTPATIENT /HOSPITAL ENCOUNTER FOR CLOSED FRACTURE 5/22/2017 4/30/2017 5/19/2017 85610 PROTHROMBIN TIME; S2242XA MULTIPLE FRACTURES OF PROFESSIONAL RIBS, LEFT SIDE, INITIAL OUTPATIENT /HOSPITAL E NCOUNTER FOR CLOSED FRACTURE 5/24/2017 5/13/2017 5/23/201] 5/24/2017 5/14/2017 5/23/2017 $266.02 $460.00 MALE SUBSCRIBER 1 BCC $1,580.99 $2],699.00 MALE SUBSCRIBER 1 BCC $0.00 $380.00 MALE SUBSCRIBER 1 BCC $0.00 $254.00 MALE SUBSCRIBER 1 BCC $0.00 $254.00 MALE SUBSCRIBER 1 BCC $0.00 $254.00 MALE SUBSCRIBER 1 BCC $0.00 $254.00 MALE SUBSCRIBER 1 BCC $0.00 $254.00 MALE SUBSCRIBER 1 BCC 4/29/2017 5/4/2017 $3,801.41 $15,535.55 MALE SUBSCRIBER 1 BCC $0.00 $190.00 MALE SUBSCRIBER 1 BCC $0.00 $190.00 MALE SUBSCRIBER 1 BCC $0.00 $190.00 MALE SUBSCRIBER 1 BCC $0.00 $190,00 MALE SUBSCRIBER 1 BCC $0.00 $190.00 MALE SUBSCRIBER 1 BCC $0.00 $190.00 MALE SUBSCRIBER 1 BCC $0.00 $190.00 MALE SUBSCRIBER 1 BCC $0.00 $380.00 MALE SUBSCRIBER 1 BCC $615.93 $1,450.00 MALE SUBSCRIBER 1 BCC $0.00 $41.00 MALE SUBSCRIBER 1 BCC $0.00 $36.00 MALE SUBSCRIBER 1 BCC $0.00 $63.00 MALE SUBSCRIBER 1 BCC $0.00 $23.00 MALE SUBSCRIBER 1 BCC $0.00 $36.00 MALE SUBSCRIBER 1 BCC $0.00 $27.00 MALE SUBSCRIBER 1 BCC $0.00 $18.00 MALE SUBSCRIBER 1 BCC $0.00 $190.00 MALE SUBSCRIBER 1 BCC $O.OD $190.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 w Z 3559 N 3559 3559 3559 3559 3559 7 3559 a 3559 3559 w 3559 lu 3559 > } 3559 3559 2 CL 3559 Q, 3559 3559 3559 ELiii 1 III. 3559 3559 3559 3559 3559 3559 C.7.f 5/24/2017 5/15/2017 5/23/2017 *xx »x * * * ** * » » ** * * * ** * * * ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 5/24/2017 5/16/2017 5/23/2017 * * * ** * * » »* ° " " ** " * * ** * * * *» $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 5/24/2017 5/17/2017 5/23/2017 * * +«+ *xx.x +«« +* . *xxr *xx ». $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 5/24/2017 5/18/2017 5/23/2017 *x * «* * * * «* " » » +* * * * ** * * * *« $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 5/24/2017 5/19/2017 5/23/2017 *` * ** * * » ** *` * *` » * * *» * * *x« $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 5/25/2011 5/5/201] 5/23/2017 * * * »* * * * ** * * » ** * * *xr * * * »* $8,220.00 $22,311.62 MALE SUBSCRIBER 1 BCC 3559 6/1/2017 5/22/2017 5/31/2017 *x * «* * * * ** * " * ** * * "` * *` »* $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/1/2017 5/23/2017 5131/2017 * " ** * * » ** *` * ** » * * ** * * * *« $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/1/2017 5/25/2017 5/31/2017 #kYZ* * * * ** * * " ** * * * ** * * * ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/1/2017 5/26/2017 5/31/2017 * * » ** * * * ** * " * ** " * * ** * * * ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/6/2017 5/2/2017 5131/2017 * * * "* * *xr* *` " ** » * * ** * * * +r $95.50 $254.00 MALE SUBSCRIBER 1 BCC 3559 6/6/201] 5/6/2017 5/31/201] * * *r+ * * * ** *zzzz » * * ** * * * ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/6/2017 5/8 /2017 5/31/2017 * * * ** * *` ** * * * ** * * * ** * *` ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/6/2017 5/9/2017 5/31/2017 * * * "* * * *z< *s. : ** zzz*z z **xz $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/6/2017 5/10/2017 5/31/2017 * "" +.. *. ., * *, * + +.. +...* $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/6/2017 5/11/2017 5/31/2017 * » »++ w.www + ++ ++ x + * «* w. *ww $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/6/2017 5/12/2017 5/31/2017 * * *zw * * * ** * *z +* z * * *z * +x ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/7/2017 5129/2017 6/6/2017 * * * ** * * *'» * +z ** » * * ** x *xaa $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/7/2017 5/29/2017 6/6/2017 *xa ++ .xx.w > ++ ++ xww *. .xxx. $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/7/2017 5/30/2017 6/6/2017 * » * "* * * * ** * * » ** * * * ** * * * ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/7/2017 5/31/2017 6/6/2017 * * * ** * * » »* *« « ** * * * *» * * * *» $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/]/2017 6/2/201] 6/6/2017 *xx ++ .xx.w +« « ++ .w.rr *xxx. $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/8/2017 4/30/2017 5/31/2017 *xx »x * * * ** " » » ** « * * ** * * * ** $144.20 $380.00 MALE SUBSCRIBER 1 BCC 3559 6/8/2017 5/1/2017 5/31/2017 * * * ** * * » »* *r* *+ » + + +x * * * *» $95.50 $254.00 MALE SUBSCRIBER 1 BCC 3559 6/8/2017 5/3/2017 5/31/2017 * ** "* * * * ** *« " ** * * * *` * * * »* $95.50 $254.00 MALE SUBSCRIBER 1 BCC 3559 6/8/201] 5/4/2017 5/31/2017 *x * «* * * * ** ° " * ** « * * *« * * * ** $95.50 $254.00 MALE SUBSCRIBER 1 BCC 3559 6/8/2017 5/5/2017 5/31/2017 # # * *x «+ *` * ** » * * *« * * * «« $95.50 $254.00 MALE SUBSCRIBER 1 BCC 3559 6/9/2017 5/9/2017 5/16/2017 * * » "* * * * ** * " " ** * * * *` * * * »* $45.85 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/9/2017 5/9/2017 5/16/2017 * * * »* * * * ** * " * ** « * * *« * * * ** $0.00 ($190.00] MALE SUBSCRIBER 1 BCC 3559 6/9/2017 5/9/2017 5131/2017 * " ** * * + «+ *` * ** * * * ** * * * »« $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/9/2017 5/12/2017 5/16/2017 * * *«+ .xx.* *zz** .* + ** .xx.. $45.85 $380.00 MALE SUBSCRIBER 1 BCC 3559 6/9/2017 5/12/2017 5/16/2017 * * * "* * * * ** * * " ** * * * ** * * * ** $0.00 ($380.00) MALE SUBSCRIBER 1 BCC 3559 6/9/2017 5/12/2017 5131/2017 * * * "* * *x «+ *` " ** z * *.. * * * *« $0.00 $380.00 MALE SUBSCRIBER 1 BCC 3559 6/12/2017 5/18/2017 6/6/2017 * *zzz * * * ** *zzzz * * + ** * * * ** $5,822.00 $15,052.44 MALE SUBSCRIBER 1 BCC 3559 6/14/2017 6/5/2017 6/13/2017 * * * *` *e*x* +.* ++ *. * ** *e *** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/14/2017 6/6/2017 6/13/2017 * " * ** * ** ++ * «* +* * * **< * **x+ $0.00 $430.00 MALE SUBSCRIBER 1 BCC 3559 6/14/2017 617/2017 6/13/2017 * *zz. + + + ++ * +z *+ . + +xx + + + ++ $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/14/2017 6/8/2017 6/13/2017 * * "»+ wxr.w +xx ++ "ww *« .xrx. $0.00 $215.00 MALE SUBSCRIBER 1 BCC 3559 6/15/2017 4/30/2017 6/9/2017 * * * "* * * » ** * * » ** ° #fi * * * ** $86.41 $380.00 MALE SUBSCRIBER 1 BCC 3559 6/15/2017 5/1/2017 6/9/2017 * * * ** * *x.x * +z*+ . + + ++ xxxx. $83.68 $444.00 MALE SUBSCRIBER 1 BCC 3559 6/15/2017 5/2/2017 6/9/2017 .... » » » ** " * * ** * * * ** $45.85 $380.00 MALE SUBSCRIBER 1 BCC 3559 6/15/2017 5/2/2017 6/9/2017 *` * ** * * »*+ ... »* *+ +xa + + +*+ $45.85 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/15/2017 5/3/2017 6/9/2017 * * * ** * * * ** *« « ** » * * *` " * * ** $91.70 $380.00 MALE SUBSCRIBER 1 BCC 3559 6/15/2017 5/4/2017 6/9/2017 * * * «+ * * * ** * » » ** * *xrr * * * »* $45.85 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/16/2017 5/6/2017 5/16/2017 *` " "* ++ +*+ x " * ** r + + +« + + + ++ $0.00 ( „190,00) MALE SUBSCRIBER 1 BCC 3559 6/16/2017 5/6/2017 5/31/2017 * * *.. * * * *» *« « ** * * * *« * * * »* $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/16/2017 5/8/2017 5/16/2017 * * * »* * * *.* * " » ** . *.rr * * * ». $0.00 ($190.00] MALE SUBSCRIBER 1 BCC 3559 6/16/2017 5/8/2017 5/31/2017 *` * »* * * * ** *` * ** « * * *« * * * ** $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/16/2017 5/9/2017 5/16/2017 * * * *+ * * » ** *« « ** " * * ** * * * ** $0.00 ($190001 MALE SUBSCRIBER 1 BCL 3559 6/16/2017 5/9/2017 5/31/2017 * « *«+ s.saw +« « ++ . *sss s.s»* $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/16/2017 5/10/2017 5/16/2017 * * * »* * * * ** ° " " ** * * * *« * * * ** $0.00 ($197,00) MALE SUBSCRIBER 1 BCC 3559 6/16/2017 5/10/2017 5131/2017 * * « ** * *x «w ..z ** * * * ** * * * »* $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/16/2017 5/11/2017 5/16/2017 * ««r+ *.r.. xzzss x * *.* *xr*. $0.00 iS190.00J MALE SUBSCRIBER 1 BCC 3559 6/16/2017 5 /11 /201] 5/31/201] * * * ** * * * ** * * * *+ z * * *' * * * ** $]1.55 $190.00 MALE SUBSCRIBER 1 eCC 3559 6/16/2017 5/12/2017 5/16/2017 * * *z* * * * ** *.z ** z *... * * « ** $0.00 ($'19000) MALE SUBSCRIBER 1 BCL 3559 6/16/2017 5/12/2017 5/31/2017 x*zss + +.** xzzss * + + *. + +..* $7135 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/20/201] 6/]/2017 6/19/2017 WM GROUND W LEM PER STATUTE MILE R7309 OTHER ABNORMAL OTHER MEDICAL $13.85 $24.70 MALE SUBSCRIBER 1 BCC 3559 GLUCOSE 6/20/2017 6/7/2017 6/19/2017 A0427 AMBULANCESERVICE, ADVANCED LIFE SUPPORT, R7309 OTHERABNORMAL OTHER MEDICAL $437.13 $650.00 MALE SUBSCRIBER 1 BCC 3559 EMERGENCY TRANSPORT, LEVEL 1(AL51- EMERGENCY) GLUCOSE 6/21/2017 6/12/2017 612012017 * * * *+ * * * ** » » » ** " * * ** * * * »* $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 C.7.f 6/21/2017 6/13/2017 6/20/2017 k}bk $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/23/2017 5/22/2017 5/31/2017 * * * ** * * * ** °fY ** " * * ** * * * ** $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/23/2017 5/22/2017 5/31/201] ** *"+ *.x.* +x" +* . *... * « « ». $0.00 ($'190.(10, MALE SUBSCRIBER 1 BCC 3559 {U 6/23/2017 5/22/2017 6/19/2017 ..... " * * ** " * * ** * * * ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 N 6/23/2017 5/23/2017 5/31/2017 *` * ** * * * ** *` * *` " * * *« * * * ** $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/23/2017 5/23/2017 5/31/2017 * * * ** * * * "* * * " ** * * * *« * * * *" $0.00 ($190.001 MALE SUBSCRIBER 1 BCC 3559 6/23/2017 5/23/2017 6/19/2017 * « * ** * *' ** * " * ** * * "` * *` "* $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/23/2017 5/25/2017 5/31/2017 * " ** * * * ** *` * ** " * * ** * * * ** $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/23/2017 5/25/2017 5/31/201] * *rr* ... ** .«" +r x. + +. *.. ** $0.00 ($19U.UU1 MALE SUBSCRIBER 1 BCC 3559 6/23/2017 5/25/2017 6/19/201] * * * ** ` *' ** * " * ** " * * ** " *' ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/23/2017 5/26/2017 5131/2017 * * * "* * * * ** *` " ** * * * ** * * * ** $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/23/2017 5/26/2017 5/31/201] * * * ** * * * "* * * * ** " * * ** * *` *" $0.00 ($190.001 MALE SUBSCRIBER 1 BCC 3559 ate+ 6/23/2017 5/26/2017 6/19/201] * * * ** * *` ** * * * ** * *' ** " *` ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 6/23/2017 5/29/2017 6/19/2017 * * * "* * *sx< *.. : *. **zsx z *sxx $0.00 $ ,ND $190.00 MALE SUBSCRIBER 1 BCC 3559 W } 6/23/2017 5/29/2017 6/19/2017 * "'* +.. *. ., * *, * + +.. +...* $190.00 MALE SUBSCRIBER 1 BCC 3559 6/23/2017 5/30/2017 6/19/2017 * *ax. w.www sax.* x * *x* w. *ww $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 iL CL 6/23/2017 5/31/2017 6/19/2017 * * * ** * * * ** * * * ** * * * ** * ** ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC Q. 6/23/2017 6/2/2017 6/19/2017 * * * ** * * «'* * * * ** * * * ** ' * **' $0.00 $190.00 MALE SUBSCRIBER 1 BCC "11111 6/29/201] 6/21/201] 6/28/2017 saa ** xww *. * « " *• $]q.7S $126.00 MALE SUBSCRIBER 1 BCC 3559 6/30/2017 6/7/2017 6/29/2017 - - E1165 TYPE2 DIABETES HOSPITALOUTPATIE NT $2,408.00 $4,481.00 MALE SUBSCRIBER 1 BCC 3559 MELLITUS WITH HYPERGLYCEMIA ]/3/2017 4/30/2017 6/9/2017 * *aa+ ..x.* *«" +* .. *.. * « « *. ($86.411 (.5310.001 MALE SUBSCRIBER 1 BCC 3559 ]/3/2017 4/30/2017 6/30/2017 * « * ** * * * ** " * * ** " * * *` * * * ** $0.00 $380.00 MALE SUBSCRIBER 1 BCC 3559 W 7/3/2017 4/30/2017 7/1/2017 *` " ** * * * "* °fY ** " * * *« * * * *" $86.41 $380.00 MALE SUBSCRIBER 1 BCC 3559 ~ ]/3/201] 5/1/201] 6/9/2017 * * * "* * * * ** * « " ** * * * *« * * * ** ($3].831 ( <_190.OU1 MALE SUBSCRIBER 1 BCC 3559 ]/3/2017 5/1 /2017 6/30/2017 * « * ** * * * ** * " * ** * * * ** * * * ** $0.00 $444.00 MALE SUBSCRIBER 1 BCC 3559 7/3/2017 5/1/2017 7/1/2017 $444.00 MALE SUBSCRIBER 1 BCC 3559 7/3/2017 5/2/2017 6/9/2017 * * * ** * * * "* *« " ** " * * *` * * * "" ($-05.351 ($380.001 MALE SUBSCRIBER 1 BCC 3559 7/3/2017 5/2/2017 6/9/201] *' * ** * *' ** * " * ** " * * ** " * * ** $0.00 $0.00 MALE SUBSCRIBER 1 BCC 3559 7/3/2017 5/2/2017 6/30/2017 * * * "* * * * ** *` " ** * * * ** * * * ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 7/3/2017 5/2/2017 6/30/201] * * * ** * * * ** * * * ** * * * ** * * * ** $0.00 $380.00 MALE SUBSCRIBER 1 BCC 3559 d. 7/3/2017 5/2/2017 ]/1/201] * * * ** * *` ** * * * *+ * * * ** " *` ** $0.00 $380.00 MALE SUBSCRIBER 1 BCC 3559 ui 7/3/2017 5/2/2017 7/1/2017 * * * "* *rxx* *.. : *. **z*x rr*xx $45.85 $190.00 MALE SUBSCRIBER 1 BCC 3559 ]/3/2017 5/3/2017 6/9/201] *' * ** + + *.* ****z . + + ** + + * *. ($9'1 �01 (.'i380.001 MALE UB SSCRIBER 1 BCC 3559 7/3/2017 5/3/2017 6/30/2017 ` " "•* - * * "* *'• * *' * * " *• $0 .00 $380.00 MALE SUBSCRIBER 1 BCC 3559 Q 7/3/2017 5/3/2017 7/1/2017 * * * ** * * * ** * * * ** * * * ** * * * ** $45.85 $380.00 MALE SUBSCRIBER 1 BCC 3559 7/3/2017 5/4/2017 6/9/2017 * * * ** * * * ** * * * ** * * * *" * * * ** f$q.5.85J 15190. MALE SUBSCRIBER 1 BCC 3559 W 7/3/2017 5/4/2017 6/30/2017 * * * ** * * * ** saa ** * * * ** * * * ** $0.00 E l, $190.00 MALE SUBSCRIBER 1 BCC 3559 e p 7/3/2017 5/4/2017 7/1/2017 * * * "* * * * ** * * * ** * * * ** * * * ** $45.85 $190.00 MALE SUBSCRIBER 1 BCC 3559 V 7/3/2017 5/29/2017 6/6/2017 * * * ** * * *'* * * * ** * * * ** ' * * *a $29.78 $190.00 MALE SUBSCRIBER 1 BCC 3559 ]/3/2017 5/29/2017 6/6/2017 * ** *+ * * * "* * " * ** " * * *" * * * *" $0.00 ($190TUNI MALE SUBSCRIBER 1 BCC 3559 7/5/2017 6/7/2017 7/3/2017 99283 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION E1165 TYPE 2 DIABETES PROFESSIONAL $223.92 $653.00 MALE SUBSCRIBER 1 BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES MELLITUS WITH OUTPATIENT /HOSPITAL (, THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM HYPERGLYCEMIA FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED E HAMINATION; AND MEDICAL DECISION MAKING OF LLJ MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH U 7/10/2017 6/7/2017 7/7/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST E1165 TYPE DIABETES PROFESSIONAL $0.00 $36.00 MALE SUBSCRIBER 1 BCC 3559 INCLUDETHEFOLLOWING! ALBUMIN (82040), BILIRUBIN, MELLITUS WITH OUTPATIENT /HOSPITAL TOTAL ( 82247), CALCIUM, TOTAL (82310), CARBON HYPERGLYCEMIA DIOXIDE(BICARBO MATE) (82374), CHLORIDE (82435), CFJ CREATININE( 82555) , GLUCOSE (92947), PH0SPHATASE, N ALKALINE (84075), POTASSIUM (84132), PROTEIN, Tt C.7.f 7/10/2017 6/7/2017 7/7/2017 81003 URINALYSIS, BY D I P STICK OR TABLET REAGENT FOR E1165 TYPE 2 DIABETES PROFESSIONAL $0.00 $18.00 MALE SUBSCRIBER 16CC 3559 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, MELLITUS WITH OUTPATIENT /HOSPITAL LEUIKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, HYPERGLYCEMIA UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, W ITHOUT MICROSCOPY 7/10/2017 6/7/2017 7/]/201] 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HOE, E1165 TYPE 2 DIABETES PROFESSIONAL $0.00 $27.00 MALE SUBSCRIBER 1 BCC 3559 HCT, RBC, WBC AND PLATELET COUNT) MELLITUS WITH OUTPATIENT /HOSPITAL HYPERGLYCEMIA 7/12/2017 6/28/2017 7111/2017 * " ** * * * ** * * * ** * * * ** * * * »* $111.41 $185.00 MALE SUBSCRIBER 1 BCC 3559 7/13/2017 5/29/2017 6/6/201] * * *x+ ...x* +xx++ x" + ++ * * *.x $]1.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 7/13/2017 5/29/201] 6/6/201] * * *"+ + + + ++ ....+ . + + +. + + + ++ $0.00 ($190.01 MALE SUBSCRIBER 1 BCC 3559 7/13/2017 5/30/2017 6/6/2017 + * * "+ * * * ** *` " +* * * * *» * * * ** $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 7/13/2017 5/30/2017 6/6/201] * * * ** * * * "* * * * ** " * + ** * * * *" $0.00 i$190. DOj MALE SUBSCRIBER 1 BCC 3559 7/13/2017 5/31/2017 6/6/2017 * * * *` + + + :+ +.+ ++ +. + ++ + + + +: $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 7/13/2017 5/31/2017 6/6/20 17 * * + ** + +s ++ * * * ** . + + +s * +>-a+ $0.00 (5190,007 MALE SUBSCRIBER 1 BCC 3559 7/13/2017 5131/2017 6/20/2017 * * * ** * * * "" * * * ** ` * *a" * * * *" 3,624 $.00 $10,649.73 MALE SUBSCRIBER 1 BCC 3559 7/13/2017 6/2/201] 6/6/2017 * * ° "* * * * ** *a. ** " * * ** * * * ** $]1.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 7/13/2017 6/2/2017 6/6/2017 $0.00 ($190.00) MALE SUBSCRIBER 1 BCC 3559 8/10/2017 5/13/2017 8/3/2017 * * * ** * *"•• +x + ++ . + + ++ +.... $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/10/2017 5/14/201] 8/3/2017 " *a ** * * * ** * " " ** " * * ** * * * ** $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/10/2017 5/15/2017 8/3/2017 * * " ** $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/10/2017 5/16/2017 8/3/2017 ..... *« « ** * * * "+ " *.+. $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/10/2017 5/17/201] 8/3/2017 * * * "* $]1.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/10/2017 5/18/2017 8/3/2017 *` " ** + + +++ ..w +* + + + +« + + + ++ $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/10/2017 5/19/2017 8/3/2017 * * * «* * * " ** *« « ** * * * *« * * * ** $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/10/2017 6/5/2017 8/3/2017 * * " "* * * * ** * " " ** * * "` * *' ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/10/2017 6/7/2017 8/3/2017 *` " ** * * * ++ * * * ** « * * *« * * + *+ $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/10/2017 6/12/2017 8/3/2017 * * * ++ * * * ** *« « ** " * * ** * * * ** $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/10/2017 6/13/2017 8/3/201] * + +x+ w.. w.* +« + ++ a + + ++ w...* 50,00 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/11/2017 6/5/2017 6/13/2017 * * * "* + + * ++ * * " ** + * + +* + + + *+ $0.00 ($190.DUj MALE SUBSCRIBER 1 BCC 3559 8/11/2017 6/S/2017 8/3/2017 $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/11/2017 6/7 /2017 6/13/2017 $0.00 (.$19.x.001 MALE SUBSCRIBER 1 BCC 3559 8/11/2017 6/] /201] 8/3/201] * * * *` * * * ++ * * * ++ * + + +* + ++++ $]1.55 $190.00 MALE SUBSCRIBER 1 SCC 3559 8/11/2017 8/8/2017 8/9/2017 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE S46292A OTHER INJURY OF OTHER MEDICAL $225.00 $300.00 MALE SUBSCRIBER 1 BCC 3559 EVALUATION AND MANAGEMENT OF A NEW PATIENT, MUSCLE, FASCIA AND WHICH REQUIRES THESE 3 KEY COMPONENTS :A DETAILED TENDON OF OTHER PARTS HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION OF BICEPS, LE FT ARM, MAKI NO OF LOW COM PLEXITY, COUNSELING AND /OR I N ITIAL E N COU INTER COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE P 8/11/2017 8/8/2017 8/9/2017 A4566 SHOULDER SLING OR VEST DESIGN, ABDUCTION S46292A OTHER INJURY OF OTHER MEDICAL $0.00 $17.00 MALE SUBSCRIBER 1 BCC 3559 RESTRAINER, WITH OR WITHOUT SWATHE MUSCLE, FASCIA AND TENDON OF OTHER PARTS OF BICEPS, LE FT ARM, INITIAL ENCOUNTER 8117/2017 6/12/2017 6/20/2017 *` " ** * * * ++ * * * ** « * * *« * * + *+ $71.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/17/2017 6/12/2017 6/20/2017 * * * ++ * * * ** *« « ** " + + +. * * * ** $0.00 ($190.00! MALE SUBSCRIBER 1 BCC 3559 8/17/2017 6/13/2017 6/20/201] * * +x+ +.*w+ ++ + ++ a + + ++ w...* $]1.55 $190.00 MALE SUBSCRIBER 1 BCC 3559 8/17/2017 6/13/2017 6/20/2017 * * * "* + + * ++ * * " ** + * + +* + + + *+ $0.00 ($190.001 MALE SUBSCRIBER 1 BCC 3559 8/24/2017 8/1S/2017 8123/2017 99217 OBSERVATION CARE DISCHARGE DAY MANAGEMENT N289 DISORDER OF KIDNEY AND PROFESSIONAL $67.69 $319.00 MALE SUBSCRIBER 1 DEC 3559 (THIS CODE ISTO BE UTILIZED BY THE PHYSICIAN TO URETER, UNSPECIFIED OUTPATIENT /HOSPITAL REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM OBSERVATION STATUS IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF OBSERVATION STATUS. TO REPORT SERVICES TO A PATIENT DESIGNAT 8/25/2017 8/9/2017 8/24/2017 73030 RADIOLDGIC EXAMINATION, SHOULDER; COMPLETE, M25512 PAIN IN LEFT SHOULDER PROFESSIONAL OFFICE $39.02 $125.00 MALE SUBSCRIBER 1 BCC 3559 MINIMUM OF TWO VIEWS 8/25/2017 8/9/2017 812412017 8/25/2017 8/16/2017 8/24/2017 8/25/2017 8/16/2017 8/24/2017 8/30/2017 8/15/2017 8/29/2017 8/30/2017 8/16/2017 8/28/2017 8/31/2017 8/16/2017 8/23/2017 9/5/2017 4/30/2017 9/2/2017 9/5/2017 4/30/2017 9/2/2017 9/5/2017 4/30/2017 9/2/2017 9/5/2017 8/14/2017 8/29/2017 9/5/2017 8/22/2017 9/2/2017 9/5/2017 8/25/2017 9/2/2017 9/6/2017 8/16/2017 9/5/2017 - 9/7/2017 6/14/2017 812312017 * * *•• 99201 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M25512 PAIN IN LEFT SHOULDER PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, $34.00 MALE SUBSCRIBER 1 BCC WHICH REQUIRES THESE 3 KEY COMPONENTS: A $36.00 MALE SUBSCRIBER 1 BCC PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED $306.00 MALE SUBSCRIBER 1 BCC EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION $78.00 MALE SUBSCRIBER 1 BCC MAKING. COUNSELING AND /OR COORDINATION OF CARE $448.00 MALE SUBSCRIBER 1 BCC WITH OTHER PROVIDERS OR AG $36.00 MALE SUBSCRIBER 1 BCC 12004 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, 541112A LACERATION WITHOUT PROFESSIONAL NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND /OR FOREIGN BODY OF LEFT OUTPATIENT /HOSPITAL EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM UPPER ARM, INITIAL T012.5 CM ENCOUNTER 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 541112A LACERATION WITHOUT PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES FOREIGN BODY OF LEFT OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS UPPER ARM, INITIAL IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL ENCOUNTER CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 73221 MAGNETIC RESONANCE(EG, PROTON) IMAGING, ANY M25512 PAIN IN LEFT SHOULDER PROFESSIONAL JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST OUTPATIENT /HOSPITAL MATERIALS) 73060 RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF N119012 PRIMARY PROFESSIONAL TWO VIEWS OSTEOARTHRITIS, LEFT OUTPATIENT /HOSPITAL SHOULDER 73030 RADIOLOGIC EXAM I NATION, SHOULDER; COMPLETE, 54992XA UNSPECIFIED INJURY OF PROFESSIONAL MINIMUM OF TWO VIEWS LEFTSHOULDERAND OUTPATIENT /HOSPITAL UPPER ARM, INITIAL ENCOUNTER 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT S2242XA MULTIPLE FRACTURES OF PROFESSIONAL CONTRAST MATERIAL RIBS, LEFT SIDE, INITIAL OUTPATIENT /HOSPITAL ENCOUNTER FOR CLOSED FRACTURE 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, S2242XA MULTIPLE FRACTURES OF PROFESSIONAL FRONTAL AND LATERAL; RIBS, LEFT SIDE, INITIAL OUTPATIENT /HOSPITAL ENCOUNTER FOR CLOSED FRACTURE 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST S2242XA MULTIPLE FRACTURES OF PROFESSIONAL MATERIALS) RIBS, LEFT SIDE, INITIAL OUTPATIENT /HOSPITAL ENCOUNTER FOR CLOSED FRACTURE 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 8531 WEAKNESS PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M66829 SPONTANEOUS RUPTURE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF OTHER TENDONS, PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY UNSPECIFIED UPPER ARM COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 95819 ELECTROENCEPHALOGRAM (EEG); INCLUDING R569 UNSPECIFIED PROFESSIONAL OFFICE RECORDING AWAKE AND ASLEEP CONVULSIONS - 541112A LACERATION WITHOUT HOSPITAL OUTPATIENT FOREIGN BODY OF LEFT UPPER ARM, INITIAL ENCOUNTER $60.04 $145.00 MALE SUBSCRIBER 1 BCC $13835 $651.00 MALE SUBSCRIBER 1 BCC $31341 $1,481.00 MALE SUBSCRIBER 1 BCC $112.42 $261.00 MALE SUBSCRIBER 1 BCC $13.86 $34.00 MALE SUBSCRIBER 1 BCC $15.49 $36.00 MALE SUBSCRIBER 1 BCC $139.50 $306.00 MALE SUBSCRIBER 1 BCC $35.97 $78.00 MALE SUBSCRIBER 1 BCC $207.94 $448.00 MALE SUBSCRIBER 1 BCC $14.94 $36.00 MALE SUBSCRIBER 1 BCC $47.13 $125.00 MALE SUBSCRIBER 1 BCC $369.99 $800.00 MALE SUBSCRIBER 1 BCC $3,988.60 $4,496.60 MALE SUBSCRIBER 1 BCC $146.80 $813.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 9/18/2017 8/25/2017 9/15/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE T148 OTHER INJURY OF OTHER MEDICAL {$430.00) MALE SUBSCRIBER 1 BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED $0.00 UNSPECIFIED BODY SUBSCRIBER 1 BCC 3559 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY (511.5,00) MALE REGION 1 BCC 3559 $0.00 COMPONENTS: AN EXPANDED PROBLEM FOCUSED SUBSCRIBER Q! 3559 $225.00 $300.00 MALE HISTORY; AN EXPANDED PROBLEM FOCUSED 1 BCC 3559 $95.50 $254.00 MALE SUBSCRIBER EXAMINATION; MEDICAL DECISION MAKING OF LOW 3559 {$3,988.60) {$4,495.60) MALE SUBSCRIBER COMPLEXITY. COUNSELING AND COORD 3559 $254.00 MALE 101 8/16/2017 91 - - S41112A LACERATION WITHOUT HOSPITAL OUTPATIENT 1 BCC 3559 $95.50 $254.00 MALE SUBSCRIBER FOREIGN BODY OF LEFT 3559 $0.00 (.$254.001 MALE SUBSCRIBER 1 Bcc UPPER ARM, INITIAL $4,496.60 $4,496.60 MALE SUBSCRIBER 1 BCC 3559 ENCOUNTER 101 8/16/2017 10/2/2017 - - S41112A LACERATION WITHOUT HOSPITAL OUTPATIENT SUBSCRIBER 1 BCC 3559 $0.00 $190.00 MALE FOREIGN BODY OF LEFT 1 BCC 3559 (7197.00! MALE SUBSCRIBER UPPER ARM, INITIAL 3559 $0.00 $190.00 MALE SUBSCRIBER 1 BCC ENCOUNTER 101 8/16/2017 101212017 - - 541112A LACERATION WITHOUT HOSPITAL OUTPATIENT FOREIGN BODY OF LEFT $225.00 $300.00 MALE SUBSCRIBER 1 BCC 3559 UPPER ARM, INITIAL ENCOUNTER 101 9/2/2017 10/2/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 74802 ENCOUNTER FOR OTHER MEDICAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED REMOVAL OF SUTURES PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 101 6/6/2017 6/13/2017 *xxx* * * * ** *« « ** * * * ** * * * ** 101 6/6/2017 6/13/201] 10/4/2017 6/6/2017 9/30/2017 101 6/8/2017 6/13/2017 *x.x* 101 9/5/2017 101 96312 Therapeutic, prophylactic, ordiagnostic injection (specify L03899 ACUTE LYMPHANGITIS OF OTHER MEDICAL substance rdrug); s.bcutane- or l ntramuscular OTHER SITES 101 9/5/2017 101 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L03898 ACUTE LYMPHANGITIS OF OTHER MEDICAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED OTHER SITES PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. 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COUNSELING AND COORD 12/14/2017 12/1/2017 12/12/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H16122 FILAMENTARY KERATITIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, LEFT EYE WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMP REHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 12/14/2017 12/4/2017 12/12/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H16122 FILAMENTARY KERATITIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHEO LEFT EYE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 12/14/2017 12/5/2017 12/12/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H16122 FILAMENTARY KERATITIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LEFT EYE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 12/14/2017 12/8/2017 12/12/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H16122 FILAMENTARY KERATITIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LEFT EYE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD $0.00 {.$190.007 MALE SUBSCRIBER 1 BCC 3559 $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 y� $0.00 {$'190.DOj MALE SUBSCRIBER 1 BCC 3559 {U $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 N $0.00 I MALE i$190.0000 SUBSCRIBER 1 BCC 3559 $0.00 $190. MALE SUBSCRIBER 1 BCC 3559 $0.00 {.$190.001 MALE SUBSCRIBER 1 BCC 3559 $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 {$190.001 MALE SUBSCRIBER 1 BCC 3559 > $0.00 $190.00 MALE SUBSCRIBER 1 BCC 3559 "a $17,779.00 $24,359.55 MALE SUBSCRIBER 1 BCC 3559 $0.00 $69.00 MALE SUBSCRIBER 1 BCC 3559 W } $266.40 $1,481,00 MALE SUBSCRIBER 1 BCC 3559 E. CL CL Q Q $45.92 $125.00 MALE SUBSCRIBER 1 BCC 3559 $173.99 $250.00 MALE SUBSCRIBER 1 BCC 3559 $73.74 $150.00 MALE SUBSCRIBER 1 BCC 3559 $73.74 $150.00 MALE SUBSCRIBER 1 BCC 3559 $73.74 $150.00 MALE SUBSCRIBER 1 BCC 3559 12/20/2017 12/12/2017 12/19/2017 99213 OFFICE 0R OTHER OUTPATIENT VISIT FOR THE H16122 FILAMENTARY KERATITIS, PROFESSIONAL OFFICE $0.00 EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC LEFT EYE $64.36 PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY 1 BCC 3559 COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 12/27/2017 12/22/2017 12/26/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H16122 FILAMENTARY KERATITIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LEFT EYE PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT Sub TOtal 3.25E +10 1/30/2017 1/9/2017 1/19/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5136 OTHERINTERVERTEBRAL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISC DEGENERATION, PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY LUMBAR REGION COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 1/30/2017 1/16/2017 1118/2017 99204 OFFICE DR OTHER OUTPATIENT VISIT FOR THE 539012A STRAIN OF MUSCLE, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, FASCIA AND TENDON OF WHICH REQUIRES THESE 3 KEY COMPONENTS: A LOWER BACK, INITIAL COMPREHENSIVE HISTORY; A COMPREHENSIVE ENCOUNTER EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 1/30/2017 1/23/2017 1/24/2017 71020 RADIOLDGIC EXAMINATION, CHEST, TWO VIEWS, R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL FRONTAL AND LATERAL; OUTPATIENT /HOSPITAL 1/30/2017 1/23/2017 1/24/2017 71275 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST 8079 CHEST PAIN, UNSPECIFIED PROFESSIONAL )NONCORONARY), WITH CONTRAST MATERIAL(S), OUTPATIENT /HOSPITAL INCLUDING NDNCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING 2/10/2017 1/30/2017 2/3/2017 99214 OFFICE DR OTHER OUTPATIENT VISIT FOR THE M5136 OTHERINTERVERTEBRAL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISC DEGENERATION, PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LUMBAR REGION CO M PD N E NTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 2/16/2017 1/23/2017 1/31/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 1441 CHRONIC OBSTRUCTIVE PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES PULMONARY DISEASE OUTPATIENT /HOSPITAL THESE KEY COMPONENTS WITHIN THE CONSTRAINTS WITH (ACUTE) IMPOSED BYTHE URGENCY OFTHE PATIENT'S CLINICAL EXACERBATION CONDITION AND /OR MENTALSTATUS: ACOMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 2/17/2017 1/16/2017 2/10/2017 72148 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL M5126 OTHERINTERVERTEBRAL OTHER MEDICAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST DISC DISPLACEMENT, MATERIAL LUMBAR REGION 3/8/2017 2/27/2017 3/3/2017 36415 COLLECTION OFVENOUS BLOOD BYVENIPUNCTURE Z79899 OTHER LONG TERM PROFESSIONAL OFFICE (CURRENT)DRUG THERAPY $73.74 $150.00 MALE SUBSCRIBER 1 BCC $44.07 $100.00 MALE SUBSCRIBER 1 BCC $67,315.18 $211,297.37 $52.92 $175.00 FEMALE SPOUSE 1 BCC $116.16 $722.00 FEMALE SPOUSE 1 BCC C.7.f 3559 w Al N m (D U) 3559 7 fl } fl s® CL CL 3559 W. $0.00 $67.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $507.00 FEMALE SPOUSE 1 BCC 3559 $64.36 $463.00 FEMALE SPOUSE 1 BCC 3559 $201.61 $665.00 FEMALE SPOUSE 1 BCC $313.77 $1,270.00 FEMALE SPOUSE 1 BCC 3559 $1.80 $35.00 FEMALE SPOUSE 1 BCC 3559 C.7.f 3/13/2017 3/3/2017 3/6/2017 644931Nectio n(s), diagnostic or the ra peutic agent, pa raverte brat M4726 OTHER SPONDYLOSIS PROFESSIONAL OFFICE $244.28 $633.69 FEMALE SPOUSE 1 BCC 3559 facet (zygapophysea lj joint jor nerves innervating that WITH RADICULOPATHY, joint) ith image guidance (fluoroscopy or CT), lumbar or LUMBAR REGION C! sacral, single level N 3/13/2017 3/3/2017 3/6/2017 644941njectlan(sj, diagnostic or therapeutic agent, paravertebral M4726 OTHER SPONDYLOSIS PROFESSIONAL OFFICE $124.30 $322.45 FEMALE SPOUSE 1 BCC 3559 facet(zygapophyseal) joint (or nerves innervatingthat WITH RADICULOPATHY, joint) w ith image guidance) fluoroscopy .,CT), lumbar., LUMBAR REGION cord l wel (List separately io addition to code for primary procedure) > i' 3/13/2017 3/3/2017 3/6/2017 99152 Moderate sedation ,r provided bythe same M4726 OTHER SPONDYLOSIS PROFESSIONAL OFFICE $53.99 $186.76 FEMALE SPOUSE 1 BCC 3559 physician or other qualified health care professional WITH RADICULOPATHY, performingthe diagnostic or therapeutic service that LUMBAR REGION W 3/13/2017 3/3/2017 3/6/201713301 INJECTION, TRIAMCINOLONE ACETONIDE, NOT M4726 OTHER SPONDYLOSIS PROFESSIONAL OFFICE $17.95 $75.00 FEMALE SPOUSE 1BCC } 3559 {j OTHERWISE SPECIFIED, 10 MG WITH RADICULOPATHY, N. CL LUMBAR REGION Q, Q 3/15/2017 1/23/2017 1/30/2017 * *' "* " "* * " " ** ° #fi " "' $7,390.14 $13,887.00 FEMALE SPOUSE 1 BCC 3559 v 3/17/2017 3/10/2017 3/14/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N15136 OTHERINTERVERTEBRAL PROFESSIONAL OFFICE $64.36 $463.00 FEMALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISC DEGENERATION, PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LUMBAR REGION COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF h MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 3/17/2017 3/14/2017 3/15/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $10.57 $45.00 FEMALE SPOUSE 1 BCC 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 3/17/2017 3/14/2017 3/15/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILI2ATION/ M545 LOW BACK PAIN OTHER MEDICAL $10.00 $45.00 FEMALE SPOUSE 1 BCC 3559 Q MANIPULATION, MANUAL LYMPHATIC DRAINAGE, U.1 MANUAL TRACTION), LOB MORE REGIONS, EACH 15 MINUTES Uy 3/17/2017 3/14/2017 3/15/2017 97161 Physical therapy evaluation: low complexity, requiring M545 LOW BACK PAIN OTHER MEDICAL $34.54 $180.00 FEMALE SPOUSE 1 BCC 3559 these components: A history with no personal factors and /or comorbidities that impact the plan of W 3/17/2017 3/14/2017 3/15/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT M545 LOW BACK PAIN OTHER MEDICAL $2230 $90.00 FEMALE SPOUSE 1BCC 3559 CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 J MINUTES 3/23/2017 3/16/2017 3/22/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $21.16 $90.00 FEMALE SPOUSE 1 BCC 3559 v MINUTES; THERAPEUTIC EXERCISES TO DEVELOP r STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY W 3/23/2017 3/16/2017 3/22/2017 97140 MANUAL THERAPY TECH NIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $20.01 $90.00 FEMALE SPOUSE 1 BCC 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 (' MINUTES 3/23/2017 3/16/2017 3/22/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE - ON- ONE)PATIENT M545 LOW BACK PAIN OTHER MEDICAL $0.00 $45.00 FEMALE SPOUSE 1BCC 3559 CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES Q TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 4/28/2017 4/24/2017 4/27/2017 MINUTES 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE S239XXA SPRAIN OF UNSPECIFIED PROFESSIONAL OFFICE $34.83 $316.00 FEMALE SPOUSE IBCC 3559 N EVALUATION AND MANAGEMENT OF AN ESTABLISHED PARTS OF THORAX, _ PATIENT, WH ICH REQUIRES AT LEAST 2 OF THESE 3 KEY I NITIAL ENCOU NTER y COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED ._ EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 5/26/2017 5/22/2017 5/25/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5136 OTHERINTERVERTEBRAL PROFESSIONAL OFFICE $64.36 $463.00 FEMALE SPOUSE 1BICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISC DEGENERATION, PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LUMBAR REGION COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/13/2017 6/7/2017 6/12/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5136 OTHERINTERVERTEBRAL PROFESSIONAL OFFICE $34.83 $316.00 FEMALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISC DEGENERATION, PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LUMBAR REGION COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 6/13/2017 6/7/2017 6/12/2017 93000 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 Z01810 ENCOUNTER FOR PROFESSIONAL OFFICE $12.86 $75.00 FEMALE SPOUSE 1 BCC LEADS; WITH INTERPRETATION AND REPORT PREPROCEDURAL CARDIOVASCULAR EXAMINATION 6/13/2017 6/7/2017 6/12/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 701810 ENCOUNTER FOR PROFESSIONAL OFFICE $161.70 $300.00 FEMALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF ANEW PATIENT, PREPROCEDURAL WHICH REQUIRES THESE 3 KEY COMPONENTS: A CARDIOVASCULAR COMPREHENSIVE HISTORY; ACOMPREHENSIVE EXAMINATION EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE 6/22/2017 6/14/2017 6/21/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION M4687 OTHER SPECIFIED PROFESSIONAL $138.58 $250.00 FEMALE SPOUSE 1 BCC AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INFLAMMATORY INPATIENT /HOSPITAL THESE3 KEYCOMPDNENTS: A COMPREHENSIVE HISTORY; SPONDYLOPATHIES, A COMPREHENSIVE EXAMINATION; AND MEDICAL LUMBOSACRAL REGION DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 6/22/2017 6115/2017 6/21/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4687 OTHER SPECIFIED PROFESSIONAL $71.21 $140.00 FEMALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INFLAMMATORY INPATIENT /HOSPITAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A SPONDYLOPATHIES, DETAI LED I MILE RVA L H ISTO RY; A DETAI LED EXAM I NATIO N; LUMBOSACRAL REGION MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/22/2017 6/16/2017 6/21/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4687 OTHER SPECIFIED PROFESSIONAL $71.21 $140.00 FEMALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INFLAMMATORY INPATIENT /HOSPITAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A SPONDYLOPATHIES, DETAI LED I MILE RVA L H ISTO BY; A DETAI LED EXAM I NATIO N; LUMBOSACRAL REGION MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/22/2017 6/17/2017 6/21/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4687 OTHER SPECIFIED PROFESSIONAL $71.21 $140.00 FEMALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INFLAMMATORY INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A SPONDYLOPATHIES, DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; LUMBOSACRAL REGION MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI C.7.f 6/22/2017 6/18/2017 6/21/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4687 OTHER SPECIFIED PROFESSIONAL $71.21 $140.00 FEMALE SPOUSE 1BCC 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INFLAMMATORY INPATIENT /HOSPITAL REQUIRESATLEA5T20FTHESE3 KEYCOMPONENTS:A SPONDVLOPATHIES, Z DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; LUMBOSACRAL REGION N MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM A t 6/22/2017 6/19/2017 6/21/2017 99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES M4687 OTHER SPECIFIED PROFESSIONAL $4846 $100.00 FEMALE SPOUSE 1 BCC 3559 7 OR LESS INFLAMMATORY INPATIENT /HDSPITAL SPONDVLOPATHIES, OR LUMBOSACRAL REGION 6/23/2017 6/14/2017 6/22/2017 20930 ALLOGRAFT, MORSELIZED, OR PLACEMENT OF S239XXA SPRAIN OF UNSPECIFIED PROFESSIONAL $0.00 $870.00 FEMALE SPOUSE 1BCC 3559 lu } 05TEOPROMOTIVE MATERIAL, FOR SPINE SURGERY ONLY PARTS OF THORAX, INPATIENT /HOSPITAL (LIST SEPARATELY I N ADDITION TO CODE FOR PRI MARY I NITIAL ENCOU INTER iL CL PROCEDURE) Q, 6123/2017 6/14/2017 6/22/2017 22612 ARTHR0DESIS, POSTERIOR OR POSTEROLATERAL S239XXA SPRAIN OF UNSPECIFIED PROFESSIONAL $1,143.65 $11,793.00 FEMALE SPOUSE 1BCC 3559 TECHNIQUE, SINGLE LEVEL; LUMBAR (WITH LATERAL PARTS OF THORAX, INPATIENT /HOSPITAL TRANSVERSE TECHNIQUE, WHEN PERFORMED( I NITIAL ENCOU INTER 6/23/2017 6/14/2017 6/22/2017 22614 ARTHR0DESIS, POSTERIOR OR POSTEROLATERAL S239XXA SPRAIN OF UNSPECIFIED PROFESSIONAL $293.18 $3,080.00 FEMALE SPOUSE 1BCC 3559 TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL PARTS OF THORAX, INPATIENT /HOSPITAL SEGME MT (LIST SEPARATELY IN ADDITION TO CODE FOR I NITIAL ENCOU INTER uj PRIMARY PROCEDURE) 6/23/2017 6/14/2017 6/22/2017 22842 POSTERIOR SEGMENTAL INSTRUMENTATION IDS, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND S239XXA SPRAIN OF UNSPECIFIED PARTS OF THORAX, PROFESSIONAL INPATIENT /HOSPITAL $572.35 $1,565.00 FEMALE SPOUSE 1 BCC � 3559 SUBLAM I MAR WIRES(; 3 T06 VERTEBRAL SEGMENTS(LIST I NITIAL ENCOU INTER _ SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 6/23/2017 6/14/2017 6/22/2017 63047 LAM I NECTOMY, FACETECTOMY AND FORAM I NOTOMV S239XXA SPRAIN OF UNSPECIFIED PROFESSIONAL $392.70 $9,238.00 FEMALE SPOUSE 1 BCC 3559 (UNILATERAL OR BILATERAL WITH DE COMPRESSIONOF PARTSOFTHORAX, INPATIENT /HDSPITAL IL SPINAL CORD, CAUDA EQUINAAND /OR NERVE ROOTASA ", INITIAL ENCOUNTER ui AEG, SPINAL 0R LATERAL RECESS STENOS I ), S NO LE VERTEBRAL SEGMENT; LUMBAR UJ 6/23/2017 6/14/2017 6/22/2017 63048 LAM AECTOMY, FACETECTO MY AN D FO RAM I N OTO MV S239XXA SPRAIN OF UNSPECIFIED PROFESSIONAL $15941 $3,932.00 FEMALE SPOUSE 1 BCC 3559 0 (UNILATERAL OR BILATERAL WITH DE COMPRESSIONOF PARTS OF THORAX, INPATIENT /HOSPITAL SPINAL CORD, CAD DA EQU I NA AND /OR NERVE ROUTES(, I NITIAL ENCOU NTER LLJ SPINAL OR LATERAL RECESS STENOSIS((, SINGLE (EG, VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT, � CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN J ADDITION TO CODE FOR PRIMARY PROCEDURE) v 6/23/2017 6/14/2017 6/22/2017 76000 FLUOROSCOPY (SEPARATE PROCEDURE), UPTO I HOUR S239XXA SPRAIN OF UNSPECIFIED PROFESSIONAL $5.61 $280.00 FEMALE SPOUSE 1 BCC 3559 PHYSICIAN TIME, OTHER THAN 710230R 71034 LEG, PARTS OF THORAX, INPATIENT/HOSPITAL llJ CARDIAC FLUOROSCOPY( INITIAL ENCOUNTER 6/28/2017 6/5/2017 6/23/2017 * * *x* v... w.* .« « +* . **... v...*w 6/14/2017 # #p # # # ## $4],]50.55 $134,597.55 FEMALE SPOUSE 1 BCC 3559 (' 7/3/2017 6/5/2017 6/30/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 110 ESSENTIAL (PRIMARY) PROFESSIONAL $15.29 $83.00 FEMALE SPOUSE 1 BCC 3559 FRONTAL AND LATERAL; HYPERTENSION OUTPATIENT /HOSPITAL 7/3/2017 6/14/2017 6/30/2017 * *' ** * * * ** *' * ** * * * *' * * * ** $1,016.58 $5,439.00 FEMALE SPOUSE 1 BCC 3559 7/3/2017 6/14/2017 6/30/2017 ' * * *` ' * * *. *.:.* ...... .: :.* $1,016.58 $5,387.20 FEMALE SPOUSE 1 BCC 3559 hl 7/3/2017 6/14/2017 6130/2017 72300 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO M545 LOW BACK PAIN PROFESSIONAL $15.77 $106.00 FEMALE SPOUSE BCC 3559 OR THREE VIEWS INPATIENT /HOSPITAL 7/5/2017 6/29/2017 71412017 99211 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z79899 OTHER LONG TERM PROFESSIONAL OFFICE W EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC (CURRENT) DRUG $0.00 PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A 1 BCC THERAPY $0.00 PHYSICIAN. USUALLY, THE PRESENTING PROBLEM(S) ARE 1 BCC 3559 $0.00 MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT 1 BCC Q! $14444 PERFORMING OR SUPERVISING THESE SERVICES. 1 BCC 3559 7/10/2017 6/14/2017 7/7/2017 95870 NEEDLE ELECTROMYOGRAPHY; LIMITED STUDY OF M4806 SPINAL STENOSIS, PROFESSIONAL 3559 MUSCLES IN 1 EXTREMITY OR NON -LIMB )AXIAL) MUSCLES LUMBAR REGION INPATIENT / HDSPITAL (UNILATERAL OR BILATERAL), OTHER THAN THORACIC PARASPINAL, CRANIAL NERVE SUPPLIED MUSCLES, OR SPHINCTERS 7/10/2017 6/14/2017 7/7/2017 95938 SHORT - LATENCY SOMATOSENSORY EVOKED POTENTIAL M4806 SPINAL STENOSIS, PROFESSIONAL STUDY, STIMULATION OF ANY /ALL PERIPHERAL NERVES $0.00 LUMBAR REGION INPATIENT /HOSPITAL 1 BCC OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER AND LOWER LIMBS W 7/10/2017 6/14/2017 7/7/2017 95941 CONTINUOUS INTRAOPERATIVE NEUROPHYSIOLOGY N14806 SPINAL STENOSIS, PROFESSIONAL } MONITORING, FROM OUTSIDE THE OPERATING ROOM LUMBAR REGION INPATIENT /HOSPITAL (REMOTE OR NEARBY) OR FOR MONITORING OF MORE THAN ONE CASE WHILE IN THE OPERATING ROOM, PER CL HOUR (LIST SEPARATELY CL 8/3/2017 7/31/2017 8/2/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5136 OTHERINTERVERTEBRAL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISC DEGENERATION, PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY LUMBAR REGION COMPONENTS: AN EXPANDED PROBLEM FOCUSED 4 HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW F COMPLEXITY. COUNSELING AND COORD $316.00 FEMALE SPOUSE 1 BCC 8/18/2017 8/10/2017 8/17/2017 80050 GENERAL HEALTH PANEL THIS PANEL MUST INCLUDE THE R8290 UNSPECIFIED ABNORMAL OTHER MEDICAL FOLLOWING: COMPREHENSIVE METABOLIC PANEL FINDINGS IN URINE (80053), BLOOD COUNT, COMPLETE (CBC), AUTOMATED AND AUTOMATED DIFFERENTIAL W BC COUNT (85025 OR 85027 AND 65004), OR, BLOOD COUNT, COMPLETE (CBC), AUTOMATED (85027) AND APPROPRIATE MANUAL DIFFERENTIA 8/18/2017 8/10/2017 8/17/2017 82024 ADRENOCORTICOTROPIC HORMONE (ACTH) R8290 UNSPECIFIED ABNORMAL OTHER MEDICAL FINDINGS IN URINE 811812017 8/10/2017 8/17/2017 82533 CORTISOL; TOTAL R8290 UNSPECIFIED ABNORMAL OTHER MEDICAL FINDINGS IN URINE 811812017 811012017 8/17/2017 83001 GONADOTROPIN; FOLLICLE STIMULATING HORMONE 88290 UNSPECIFIED ABNORMAL OTHER MEDICAL (FSH� FINDINGS IN URINE 8/18/2017 8/10/2017 81 83002 GONADOTROPIN; LUTEINIZING HORMONE (LT) R8290 UNSPECIFIED ABNORMAL OTHER MEDICAL FINDINGS IN URINE 811812017 8/10/2017 8/17/2017 84439 THYROXINE; FREE R8290 UNSPECIFIED ABNORMAL OTHER MEDICAL FINDINGS IN URINE 8/21/2017 8/16/2017 8118/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 14521 MILD INTERMITTENT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, ASTHMA WITH (ACUTE) WHICH REQUIRES THESE 3 KEY COMPONENTS :A EXACERBATION COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR C.7.f $22.66 $100.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $237.75 FEMALE SPOUSE 1 BCC 3559 $0.00 $161.98 FEMALE SPOUSE 1 BCC 3559 W $133.86 FEMALE SPOUSE 1 BCC 3559 $0.00 N 1 BCC 3559 $0.00 $134.71 FEMALE SPOUSE 1 BCC 3559 $0.00 $146.23 FEMALE SPOUSE 1 BCC Q! $14444 $250.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $1,222.00 FEMALE SPOUSE 1 BCC 3559 $0.00 $1,086.00 FEMALE SPOUSE 1 BCC 3559 W } fl i® CL CL $0.00 $2,358.00 FEMALE SPOUSE 1 BCC 3559 4 F $0.00 $316.00 FEMALE SPOUSE 1 BCC 3559 Lij $0.00 $237.75 FEMALE SPOUSE 1 BCC 3559 $0.00 $161.98 FEMALE SPOUSE 1 BCC 3559 $0.00 $133.86 FEMALE SPOUSE 1 BCC 3559 $0.00 $135.25 FEMALE SPOUSE 1 BCC 3559 $0.00 $134.71 FEMALE SPOUSE 1 BCC 3559 $0.00 $146.23 FEMALE SPOUSE 1 BCC 3559 $14444 $250.00 FEMALE SPOUSE 1 BCC 3559 C.7.f 8/22/2017 7/27/2017 8/17/2017 72100 RADIO LOGIC EXAM I NATION, SPINE, LUMBOSACRAL; TWO M545 LOW BACK PAIN OTHER MEDICAL $35.78 $185.00 FEMALE SPOUSE 1BCC 3559 ORTHREEVIEWS W 9/12/2017 7/11/2017 9/11/2017 *` " ** xxx «x + *. *x xxxx« xxxxx $0.00 $200.00 FEMALE SPOUSE 1 BCC 3559 9/26/2017 6/14/2017 9/25/2017 95870 NEEDLE ELECTROMYOGRAPHY ; LIMITEDSTUDYOF M4806 SPINAL STENOSIS, PROFESSIONAL $46.50 $1,222.00 FEMALE SPOUSE 1 BCC 3559 OR MUSCLES IN 1 EXTREMITYOR NON -LIMB (AXIAL) MUSCLES LUMBAR REGION INPATIENT /HOSPITAL (UNILATERAL OR BILATERAL), OTHER THAN THORACIC PARASPINAL, CRANIAL NERVE SUPPLIED MUSCLES, OR SPHINCTERS 9/26/2017 6/14/2017 9125/2017 95938 SHORT LATENCY SOMATDSENSDRY EVOKED POTENTIAL M4806 SPINAL STENOSIS, PROFESSIONAL $53.94 $1,086.00 FEMALE SPOUSE 1 BCC 3559 } STUDY, STIMULATION OF ANY /ALL PERIPHERAL NERVES LUMBAR REGION INPATIENT /HOSPITAL OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER AND LOWER LIMBS 9/26/2017 6/14/2017 9125/2017 95941 CONTINUOUS INTRAOPERATIVE NEUROPHYSIDLDGY M4806 SPINAL STENOSIS, PROFESSIONAL $307.50 $2,358.00 FEMALE SPOUSE 1 BCC 3559 } MONITORING, FROM OUTSIDE THE OPERATING ROOM LUMBAR REGION INPATIENT /HOSPITAL (REMOTE OR NEARBY) OR FOR MONITORING OF MORE iL CL THAN ONE CASE WHILE IN THE OPERATING ROOM, PER Q, HOUR (LIST SEPARATELY 101 9/28/2017 101 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 539012A STRAIN OF MUSCLE, PROFESSIONAL $190.85 $392.00 FEMALE SPOUSE 1BCC 3559 AND MANAGEMENTOFA PATIENT, WHICH REQUIRES FASCIA AND TENDON OF OUTPATIENT /HOSPITAL rf THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A LOWER BACK, INITIAL DETAILED EXAMINATION; AND MEDICAL DECISION ENCOUNTER MAKING OF MODERATE COMPLEXITY. COUNSELING F AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR 101 9/28/2017 101512017- - 539012A STRAIN OF MUSCLE, HOSPITAL OUTPATIENT $621.69 $1,189.25 FEMALE SPOUSE 1BCC 3559 FASCIA AND TENDON OF LOWER BACK, INITIAL ENCOUNTER U' 10/18/2017 10/13/2017 10/17/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE S239XXA SPRAIN OF UNSPECIFIED PROFESSIONAL OFFICE $89.36 $463.00 FEMALE SPOUSE 1BCC 3559 Q EVALUATION AND MANAGEMENT OF AN ESTABLISHED PARTS OF THORAX, uj PATIENT, WH ICH REQUIRES AT LEAST 2 OF THESE 3 KEY I NITIAL ENCOU NTER COMPONENTS: A DETAILED HISTORY; A DETAILED UJ EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER W 10/26/2017 6/14/2017 10/19/2017 22612 ARTHRODESIS, POSTERIOR OR POSTEROIATERAL S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 $1,900.00 FEMALE SPOUSE 1 BCC 3559 TECHNIQUE, SINGLE LEVEL; LUMBAR (WITH LATERAL PARTS OF THORAX, TRANSVERSE TECHNIQUE, WHEN PERFORMED) I NITIAL ENCOU NTER J 10/26/2017 6/14/2017 10/19/2017 22614 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL 5239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 $807.50 FEMALE SPOUSE 1BCC 3559 v TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL PARTS OF THORAX, SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR I NITIAL ENCOU NTER PRIMARY PROCEDURE) uj 10/26/2017 6/14/2017 10/19/2017 22842 POSTERIOR SEGMENTAL INSTRUMENTATION ITS, PEDICLE S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 $1,425.00 FEMALE SPOUSE 1 BCC 3559 FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND PARTS OF THORAX, SUBLAM I MAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS(LIST I NITIAL ENCOU NTER (' SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 10/26/2017 6/14/2017 10119/2017 63047 LAMINECTOMY, FACETECTOMY AND FORAM I NOTOMY S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 $2,160.00 FEMALE SPOUSE 1 BCC 3559 < (UNILATERAL OR BILATERAL WITH DE COMPRESSIONOF PARTSOFTHORAX, SPINAL CORD, CAUDA EQUINA AND /OR NERVE ROOTASA ", INITIAL ENCOUNTER AEG, SPINAL OR LATERAL RECESS STENOS I SA - ), SINGLE N VERTEBRAL SEGMENT; LUMBAR n C.7.f 10/26/2017 6/14/2017 10/19/2017 63048 LAM INECTO MY, FACETECTO MY AND FORAM IN OTO MV 5239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 $240.00 FEMALE SPOUSE 1 BCC 3559 (UNILATERAL OR BILATERAL WITH DE COMPRESSIONOF PARTS OF THORAX, SPINAL CORD, CAD DA EQU I NA AND /OR NERVE ROOT(S), I NITIAL ENCOU INTER (EG, SPINAL OR LATERAL RECESS STENOSISH, SINGLE N VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 10/26/2017 6/14/2017 10123/2017 22612 ARTHRDDESIS, POSTERIOR OR POSTEROLATERAL S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 $1,900.00 FEMALE SPOUSE 1 BCC 3559 "a TECHNIQUE, SINGLE LEVEL; LUMBAR (WITH LATERAL PARTS OF THORAX, TRANSVERSE TECHNIQUE, WHEN PERFORMED( I NITIAL ENCOU INTER 10/26/2017 6/14/2017 10/23/2017 22614 ARTHRDDESIS, POSTERIOR OR POSTEROLATERAL S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 $807.50 FEMALE SPOUSE 1BCC 3559 } TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL PARTS OF THORAX, SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR I NITIAL FLOOD INTER iL CL PRIMARY PROCEDURE) ¢, 10126/2017 6/14/2017 10/23/2017 22842 POSTERIOR SEGMENTAL INSTRUMENTATION(EG, PEDICLE S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 $1,425.00 FEMALE SPOUSE 1 BCC 3559 FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND PARTS OF THORAX, SUBLAM I MAR WIRES(; 3 TO 6 VERTEBRAL SEGMENTS(LIST I NITIAL ENCOU INTER SEPARATELY IN ADDITION TO CODE FOR PRIMARY rf w• PROCEDURE) 10/26/2017 6/14/2017 10/23/2017 63047 LAM INECTOMY, FACETECTOMY AND FORAM INOTOMV S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 $2,160.00 FEMALE SPOUSE 1 BCC 3559 (UNILATERAL OR BILATERAL WITH DE COMPRESSIONOF PARTS OF THORAX, LLJ SPINAL CORD, CAUDA EQUINA AND /OR NERVE ROOTASA ", INITIAL ENCOUNTER h AEG, SPINAL OR LATERAL RECESS STENOSISA "),SINGLE VERTEBRAL SEGMENT; LUMBAR 10/26/2017 6/14/2017 1OJ23/2017 63048 LAM INECTOMY, FACETECTOMY AND FORAM I NOTOMV S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 $240.00 FEMALE SPOUSE 1 FCC 3559 (UNILATERAL OR BILATERAL WITH DE COMPRESSIONOF PARTS OF THORAX, SPINAL CORD, CAD DA EQU I NA AND /OR NERVE ROOT(S), I NITIAL ENCOU INTER (EG, SPINAL OR LATERAL RECESS STENOSISH, SINGLE Q VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT, W CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) U`J O 11/3/2017 10/13/2017 10/31/2017 72100 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO M545 LOW BACK PAIN OTHER MEDICAL $29.77 $185.00 FEMALE SPOUSE 1BCC 3559 OR THREE VIEWS LLJ 11/6/2017 6/14/2017 10/19/2017 22612 ARTHRDDESIS, POSTERIOR OR POSTEROLATERAL S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 ($1.,900.00) FEMALE SPOUSE 1 BCC 3559 TECHNIQUE, SINGLE LEVEL; LUMBAR (WITH LATERAL PARTS OF THORAX, TRANSVERSE TECHNIQUE, WHEN PERFORMED) I NITIAL ENCOU INTER J 11/6/2017 6/14/2017 10/19/2017 22614 ARTHRDDESIS, POSTERIOR OR POSTEROLATERAL S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 ($807.50) FEMALE SPOUSE 1 BCC 3559 v TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL PARTS OF THORAX, SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR I NITIAL ENCOU INTER PRIMARY PROCEDURE) IFLJ 11/6/2017 6/14/2017 10/19/2017 22842 POSTERIOR SEGMENTAL INSTRUMENTATION EEG, PEDICLE S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 ($1,425.00) FEMALE SPOUSE 1 BCC 3559 FIXATION, DUAL RODS WITH MULTIPLE HOOKSAND PARTS OF THORAX, SUBLAM I MAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS(LIST I NITIAL ENCOU INTER (' SEPARATELY IN ADDITION TO CODE FOR PRIMARY `Q PROCEDURE) 11/6/2017 6/14/2017 10119/2017 63047 LAM INECTOMY, FACETECTOMY AND FORAM I NOTOMV S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 ($2.160.001 FEMALE SPOUSE 1 BCC 3559 < Q (UNILATERAL OR BIA TERALWITH DECOMPRESSION OF PARTS OFTHORAX, SPINALCORD, CAUDA EQUINAAND /OR NERVE ROOTASA ", INITIAL ENCOUNTER AEG, SPINAL OR LATERAL RECESS STENOS I SA - ), SINGLE N VERTEBRAL SEGMENT; LUMBAR n C.7.f 11/6/2017 6/14/2017 10/19/2017 63048 LAM I NECTOMY, FACETECTO MY AND FORAM IN OTO MV 5239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $0.00 (.$240.00) FEMALE SPOUSE 1 BCC 3559 (UNILATERAL OR BILATERALWITH DECOMPRESSION OF PARTS OF THORAX, y SPINAL CORD, CAD DA EQU I NA AND /OR NERVE ROOT(S), I NITIAL ENCOU INTER (EG, SPINAL OR LATERAL RECESS STENOSISH, SINGLE N VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 11/6/2017 6/14/2017 11/3/2017 22612 ARTHRDDESIS, POSTERIOR OR POSTEROLATERAL S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $275.60 $1,900.00 FEMALE SPOUSE 1 BCC 3559 TECHNIQUE, SINGLE LEVEL; LUMBAR (WITH LATERAL PARTS OF THORAX, TRANSVERSE TECHNIQUE, WHEN PERFORMED( I NITIAL ENCOU INTER 11/6/2017 6/14/2017 11/3/2017 22614 ARTHRDDESIS, POSTERIOR OR POSTEROLATERAL S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $6937 $807.50 FEMALE SPOUSE 1BCC 3559 } TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL PARTS OF THORAX, SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR I NITIAL FLOOD NTER iL CL PRIMARY PROCEDURE) ¢, 11/6/2017 6/14/2017 11/3/2017 22842 POSTERIOR SEGMENTAL INSTRUMENTATION(EG, PEDICLE S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $135.74 $1,425.00 FEMALE SPOUSE 1 BCC 3559 FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND PARTS OF THORAX, SUBLAM I MAR WIRES(; 3 TO 6 VERTEBRAL SEGMENTS(LIST I NITIAL ENCOU INTER SEPARATELY IN ADDITION TO CODE FOR PRIMARY rf w• PROCEDURE) 11/6/2017 6/14/2017 11/3/2017 63047 LAM INECTOMY, FACETECTOMY AND FORAM INOTOMV S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $96.28 $2,160.00 FEMALE SPOUSE 1 BCC 3559 (UNILATERAL OR BILATERAL WITH DE COMPRESSIONOF PARTS OF THORAX, LLJ ", h SPINAL CORD, CAUCA EQUINA AND /OR NERVE ROOTASA INITIAL ENCOUNTER AEG, SPINAL OR LATERAL RECESS STENOSISA "),SINGLE VERTEBRAL SEGMENT; LUMBAR 11/6/2017 6/14/2017 11/3/2017 63048 LAM INECTOMY, FACETECTOMY AND FORAM I NOTOMV S239XXA SPRAIN OF UNSPECIFIED OTHER MEDICAL $37.68 $240.00 FEMALE SPOUSE 1 BCC 3559 (UNILATERAL OR BILATERAL WITH DECOMPRESSIONOF PARTS OF THORAX, SPINAL CORD, CAD DA EQU I NA AND /OR NERVE ROOT(S), I NITIAL ENCOU INTER (EG, SPINAL OR LATERAL RECESS STENOSISH, SINGLE Q VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT, W CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) U`J O 11121/2017 10/24/2017 11/20/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $28.21 $90.00 FEMALE SPOUSE 1 BCC 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP IELJ STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY Q . 11/21/2017 10/24/2017 1112012017 97140 MANUAL THERAPY TECHNIQUES LEG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $60.00 FEMALE SPOUSE 1 BCC 3559 J MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), LOB MORE REGIONS, EACH 15 v MINUTES 11/21/2017 10/24/2017 11/20/2017 97161 Physicaltherapy evaluation: low com plexitV, requiring M545 LOW BACK PAIN OTHER MEDICAL $46.05 $179.00 FEMALE SPOUSE 1 BCC 3559 these components: A history with no personal factors W and /or comorbidities that impact the plan of 11/21/2017 10/27/2017 1112012017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $47.01 $135.00 FEMALE SPOUSE 1 BCC 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP Q STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY „p 11/21/2017 10/27/2017 11120/2017 97140 MANUAL THERAPY TECHNIQUES( EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $60.00 FEMALE SPOUSE 1 BCC 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, N MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 N MINUTES = 11/21/2017 10/30/2017 1112012017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $47.01 $135.00 FEMALE SPOUSE 1 BCC 3559 y MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND ._ FLEXIBILITY 2 11/21/2017 10/30/2017 1112012017 97140 MANUAL THERAPY TECH N I QUES (EG, MOBILIZATION/ N1545 LOW BACK PAIN OTHER MEDICAL $13.34 $60.00 FEMALE SPOUSE 1 BCC MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), FOR MORE REGIONS, EACH 15 MINUTES 11/30/2017 11/1/2017 11/29/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $47.01 $135.00 FEMALE SPOUSE 1 BCC MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/30/2017 11/1/2017 11/29/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $1334 $60.00 FEMALE SPOUSE 1 BCC MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), FOR MORE REGIONS, EACH 15 MINUTES 11/30/2017 11/6/2017 11/29/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $47.01 $135.00 FEMALE SPOUSE I BCC MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 1113012017 11/6/2017 11/29/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $60.00 FEMALE SPOUSE 1 BCC MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), FOR MORE REGIONS, EACH 15 MINUTES 11/30/2017 11/8/2017 11/29/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $47.01 $135.00 FEMALE SPOUSE 1 BCC MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/30/2017 11/8/2017 11/29/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $60.00 FEMALE SPOUSE 1 BCC MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 11/30/2017 11/10/2017 11/29/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $47.01 $135.00 FEMALE SPOUSE 1 BCC MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/30/2017 11/10/2017 11/29/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $1334 $60.00 FEMALE SPOUSE 1 BCC MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), FOR MORE REGIONS, EACH 15 MINUTES 11/30/2017 11/13/2017 11/29/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $47.01 $135.00 FEMALE SPOUSE 1 BCC MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/30/2017 11/13/2017 11/29/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $60.00 FEMALE SPOUSE 1 BCC MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), FOR MORE REGIONS, EACH 15 MINUTES 11/30/2017 11/15/2017 11/29/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $47.01 $135.00 FEMALE SPOUSE 1 BCC MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/30/2017 11/15/2017 11/29/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $1334 $60.00 FEMALE SPOUSE 1 BCC MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), FOR MORE REGIONS, EACH 15 MINUTES 12/4/2017 11/27/2017 12/1/2017 99214 OFFICE DR OTHER OUTPATIENT VISIT FOR THE S239XXA SPRAIN OF UNSPECIFIED PROFESSIONAL OFFICE $89.36 $463.00 FEMALE SPOUSE 1BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED PARTS OF THORAX, PATIENT, WH ICH REQUIRES AT LEAST 20F THESE 3 KEY I NITIAL ENCOU NTER COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/11/2017 12/6/2017 12/8/2017 * * * ** * " * ** * * * ** ' * * ** * " * ** $131.64 $430.00 FEMALE SPOUSE 1 BCC SUb T—I $64,875.31 $228,216.68 3.5E +10 1/9/2017 12/13/2016 1212112016 17000 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, L570 ACTIN I C KERATOSIS PROFESSIONAL OFFICE $0.00 CRYOSURGERY, CHEMOSURGERY, SURGICAL SUBSCRIBER 1 BCC 3559 $0.00 CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC SUBSCRIBER 1 BCC 3559 $0.00 KERATOSES(; FIRST LESION SUBSCRIBER 1 BCC 3559 1/9/2017 12/13/2016 12/21/2016 17003 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, L570 ACTINIC KERATOSIS PROFESSIONAL OFFICE CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), ALL BENIGN OR PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES) OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION) 1/9/2017 12/13/2016 12/21/2016 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L570 ACTINIC KERATOSIS PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 1/11/2017 12/22/2016 12/31/2016 72100 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO M545 LOW BACK PAIN PROFESSIONAL OFFICE ORTHREE VIEWS 1/23/2017 12/22/2016 1/9/2017 .2140FFICEDRDTHEROUTPATIENT VISITFDRTHE M4806 SPINALSTENOSIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LUMBAR REGION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 1/24/2017 12/22/2016 1/9/2017 99203 OFFICE DR OTHER OUTPATIENT VISIT FOR THE M4316 SPONDYLOLISTHESIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, LUMBAR REGION WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE P 3/7/2017 2/2/2017 2/23/2017 99213 OFFICE DR OTHER OUTPATIENT VISIT FOR THE M4316 SPONDYLOLISTHESIS, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LUMBAR REGION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORO 3/8/2017 2/20/2017 2124/2017 1036F CURRENTTDBACCO NON - USER (CAD, CAP, CORD, PV( H01001 UNSPECIFIED BLEPHARITIS PROFESSIONAL (DM) (IBM RIGHT UPPER EYELID OUTPATIENT /HOSPITAL 3/8/2017 2/20/2017 2/24/2017 92012 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H01001 UNSPECIFIED BLEPHARITIS PROFESSIONAL AND EVALUATION, WITH INITIATION OR CONTINUATION RIGHT UPPER EYELID OUTPATIENT /HOSPITAL OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT 3/8/2017 2/20/2017 2/24/2017 68427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN HO1001 UNSPECIFIED BLEPHARITIS PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR RIGHT UPPER EYELID OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS 3/8/2017 2/20/2017 2/24/2017 68732 NO DOCUMENTATION OF PAIN ASSESSMENT H01001 UNSPECIFIED BLEPHARITIS PROFESSIONAL RIGHT UPPER EYELID OUTPATIENT /HOSPITAL $79.68 $135.00 MALE SUBSCRIBER 1 BCC $83.16 $209.00 MALE SUBSCRIBER 1 BCC $46.06 $117.00 MALE SUBSCRIBER 1 BCC $436.50 $970.00 MALE SUBSCRIBER 1 BCC $70.18 $346.00 MALE SUBSCRIBER 1 BCC $72.40 $476.00 MALE SUBSCRIBER 1 BCC $38.86 $316.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 KibSl Em I mw m a $0.00 $0.01 MALE SUBSCRIBER 1 BCC 3559 $0.00 $194.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $0.01 MALE SUBSCRIBER 1 BCC 3559 $0.00 $0.01 MALE SUBSCRIBER 1 BCC 3559 C.7.f 3/20/2017 3/3/2017 3/6/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, R05 COUGH PROFESSIONAL $0.00 $67.00 MALE SUBSCRIBER 1 BCC 3559 FRONTAL AND LATERAL; OUTPATIENT /HOSPITAL Z 3/21/2017 3/3/2017 3/8/2017 - - Z01810 ENCOUNTER FOR HOSPITAL OUTPATIENT $1,055.31 $2,290.00 MALE SUBSCRIBER 1 BCC 3559 N PREPROCEDURAL OR CARDIOVASCULAR EXAMINATION 3/24/2017 3/2/2017 3/14/2017 93000 ELECTROCARDIOGRAM , ROUTINE ECG WITHATLEAST12 M4316 SPONDYLOUSTHESIS, PROFESSIONAL OFFICE $12.86 $75.00 MALE SUBSCRIBER 1 BCC 3559 LEADS; WITH INTERPRETATION AND REPORT LUMBAR REGION } 3/24/2017 31 3/14/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M4316 SPONDYLOLISTHESIS, PROFESSIONAL OFFICE $85.14 $185.00 MALE SUBSCRIBER 1BUG 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED LUMBAR REGION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED } > EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR N. CL COORDINATION OF CARE WITH OTHER Q, Q 3/30/2017 3/14/2017 3/16/2017 17000 DESTRUCTION LEG, LASER SURGERY, ELECTROSURGERY, L814 OTHER MELANIN PROFESSIONAL OFFICE $79.68 $135.00 MALE SUBSCRIBER 1 BCC 3559 v CRYOSURGERY, CHEMOSURGERY, SURGICAL HYPERPIGMENTATION CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC rf KERATOSES(; FIRST LESION F 3/30/2017 3/14/2017 3/16/2017 17003 DESTRUCTION LEG, LASER SURGERY, ELECTROSURGERY, L814 OTHER MELANIN PROFESSIONAL OFFICE $22.68 $57.00 MALE SUBSCRIBER 1 BCC 3559 Ljj ~ CRYOSURGERY, CHEMOSURGERY, SURGICAL HYPERPIGMENTATION CURETTEMENT), ALL BENIGN OR PREMALIGNANT LESIONS LEG, ACTINIC KERATDSES) OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; _ SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION) O IL 3/30/2017 3/14/2017 3/16/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L814 OTHER MELANIN PROFESSIONAL OFFICE $46.06 $117.00 MALE SUBSCRIBER 1BCC 3559 {j EVALUATION AND MANAGEMENTOFAN ESTABLISHED HYPERPIGMENTATION PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY UJ COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY, COUNSELING AND COORD LLJ 0 4/5/2017 3/15/2017 3/21/2017 72100 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO N14310 SPONDYLOUSTHESIS, SITE PROFESSIONAL $15.61 $61.00 MALE SUBSCRIBER 1 BCC 3559 �p ORTHREEVIEWS UNSPECIFIED INPATIENT /HOSPITAL J 4/5/2017 3/15/2017 3/22/2017 630 ANESTHESIA FOR PROCEDURES IN LUMBAR REGION; NOT M4316 SPONDYLOUSTHESIS, OTHER MEDICAL $2,936.67 $6,426.00 MALE SUBSCRIBER 1 BCC 3559 OTHERWISE SPECIFIED LUMBAR REGION v 4/5/2017 3/15/2017 3/22/2017 99100 ANESTHESIA FOR PATIENT OF EXTREME AGE, UNDER ONE M4316 SPONDYLOLISTHESIS, OTHER MEDICAL $0.00 $238.00 MALE SUBSCRIBER 1BCC 3559 YEAR ANDOVER SEVENTY (LIST SEPARATELY INADDITION LUMBAR REGION TO CODE FOR PRIMARY ANESTHESIA PROCEDURE( LLJ 41712017 3/15/2017 3/24/2017 - - M4316 SPONDYLOUSTHESIS, HOSPITAL INPATIENT 3/15/2017 # # # # # # ## $89,601.63 $146,034.00 MALE SUBSCRIBER 1 BCC 3559 LUMBAR REGION 4/17/2017 3/15/2017 4/3/2017 88304 LEVEL III- SURGICAL PATHOLOGY, GROSS AND M4316 SPONDYLOUSTHESIS, PROFESSIONAL $42.48 $203.00 MALE SUBSCRIBER 1 BCC 3559 Q MICROSCOPIC EXAMINATION ABORTION, INDUCED, LUMBAR REGION INPATIENT / HDSPITAL ABSCESS, ANEURYSM - ARTERIAL/VENTRICULAR, ANUS, Q TAG, APPENDIX, OTHER THAN INCIDENTAL, ARTERY, ATHEROMATOUS PLAQUE, BARTHOLIN'S GLAND CYST, Cy BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE, BURSA /SYNOVIAL C 4/24/2017 3/15/2017 411112017 20936 AUTO6 RAFT FOR SPINE SURGERY ONLY (INCLUDES M4806 SPINAL STENOSIS, PROFESSIONAL $0.00 $950.00 MALE SUBSCRIBER 1 BCC 3559 HARVESTING THE GRAFT); LOCAL(EG, RIBS,SPINOUS LUMBAR REGION INPATIENT /HOSPITAL ._ PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE _ FOR PRIMARY PROCEDURE( C.7.f 4/24/2017 3/15/2017 411112017 22633 ARTHRODESIS, COMBINED POSTERIOR OR M4806 SPINAL STENOSIS, PROFESSIONAL $2,239.88 $9,612.00 MALE SUBSCRIBER 1BCC 3559 POSTEROLATERAL TECHNIQUE WITH POSTERIOR LUMBAR REGION INPATIENT /HOSPITAL INTERBODY TECHNIQUE INCLUDING LAMINECTOMY Z AND /OR DISCECTOMY SUFFICIENTTO PREPARE N INTERSPACE (DTHERTHAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; LUMBAR tu 4/24/2017 3/15/2017 4/11/2017 22840 POSTERIOR NON - SEGMENTAL INSTRUMENTATION(EG, M4806 SPINALSTENOSIS, PROFESSIONAL $864.30 $4,030.00 MALE SUBSCRIBER 1 BCC 3559 HARRINGTON RODTECHNIQUE, PEDICLE FIXATION LUMBAR REGION INPATIENT /HOSPITAL ACROSS ONE INTERSPACE, ATIANTDAXIAL } TRANSARTICUTAR SCREW FIXATION, SUBIAMINAR "a WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY FROG 4/24/2017 3/15/2017 4/11/2017 22853 Insertion of interbody biomechanical device(s) Peg, M48D6 SPINAL STENOSIS, PROFESSIONAL $316.62 $1,404.00 MALE SUBSCRIBER 1 BCC 3SS9 > } synthetic cage, mesh) with integral anterior LUMBAR REGION INPATIENT /HOSPITAL Q instrumentation for device anchoring (dg, screws, flanges), L CL CL 4124/2017 3/15/2017 4/11/2017 61783 Stereatactic computer- assisted( navigati ona l) procedure; M4806 SPINAL STENOSIS, PROFESSIONAL $316.05 $1,276.00 MALE SUBSCRIBER 1BOG 3559 spiral (Let separately in addition to code for primary LUMBAR REGION INPATIENT /HOSPITAL v procedure) 5/9/2017 3/15/2017 5/4/2017 51785 NEEDLE ELECTROMYOGRAPHY STUDIES(EMG) OF ANAL M4316 SPONDYLOUSTHESIS, PROFESSIONAL $136.97 $498.00 MALE SUBSCRIBER 1 BCC 3559 ® y OR URETHRAL SPHINCTER, ANY TECHNIQUE LUMBAR REGION INPATIENT /HOSPITAL 5/9/2017 3/15/2017 5/4/2017 95870 NEEDLE ELECTROMYOGRAPHY; LIMITED STUDY OF M4316 SPONDYLOUSTHESIS, PROFESSIONAL $65.50 $1,222.00 MALE SUBSCRIBER 1 BCC 3559 MUSCLES IN 1 EXTREMITY OR NON -LIMB (AXIAL) MUSCLES LUMBAR REGION INPATIENT /HOSPITAL Lai (UNILATERAL OR BILATERAL), OTHER THAN THORACIC ~ PARASPINAL, CRANIAL NERVE SUPPLIED MUSCLES, OR 5/9/2017 3/15/2017 5/4/2017 SPHINCTERS 95938 SHORT - LATENCY SOMATOSENSORY EVOKED POTENTIAL M4316 SPONDYLOUSTHESIS, PROFESSIONAL $0.00 $1,068.00 MALE SUBSCRIBER 1 BCC 3559 _ STUDY, STIMULATION OF ANY /ALL PERIPHERAL NERVES LUMBAR REGION INPATIENT /HDSPITAL OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER AND LOWER LIMBS IL 5/9/2017 3/15/2017 5/4/2017 95941 CONTINUOUS INTRAOPERATIVE NEUROPHYSIOLOGY M4316 SPONDYLOUSTHESIS, PROFESSIONAL $4,754.24 $4,716.00 MALE SUBSCRIBER 1 BCC 3559 {JU MONITORING, FROM OUTSIDETHE OPERATING ROOM LUMBAR REGION INPATIENT /HOSPITAL (REMOTE DR NEARBY) OR FOR MONITORING OF MORE UJ THAN ONE CASE WHILE IN THE OPERATING ROOM, PER HOUR (LIST SEPARATELY 5/23/2017 5/1/2017 5/4/2017 - - Z139 ENCOUNTER FOR HOSPITAL OUTPATIENT $3,081.00 $4,108.00 MALE SUBSCRIBER 1 BCC 3559 ILLJ SCREENING, UNSPECIFIED 6/12/2017 3/15/2017 5/4/2017 51785 NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL M4316 SPONDYLOUSTHESIS, PROFESSIONAL ($136,97) (5493,00) MALE SUBSCRIBER 1 BCC 3559 OR URETHRAL SPHINCTER, ANY TECHNIQUE LUMBAR REGION INPATIENT/HOSPITAL 6/12/2017 3/15/2017 5/4/2017 95870 NEEDLE ELECTROMYOGRAPHY; LIMITED STUDY OF M4316 SPONDYLOLISTHESIS, PROFESSIONAL ($65301 ($1,222.00% MALE SUBSCRIBER 1 BCC 3559 V MUSCLES IN 1 EXTREMITYOR NON -LIMB (AXIAL) MUSCLES LUMBAR REGION INPATIENT /HOSPITAL r (UNILATERAL OR BILATERAL), OTHER THAN THORACIC PARASPINAL, CRANIAL NERVE SUPPLIED MUSCLES, OR LLJ SPHINCTERS 6/12/2017 3/15/2017 5/4/2017 95938 SHORT - LATENCY SOMATOSENSORY EVOKED POTENTIAL M4316 SPONDYLOUSTHESIS, PROFESSIONAL $0.00 ($1,058.00) MALE SUBSCRIBER 1 BCC 3559 STUDY, STIMULATION OF ANY /ALL PERIPHERAL NERVES LUMBAR REGION INPATIENT /HDSPITAL 0 OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS F SYSTEM; IN UPPER AND LOWER LIMBS 6/12/2017 3/15/2017 5/4/2017 95941 CONTINUOUS INTRAOPERATIVE NEUROPHYSIOLOGY M4316 SPONDYLOUSTHESIS, PROFESSIONAL ($4,754.24) (;4,716.00] MALE SUBSCRIBER 1 BCC 3559 N MONITORING, FROM OUTSIDE THE OPERATING ROOM LUMBAR REGION INPATIENT /HOSPITAL N (REMOTE OR NEARBY) OR FOR MONITORING OF MORE THAN ONE CASE WHILE IN THE OPERATING ROOM, PER = HOUR (LIST SEPARATELY E 6/12/2017 3/15/2017 6/9/2017 51785 NEEDLE ELECTROMYOGRAPHY STUDIES (EMIG) OF ANAL N14316 SPONDYLOUSTHESIS, PROFESSIONAL $136.97 $498.00 MALE SUBSCRIBER 1 BCC 3559 ._ OR URETHRAL SPHINCTER, ANY TECHNIQUE LUMBAR REGION INPATIENT /HOSPITAL 0 C.7.f 6/12/2017 3/15/2017 6/9/2017 95870 NEEDLE ELECTROMYOG RAP HY; LIMITED STUDY OF M4316 SPONDYLOUSTHESIS, PROFESSIONAL $65.50 $1,222.00 MALE SUBSCRIBER 1 BCC 3559 MUSCLESIN I EXTREMITYOR NON- LIMB(AXIAL) MUSCLES LUMBAR REGION INPATIENT /HOSPITAL (UNILATERAL OR BILATERAL), OTHER THAN THORACIC �1 PARASPINAL, CRANIAL NERVE SUPPLIED MUSCLES, OR N SPHINCTERS 6/12/2017 3/15/2017 6/9/2017 95938 SHORT LATENCY SOMATOSENSORY EVOKED POTENTIAL M4316 SPONDYLOUSTHESIS, PROFESSIONAL $56.83 $1,068.00 MALE SUBSCRIBER 1 BCC 3559 STUDY, STIMULATION OF ANY /ALL PERIPHERAL NERVES LUMBAR REGION INPATIENT /HOSPITAL DR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER AND LOWER LIMBS } 6/12/2017 3/15/2017 6/9/2017 95941 CONTINUOUS INTRAOPERATIVE NEUROPHYSIOLOGY M4316 SPONDYLOLISTHESIS, PROFESSIONAL $4,779.72 $4,716.00 MALE SUBSCRIBER 1 BCC 3559 MONITORING, FROM OUTSIDETHE OPERATING ROOM LUMBAR REGION INPATIENT /HOSPITAL (REMOTE DR NEARBY) OR FOR MONITORING OF MORE THAN ONE CASE WHILE IN THE OPERATING ROOM, PER } HOUR (LIST SEPARATELY {j CL s. 6/13/2017 5/18/2017 5/26/2017 72100 RADIDLOGIC EXAMINATION, SPINE, LUMBOSACRAL;TWO M545 LOW BACK PAIN PROFESSIONAL OFFICE $582.00 $970.00 MALE SUBSCRIBER 1BCC 3559 Q, OR THREE VIEWS 10/2/2017 9/26/2017 9/28/2017 17000 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, L570 ACTINIC KERATOSIS PROFESSIONAL OFFICE $79.68 $135.00 MALE SUBSCRIBER 1 BCC 3559 CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION F 10/2/2017 9/26/2017 9/28/2017 17003 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, L570 ACTINIC KERATOSIS PROFESSIONAL OFFICE $15.12 $38.00 MALE SUBSCRIBER 1 BCC 3559 LL! ~ CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), ALL BENIGN OR PREMALIGNANT LESIONS (EG, ACTINIC KERATDSES) OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; _ SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION) O IL 101 9/26/2017 9/28/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L570 ACTINIC KERATOSIS PROFESSIONAL OFFICE $71.06 $117.00 MALE SUBSCRIBER 1 BCC 3559 {i EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY UJ COMPONENTS: AN EXPANDED PROBLEM FOCUSED cn HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD LLJ 0 1012712017 10/23/2017 10/25/2017 99397 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z0000 ENCOUNTER FOR PROFESSIONAL OFFICE $129.18 $250.00 MALE SUBSCRIBER 1 BCC 3559 REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL GENERAL ADULT MEDICAL J INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS v GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE DRDERING OF LABDRATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; 65 YEARS AND LLJ OLDER 12/8/2017 11/20/2017 11/27/2017 - - 16529 OCCLUSION AND HOSPITAL OUTPATIENT $1,989.00 $2,652.00 MALE SUBSCRIBER 1 BCC 3559 STENOSIS OF UNSPECIFIED �y CAROTID ARTERY F 12/11/2017 11/20/2017 11/28/2017 93880 DUPLEXSCAN OF EXTRACRANIAL ARTERIES; COMPLETE 1672 CEREBRAL PROFESSIONAL $52.92 $118.00 MALE SUBSCRIBER 1 BCC 3559 BILATERALSTUDY ATHEROSCLEROSIS OUTPATIENT/HOSPITAL N SUB Total $109,500.79 $191,815.03 = 3.875E +10 1/10/2017 11/18/2016 11/23/2016 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $45,378.00 $60,504.00 FEMALE SUBSCRIBER 1 BCC 3559 y ANTINEOPLASTIC CHEMOTHERAPY .0 1/10/2017 12/29/2016 1/7/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; R05 COUGH PROFESSIONAL OFFICE $76.83 $184.00 FEMALE SUBSCRIBER 1 BCC 3559 �, C.7.f 111012017 12/29/2016 1/7/2017 94640 NONPRESSURIZED INHALATION TREATMENT FOR ACUTE R05 COUGH PROFESSIONAL OFFICE $51.22 $93.00 FEMALE SUBSCRIBER 1 BCC 3559 AIRWAY OBSTRUCTION 1/10/2017 12/29/2016 1/7/2017 96372 Therapeutic, prophylactic, o,di,gnostic injection (specify R05 COUGH PROFESSIONAL OFFICE $69.94 $75.00 FEMALE SUBSCRIBER 1 BCC 3559 substance or drug); subcutaneous or Intramuscular 111012017 12/29/2016 1/7/2017 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R05 COUGH PROFESSIONAL OFFICE $303.44 $300.00 FEMALE SUBSCRIBER 1 BCC 3559 EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY CDMPDNENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE P 1/10/2017 12/29/2016 1/7/2017 J0696 INJECTION, CEFTRIAXONE SODIUM, PER 250 MG RES COUGH PROFESSIONAL OFFICE $152.00 $152.00 FEMALE SUBSCRIBER 1BOO 3SS9 1/10/2017 12/29/2016 1/7/2017 J7620 ALBUTEROL, UP T02.5 MG AND IPRATROPIUM BROMIDE, R05 COUGH PROFESSIONAL OFFICE $33.00 $33.00 FEMALE SUBSCRIBER 1BCC 3559 UP TO 0.5 MG, FDA - APPROVED 1123/2017 12/2/2016 12/9/2016 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $45,513.75 $60,685.00 FEMALE SUBSCRIBER 1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 1/23/2017 12/2/2016 12/9/2016 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT (s 1 ]37.5) 5f ti85.00) FEMALE SUBSCRIBER 1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 1/30/2017 1/10/2017 1/13/2017 * * * ** * * *'* * * * ** ' * * ** * * * *' $106.61 $259.00 FEMALE SUBSCRIBER 1 BCC 3559 1/31/2017 1/6/2017 111212017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $40,295.92 $62,789.00 FEMALE SUBSCRIBER 1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 1/31/2017 1/20/2017 1/26/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $45,046.11 $60,482.00 FEMALE SUBSCRIBER 1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 3/2/2017 2/9/2017 2/15/2017 * * * "" * * * ** *• " ** w * * ** * * * ** $131.61 $259.00 FEMALE SUBSCRIBER 1 BCC 3559 3/13/2017 2/17/2017 2127/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $0.00 $60,482.00 FEMALE SUBSCRIBER 1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 3/14/2017 2/17/2017 2/27/2017 - - 25111 ENCOUNTER FOR HOSPITAL OUTPATIENT $45,361.50 $60,482.00 FEMALE SUBSCRIBER 1 BCC 3SS9 ANTINEOPLASTIC CHEMOTHERAPY 3115/2017 2/3/2017 2/9/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $45,497.25 $60,66100 FEMALE SUBSCRIBER 1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 3/20/2017 3/3/2017 3/9/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $45,497.25 $60,663.00 FEMALE SUBSCRIBER 1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 4/5/2017 3/27/2017 4/3/2017 - - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $3,636.75 $4,849.00 FEMALE SUBSCRIBER 1 BCC 3559 OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS ORLUNG 4/6/2017 3/27/2017 4/4/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST C3490 MALIGNANT NEOPLASM PROFESSIONAL $107.49 $383.00 FEMALE SUBSCRIBER 1 BCC 3559 MATERIAL(S) OF UNSPECIFIED PART OF OUTPATIENT /HOSPITAL UNSPECIFIED BRONCHUS ORLUNG 4/7/2017 3/17/2017 3/29/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $45,361.50 $60,482.00 FEMALE SUBSCRIBER 1 BCC 3559 ANTINEOPLASTIC CHEMOTHERAPY 4/14/2017 4/5/2017 4/13/2017 93978 DUPLEXSCAN OFAORTA, INFERIOR VENA CAVA, ILIAC 1728 ANEURYSM OFOTHER PROFESSIONAL OFFICE $189.52 $512.08 FEMALE SUBSCRIBER 1 BCC 3559 VASCULATURE,OR BYPASS GRAFTS; COMPLETE STUDY SPECIFIED ARTERIES 4/14/2017 4/5/2017 4/13/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1728 ANEURYSM OF OTHER PROFESSIONAL OFFICE 1 BCC $45,361.50 $60,48100 FEMALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC SPECIFIED ARTERIES $60,665.00 FEMALE SUBSCRIBER 1 BCC $808.20 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SUBSCRIBER 1 BCC $94.49 $258.00 FEMALE SUBSCRIBER 1 BCC COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/17/2017 3/16/2017 4/13/2017- - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS ORLUNG 4/21/2017 3/31/2017 4/6/2017- - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 5/4/2017 4/14/2017 4/20/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 5/17/2017 4/28/2017 5/8/2017 - - 201812 ENCOUNTER FOR HOSPITAL OUTPATIENT PREPROCEOURAL LABORATORY EXAMINATION 5/18/2017 5/4/2017 5/16/2017 * * " ** * * *'* * * * ** ' * * ** * * * *' 5/25/2017 3/16/2017 5/23/2017 99214 OFFICE OR OTHER 0UTPATIENTVISIT FOR THE C3490 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF UNSPECIFIED PART OF OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY UNSPECIFIED BRONCHUS COMPONENTS: A DETAILED HISTORY; A DETAILED ORLUNG EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5/25/2017 4/5/2017 5/23/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C3490 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF UNSPECIFIED PART OF OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY UNSPECIFIED BRONCHUS COMPONENTS: A DETAILED HISTORY; A DETAILED OR LUNG EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5/25/2017 5/12/2017 5/23/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 5/30/2017 5/25/2017 5/29/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT R42 DIZZINESSANO GIDDINESS PROFESSIONAL CONTRAST MATERIAL OUTPATIENT/HOSPITAL 5/30/2017 5/25/2017 5/29/2017 71010 RADI0L0GIC EXAMINATION, CHEST; SINGLE VIEW, R42 DIZZINESS AND GIDDINESS PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 6/5/2017 5/25/2017 6/1/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 H8111 BENIGN PAROXYSMAL PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY VERTIGO, RIGHT EAR OUTPATIENT /HOSPITAL 6/5/2017 5/25/2017 6/1/2017 99285 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION H8111 BENIGN PAROXYSMAL PROFESSIONAL AND MANAGEMENTOF A PATIENT, WHICH REQUIRES VERTIGO, RIGHT EAR OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF TH E PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DEC15 6/5/2017 5/25/2017 6/1/2017 - - H8111 BENIGN PAROXYSMAL HOSPITAL OUTPATIENT VERTIGO, RIGHT EAR $124.69 $289.55 FEMALE SUBSCRIBER 1 BCC $273.00 $455.00 FEMALE SUBSCRIBER 1 BCC $46,884.75 $62,513.00 FEMALE SUBSCRIBER 1 BCC $45,361.50 $60,48100 FEMALE SUBSCRIBER 1 BCC $45,498.75 $60,665.00 FEMALE SUBSCRIBER 1 BCC $808.20 $1,347.00 FEMALE SUBSCRIBER 1 BCC $94.49 $258.00 FEMALE SUBSCRIBER 1 BCC $9449 $258.00 FEMALE SUBSCRIBER 1 BCC $1,153.50 $1,538.00 FEMALE SUBSCRIBER 1 BCC $73.20 $322.00 FEMALE SUBSCRIBER 1 BCC $15.65 $58.00 FEMALE SUBSCRIBER 1 BCC $0.00 $35.00 FEMALE SUBSCRIBER 1 BCC $268.82 $665.00 FEMALE SUBSCRIBER 1 BCC $6,615.75 $8,821.00 FEMALE SUBSCRIBER 1 BCC C.7.f 3559 ®' 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 gm 6/8/2017 5/26/2017 6/1/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $44,727.00 $59,636.00 FEMALE SUBSCRIBER 1 BCC 1 BCC ANTINEOPLASTIC VERTIGO, UNSPECIFIED CHEMOTHERAPY EAR 6/8/2017 6/5/2017 6/7/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H8110 BENIGN PAROXYSMAL PROFESSIONAL OFFICE $120.06 $255.00 FEMALE SUBSCRIBER 1BCC $164.40 $274.00 FEMALE SUBSCRIBER EVALUATION AND MANAGEMENTOFAN ESTABLISHED VERTIGO, UNSPECIFIED OF UNSPECIFIED PART OF PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY EAR UNSPECIFIED BRONCHUS COMPONENTS: A DETAILED HISTORY; A DETAILED ORLUNG EXAMINATION; MEDICAL DECISION MAKING OF 7/24/2017 7/12/2017 7/21/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C3411 MALIGNANT NEOPLASM MODERATE COMPLEXITY. COUNSELING AND /OR $94.49 $258.00 FEMALE SUBSCRIBER 1BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED COORDINATION OF CARE WITH OTHER OUTPATIENT /HOSPITAL 6/12/2017 4/5/2017 6/9/2017 - - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $164.40 $274.00 FEMALE SUBSCRIBER 1 BCC COMPONENTS: A DETAILED HISTORY; A DETAILED OF UNSPECIFIED PART OF EXAMINATION; MEDICAL DECISION MAKING OF UNSPECIFIED BRONCHUS GRILLING 6119/2017 6/8/2017 6/15/2017 - - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $676.50 $902.00 FEMALE SUBSCRIBER 1 BCC 7/25/2017 OF UNSPECIFIED PART OF 7/17/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $50,052.75 $66,737.00 FEMALE SUBSCRIBER 1 BCC UNSPECIFIED BRONCHUS ANTINEOPLASTIC GRILLING 6/23/2017 6/9/2017 6/21/2017 - - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $164.40 $274.00 FEMALE SUBSCRIBER 1 BCC - Z5111 ENCOUNTERFOR HOSPITAL OUTPATIENT $50,384.25 OF UNSPECIFIED PART OF SUBSCRIBER 1 BCC ANTINEOPLASTIC UNSPECIFIED BRONCHUS CHEMOTHERAPY GRILLING 6/27/2017 6/9/2017 6/16/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $44,727.00 $59,636.00 FEMALE SUBSCRIBER 1 BCC 1 BCC ANTINEOPLASTIC ANTINEOPLASTIC CHEMOTHERAPY CHEMOTHERAPY 7/10/2017 6/9/2017 7/6/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C3411 MALIGNANT NEOPLASM PROFESSIONAL $9449 $258.00 FEMALE SUBSCRIBER 1BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF UPPER LOBE, RIGHT OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY BRONCHUS OR LUNG COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY, COUNSELING AND /DR COORDINATION OF CARE WITH OTHER 7/14/2017 6/8/2017 7/7/2017 - - H8110 BENIGN PAROXYSMAL HOSPITAL OUTPATIENT $471.00 $628.04 FEMALE SUBSCRIBER 1 BCC VERTIGO, UNSPECIFIED EAR 7/24/2017 7/12/2017 7/21/2017 - - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $164.40 $274.00 FEMALE SUBSCRIBER 1 BCC OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS ORLUNG 7/24/2017 7/12/2017 7/21/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C3411 MALIGNANT NEOPLASM PROFESSIONAL $94.49 $258.00 FEMALE SUBSCRIBER 1BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF UPPER LOBE, RIGHT OUTPATIENT /HOSPITAL PATIENT,WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY BRONCHUS OR LUNG COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 7/25/2017 6/23/2017 7/17/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT $50,052.75 $66,737.00 FEMALE SUBSCRIBER 1 BCC ANTINEOPLASTIC CHEMOTHERAPY 7/28/2017 71712017 7/17/2017 - - Z5111 ENCOUNTERFOR HOSPITAL OUTPATIENT $50,384.25 $67,179.00 FEMALE SUBSCRIBER 1 BCC ANTINEOPLASTIC CHEMOTHERAPY 8/8/2017 7/21/2017 7/27/2017 - - Z5111 ENCOUNTERFOR HOSPITAL OUTPATIENT $50,290.50 $67,054.00 FEMALE SUBSCRIBER 1 BCC ANTINEOPLASTIC CHEMOTHERAPY 61812017 7/26/2017 81112017 - - Z136 ENCOUNTER FOR HOSPITAL OUTPATIENT 1 BCC $212.45 $501.00 FEMALE SUBSCRIBER 1 BCC SCREENING FOR $366.00 FEMALE SUBSCRIBER 1 BCC CARDIOVASCULAR DISORDERS 8/22/2017 8/4/2017 8/10/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 8/23/2017 7/26/2017 8/22/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET )WITH C3490 MALIGNANT NEOPLASM PROFESSIONAL CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY OF UNSPECIFIED PART OF OUTPATIENT /HOSPITAL (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL UNSPECIFIED BRONCHUS LOCALIZATION IMAGING; SKULL BASETO MID -THIGH DRILLING 8/24/2017 8/9/2017 8/22/2017 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C3411 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF UPPER LOBE, RIGHT OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY BRONCHUS OR LUNG COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 8/25/2017 8/9/2017 812212017- - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS DRILLING 8/30/2017 8/11/2017 812912017 88360 MORPHOMETRIC ANALYSIS, TUMOR C3411 MALIGNANT NEOPLASM OTHER MEDICAL IMMUNOHISTOCHEMISTRY HEG ,HER- 2 /NEU, ESTROGEN OF UPPER LOBE, RIGHT RECEPTO R /PROG ESTE RONE RECEPTOR, QUANTITATIVE BRONCHUS OR LUNG OR SEMIQUANTITATIVE, PER SPECIMEN, EACH SINGLE ANTIBODY STAIN PROCEDURE; MANUAL 9/15/2017 5/4/2017 9/13/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C3490 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF UNSPECIFIED PART OF OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY UNSPECIFIED BRONCHUS COMPONENTS: A COMPREHENSIVE HISTORY; A DRILLING COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 9/20/2017 8/4/2017 8/10/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 9/20/2017 8/4/2017 8/10/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 9/29/2017 9/21/2017 9/27/2017 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C3411 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF UPPER LOBE, RIGHT OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY BRONCHUS OR LUNG COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 10/9/2017 9/28/2017 10/6/2017 10/12/2017 9/21/2017 10/10/2017 - - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS DRILLING 1011312017 9/28/2017 10/11/2017 10/18/2017 10/9/2017 10/16/2017 * * ° ** 10/30/2017 10/10/2017 10/26/2017 * * * ** $4,321.20 $7,202.00 FEMALE SUBSCRIBER 1 BCC $2,008.50 $67,718.00 FEMALE SUBSCRIBER 1 BCC $212.45 $501.00 FEMALE SUBSCRIBER 1 BCC $133.51 $366.00 FEMALE SUBSCRIBER 1 BCC $942.60 $1,571.00 FEMALE SUBSCRIBER 1 BCC $66.39 $203.00 FEMALE SUBSCRIBER 1 BCC $133.51 $366.00 FEMALE SUBSCRIBER 1 BCC $50,788.50 $67,718.00 FEMALE SUBSCRIBER 1 BCC ($2.008,501 f$67,718, 00) FEMALE SUBSCRIBER 1 BCC $133.51 $366.00 FEMALE SUBSCRIBER 1 BCC $177.83 $453.00 FEMALE SUBSCRIBER 1 BCC $97910 $1,632.00 FEMALE SUBSCRIBER 1 BCC $20].49 $549.00 FEMALE SUBSCRIBER 1 BCC $77875 $1,939.00 FEMALE SUBSCRIBER 1 BCC $870.51 $2,083.00 FEMALE SUBSCRIBER 1 BCC 11/3/2017 10/27/2017 11/1/2017- - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT 1 BCC $150.40 $774.00 FEMALE SUBSCRIBER OF UNSPECIFIED PART OF $24.67 $125.00 FEMALE SUBSCRIBER 1 BCC $114.17 UNSPECIFIED BRONCHUS 1 BCC ORLUNG 11/8/2017 11/2/2017 11/7/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST Z85119 PERSONAL HISTORY OF PROFESSIONAL MATERIALS) OTHER MALIGNANT OUTPATIENT /HOSPITAL NEOPLASM OF BRONCHUS AND LUNG 11/8/2017 11/2/2017 11/772017 74177 Computed[. m.gmphy, a bdome, and pelvis; with Z85118 PERSONAL HISTORY OF PROFESSIONAL contrast materials) OTHER MALIGNANT OUTPATIENT /HOSPITAL NEOPLASM OF BRONCHUS AND LUNG 11/13/2017 11/3/2017 11/10/2017 70355 ORTHOPANTOGRAM (EG, PANORAMIC X -RAY) MS700 IDIOPATHIC ASEPTIC PROFESSIONAL OFFICE NECROSIS OF UNSPECIFIED BONE 11113/2017 11/3/2017 11/10/2017 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M8700 IDIOPATHIC ASEPTIC PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, NECROSIS OF WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED UNSPECIFIED BONE HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE P 11/15/2017 11/2/2017 11/772017- - C3490 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF UNSPECIFIED PART OF UNSPECIFIED BRONCHUS ORLUNG 11/27/2017 11/20/2017 11122/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 11128/2017 11/13/2017 11/20/2017 - - K8590 ACUTE PANCREATITIS HOSPITAL OUTPATIENT WITHOUT NECROSIS OR INFECTION, UNSPECIFIED 1113012017 11/17/2017 1112812017- - C3411 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF UPPER LOBE, RIGHT BRONCHUS OR LUNG 12/7/2017 11/17/2017 12/5/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C3411 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF UPPER LOBE, RIGHT OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY BRONCHUS OR LUNG COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/11/2017 11/21/2017 12/8/2017 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K8531 DRUG INDUCED ACUTE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, PANCREATITIS WITH WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED UNINFECTED NECROSIS HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIESARE P 12/19/2017 10/23/2017 12/8/2017 * *' "* 11— —1.1 —1- ...r. $1,254.75 $1,673.00 FEMALE SUBSCRIBER 1 BCC $107.49 $383.00 FEMALE SUBSCRIBER 1 BCC $150.40 $774.00 FEMALE SUBSCRIBER 1 BCC $24.67 $125.00 FEMALE SUBSCRIBER 1 BCC $114.17 $350.00 FEMALE SUBSCRIBER 1 BCC $9,198.00 $12,264.00 FEMALE SUBSCRIBER 1 BCC $120.06 $255.00 FEMALE SUBSCRIBER 1 BCC $1,393.50 $1,858.00 FEMALE SUBSCRIBER 1 BCC $172.80 $288.00 FEMALE SUBSCRIBER 1 BCC $94.49 $258.00 FEMALE SUBSCRIBER 1 BCC $97.40 $358.00 FEMALE SUBSCRIBER 1 BCC $46,602.00 $77,670.00 FEMALE SUBSCRIBER 1 BCC 12/20/2017 12/12/2017 12/1812017 - - K8590 ACUTE PANCREATITIS HOSPITAL OUTPATIENT $1,043.25 $1,391.00 FEMALE SUBSCRIBER 1 BCC WITHOUT NECROSIS OR INFECTION, UNSPECIFIED 12/29/2017 12/12/2017 12/18/2017 - - K8590 ACUTE PANCREATITIS HOSPITAL OUTPATIENT $0.00 $1,391.00 FEMALE SUBSCRIBER 1 BCC WITHOUT NECROSIS OR INFECTION, UNSPECIFIED 12/29/2017 12/18/2017 12/27/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C3411 MALIGNANT NEOPLASM PROFESSIONAL $9449 $258.00 FEMALE SUBSCRIBER 1 BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF UPPER LOBE, RIGHT OUTPATIENT /HOSPITAL PATIENT,WHICH REQUIRES AT LEAST 20F THESE 3 KEY BRONCHUS OR LUNG COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER Sub TOta1 $871,006.89 $1,198,962.67 4.125E +10 2/10/2017 1/18/2017 2/2/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE $78.91 $461.00 MALE SPOUSE R01 BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 2/13/2017 1/12/2017 1131/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E119 TYPE 2 DIABETES PROFESSIONAL OFFICE $0.00 $12.00 MALE SPOUSE R01 BCC MELLITUS WITHOUT COMPLICATIONS 3/20/2017 3/16/2017 3/17/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E785 HYPERLIPIDEMIA, PROFESSIONAL OFFICE $0.00 $12.00 MALE SPOUSE R01 BCC UNSPECIFIED 3/23/2017 3/16/2017 3/21/2017 83721 LIPOPROTEIN, DIRECT MEASUREMENT; LET CHOLESTEROL E119 TYPE DIABETES OTHER MEDICAL $0.00 $52.00 MALE SPOUSE R01 BCC MELLITUS WITHOUT COMPLICATIONS 4/3/2017 3/13/2017 4/1/2017 20550 INJECTION(S); SINGLETENDON SHEATH, OR LIGAMENT, M25522 PAIN IN LEFT ELBOW PROFESSIONAL OFFICE $0.00 $135.00 MALE SPOUSE R01 BCC APONEUROSIS (EG, PLANTAR "FASCIA') 4/3/2017 3/13/2017 4/1/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M25522 PAIN IN LEFT ELBOW PROFESSIONAL OFFICE $58.90 $195.00 MALE SPOUSE R01 BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/3/2017 3/13/2017 4/1/201711030 INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG N125522 PAIN IN LEFT ELBOW PROFESSIONAL OFFICE $0.00 $30.00 MALE SPOUSE R01 BCC 5/22/2017 3/22/2017 5119/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE $78.91 $461.00 MALE SPOUSE R01 BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/9/2017 5/24/2017 6/8/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE $78.91 $461.00 MALE SPOUSE R01 BCC EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING ANO /OR COORDINATION OF CARE WITH OTHER C.7.f 6/19/2017 6/15/2017 6/16/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE $44.57 $314.00 MALE SPOUSE R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED N HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 9/29/2017 9/27/2017 9/28/2017 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 1208 OTHER FORMS OF PROFESSIONAL OFFICE $0.00 $65.00 MALE SPOUSE R01 BCC 3559 7 LEA05; WITH INTERPRETATION AND REPORT ANGINA PECTORIS 9/29/2017 9/27/2017 9/28/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1208 OTHER FORMS OF PROFESSIONAL OFFICE $51.53 $276.00 MALE SPOUSE RD1 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED ANGINA PECTORIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY } COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED iL CL EXAMINATION; MEDICAL DECISION MAKING OF LOW Q, COMPLEXITY. COUNSELING AND COORD ` `��. 10/4/2017 8/29/2017 10/3/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R05 COUGH PROFESSIONAL OFFICE $44.57 $314.00 MALE SPOUSE R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED LIJ h EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 10/9/2017 8/29/2017 10/6/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 1189 PNEUMONIA, OTHER MEDICAL $0.00 $164.00 MALE SPOUSE R01 BCC 3559 FRONTAL AND LATERAL; UNSPECIFIED ORGANISM 10/9/2017 9/5/2017 10/8/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1189 PNEUMONIA, PROFESSIONAL OFFICE $44.57 $314.00 MALE SPOUSE R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED ORGANISM a. PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY ui COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED UJ EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 11/2/2017 10/31/2017 11/1/2017 - - Z1211 ENCOUNTER FOR HOSPITAL OUTPATIENT $2,291.38 $23,200.00 MALE SPOUSE RO1 BCC 3559 LLJ SCREENING FOR `✓ MALIGNANT NEOPLASM OF COLON J 11/6/2017 10/31/2017 11/3/2017 810 ANESTHESIA FOR LOWER INTESTINAL EN DOSCOPIC 21211 ENCOUNTER FOR PROFESSIONAL $468.00 $1,125.00 MALE SPOUSE ROl BCC 3559 PROCEDURES, ENDOSCOPE INTRODUCED DISTALTO SCREENING FOR OUTPATIENT /HOSPITAL v DUODENUM MALIGNANT NEOPLASM OFCOLON 11/8/2017 10/31/2017 11/7/2017 - - D126 BENIGN NEOPLASM OF HOSPITAL OUTPATIENT $640.50 $4,381.00 MALE SPOUSE RO1 BCC 3559 uj COLON, UNSPECIFIED 11/13/2017 11/8/2017 11/10/2017 99214 OFFICE OR OTHER 0UTPATIENTVISIT FOR THE C186 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $157.99 $200.00 MALE SPOUSE R01 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF DESCENDING COLON (' PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER f'V N 11/16/2017 11/6/2017 11/10/2017- - C189 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,559.75 $13,701.00 MALE SPOUSE R01 BCC 3559 = OF COLON, UNSPECIFIED {y E 11/17/2017 11/4/2017 11/10/2017- - C189 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $8,534.24 $17,821.00 MALE SPOUSE R01 BCC 3559 ._ OF COLON, UNSPECIFIED 2 11/21/2017 11/6/2017 1112012017 1112212017 10/31/2017 11/21/2017 11/22/2017 10/31/2017 11/21/2017 11/22/2017 10/31/2017 11/21/2017 11/22/2017 10/31/2017 11/21/2017 1112712017 11/6/2017 1112212017 11/27/2017 11/13/2017 11/17/2017 11/27/2017 11/15/2017 11/21/2017 11/27/2017 11/15/2017 11121/2017 11/28/2017 11/4/2017 11/21/2017 11/29/2017 11/13/2017 1112212017 11/29/2017 11/15/2017 11/28/2017 12/5/2017 11/15/2017 11121/2017 12/6/2017 11/15/2017 11/22/2017 - 12/12/2017 11115/2017 12/11/2017 G0452 74177 Computed tomography, abdomen and pelvis;with C189 MALIGNANT NEOPLASM PROFESSIONAL $112.00 $360.00 MALE SPOUSE R01 BCC cantrast materials) OF COLON, UNSPECIFIED OUTPATIENT /HOSPITAL 43239 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, Z1211 ENCOUNTER FOR PROFESSIONAL $98.06 $1,100.00 MALE SPOUSE RO1 BCC TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE SCREENING FOR OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM OFCOLON 45380 COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR Z1211 ENCOUNTER FOR PROFESSIONAL $27.21 $1,450.00 MALE SPOUSE RO1 BCC MULTIPLE SCREENING FOR OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM OFCOLON 45381 COLONOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL Z1211 ENCOUNTER FOR PROFESSIONAL $26.36 $1,400.00 MALE SPOUSE BET BCC INJECTIONIS), ANY SUBSTANCE SCREENING FOR OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM OFCOLON 45385 COLONOSCOPY, FLEXIBLE; WITH REMOVALOF TUMOR(S), Z1211 ENCOUNTER FOR PROFESSIONAL $481.04 $1,700.00 MALE SPOUSE R01 BCC POLYPISE OR OTHER LESION(S) BY SNARE TECHNIQUE SCREENING FOR OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM OFCOLON 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST C189 MALIGNANT NEOPLASM PROFESSIONAL $76.78 $239.00 MALE SPOUSE RO1 BCC MATERIALPS) OF COLON, UNSPECIFIED OUTPATIENT /HOSPITAL - Z01810 ENCOUNTER FOR HOSPITAL OUTPATIENT $676.00 $676.00 MALE SPOUSE Rol BCC PREPROCEOURAL CARDIOVASCULAR EXAMINATION 44204 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH C186 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $4,850.00 MALE SPOUSE R01 BCC ANASTOMOSIS OF DESCENDING COLON INPATIENT /HOSPITAL 442131APAROSCOPY, SURGICAL, MOBILIZATION (TAKE -DOWN) C186 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $700.00 MALE SPOUSE R01 BCC OF SPLENIC FLEXURE PERFORMED IN CONJUNCTION WITH OF DESCENDING COLON INPATIENT /HOSPITAL PARTIAL COLECTOMY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) 78815 POSITRON EMISSION TOMOGRAPHY (PET)WITH C189 MALIGNANT NEOPLASM PROFESSIONAL $194.31 $477.00 MALE SPOUSE R01 BCC CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY OF COLON, UNSPECIFIED OUTPATIENT /HOSPITAL )CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID -THIGH 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 201818 ENCOUNTER FOR OTHER PROFESSIONAL $17.64 $42.00 MALE SPOUSE RO1 BCC FRONTAL AND LATERAL; PREPROCEOURAL OUTPATIENT /HOSPITAL EXAMINATION 88309 LEVELVI- SURGICAL PATHOLOGY, GROSS AND C186 MALIGNANT NEOPLASM PROFESSIONAL $201.08 $876.00 MALE SPOUSE R01 BCC MICROSCOPIC EXAMINATION BONE RESECTION, BREAST, OF DESCENDING COLON INPATIENT /HOSPITAL MASTECTOMY - WITH REGIONAL LYMPH NODES, COLON, SEGMENTAL RESECTION FOR TUMOR, COLON, TOTAL RESECTION, ESOPHAGUS, PARTIAL/TOTAL RESECTION, EXTREMITY, DISARTICULATION, FETUS, WITH DISSECTION, LARYNX, P 44204 LAPAROSCDPY, SURGICAL; COLECTOMY, PARTIAL, WITH C186 MALIGNANT NEOPLASM PROFESSIONAL $486.27 $4,850.00 MALE SPOUSE R01 BCC ANASTOMOSIS OF DESCENDING COLON INPATIENT /HOSPITAL - C186 MALIGNANT NEOPLASM HOSPITAL INPATIENT 11/15/2017 # # # # # # ## $32,179.46 $128,070.03 MALE SPOUSE R01 BCC OF DESCENDING COLON MOLECULAR PATHOLOGY PROCEDURE; PHYSICIAN C186 MALIGNANT NEOPLASM PROFESSIONAL $21.30 $60.00 MALE SPOUSE R01 BCC INTERPRETATION AND REPORT OF DESCENDING COLON OUTPATIENT /HOSPITAL C.7.f 3559 w Z 3559 N 3559 3559 3559 3559 3559 3559 3559 9w 3559 3559 3559 3559 3559 rl 12/12/2017 11/15/2017 12/1112017 81210 B RAF )V -RAF MUR IN E SARCOMA VIRAL ON COG ENE C186 MALIGNANT NEOPLASM PROFESSIONAL $126.16 $225.00 MALE SPOUSE R01 BCC HDMDLDG Bl) )EG, COLON CANCER), GENE ANALYSIS, OF DESCENDING COLON OUTPATIENT /HOSPITAL V600E VARIANT 12/12/2017 11/15/2017 12/11/2017 81275 KRAS (V-KI-RAS2 KIRSTEN RAT SARCOMA VIRAL C186 MALIGNANT NEOPLASM PROFESSIONAL $139.00 $436.00 MALE SPOUSE R01 BCC ONCOGENE))EG, CARCINOMA) GENE ANALYSIS, VARIANTS OF DESCENDING COLON OUTPATIENT /HOSPITAL IN CODONS 12 AND 13 12/12/2017 11/15/2017 12/11/2017 81276 KRAS(Kii - cm, Lot ,a -ma viral Dn,.gc,s homolog) deg, C186 MALIGNANT NEOPLASM PROFESSIONAL $139.00 $872.00 MALE SPOUSE R01 BCC ma)gene analysis; additi ona l vari— P)(eg, cod0n OF DESCENDING COLON OUTPATIENT /HOSPITAL 61, codon 146) 12/12/2017 11/15/2017 12/11/2017 81301 MICROSATELLITE INSTABILITY ANALYSIS(EG, HEREDITARY C186 MALIGNANT NEOPLASM PROFESSIONAL $27804 $539.00 MALE SPOUSE R01 BCC NON - POLYPOSIS COLORECTAL CANCER, LYNCH OF DESCENDING COLON OUTPATIENT/HOSPITAL SYNDROME) OF MARKERS FOR MISMATCH REPAIR DEFICIENCY (EG, BATES, BAT26), INCLUDES COMPARISON OF NEOPLASTIC AND NORMAL TISSUE, IF PERFORMED 12/12/2017 11/15/2017 12/11/2017 81311 NRAS)n— blastoma RAS Viral 41 -1110 lir ene C186 MALIGNANT NEOPLASM PROFESSIONAL $208.50 $372.00 MALE SPOUSE R01 BCC homolog) leg, colorectal carcinoma), gene analysis, OF DESCENDING COLON OUTPATIENT/HOSPITAL iant, In -on 2 leg, codon, 12 and 13) and exon 3 (eg, '.don 61) 12/12/2017 11/15/2017 12/1112017 81403 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 4(EG, C186 MALIGNANT NEOPLASM PROFESSIONAL $375.70 $846.00 MALE SPOUSE R01 BCC ANALYSIS OF SINGLE EXON BY DNA SEQUENCE ANALYSIS, OF DESCENDING COLON OUTPATIENT /HOSPITAL ANALYSIS OF > 10 AM PLICONS USING MULTIPLEX PCR IN 2 OR MORE INDEPENDENT REACTIONS, MUTATION SCANNING OR DUPLICATION /DELETION VARIANTS OF 2 -5 EXONS) ABL1 (0- 12/14/2017 11/15/2017 12/4/2017 790 ANESTHESIA FOR INTRAPERITONEAL PROCEDURES IN C189 MALIGNANT NEOPLASM OTHER MEDICAL $1,755.60 $3,999.00 MALE SPOUSE R01 BCC UPPER ABDOMEN INCLUDING LAPAROSCOPY; NOT OF COLON, UNSPECIFIED OTHERWISE SPECIFIED Sub Total $52,752.24 $217,833.03 4.25E +10 1/6/2017 12/22/2016 1/4/2017 72126 COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH R221 LOCALIZED SWELLING, OTHER MEDICAL $325.00 $1,635.00 MALE SPOUSE 1 BCC CONTRAST MATERIAL MASS AND LUMP, NECK 1/30/2017 1/S/2017 1/10/2017 99214 OFFICE DR OTHER OUTPATIENT VISIT FOR THE R221 LOCALIZED SWELLING, PROFESSIONAL OFFICE $78.91 $461.00 MALE SPOUSE IBCD EVALUATION AND MANAGEMENTOFAN ESTABLISHED MASS AND LUMP, NECK PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY CO M PD N E NTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 1/30/2017 1/17/2017 1/25/2017 99243 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED R221 LOCALIZED SWELLING, PROFESSIONAL OFFICE $146.39 $280.00 MALE SPOUSE 1BCC PATIENT,WHICH REQUIRESTHESE3 KEYCOMPONENTS :A MASS AND LUMP, NECK DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE 2/27/2017 2/20/2017 2/22/2017 36415 COLLECTION DE VENOUS BLOOD BY VENIPUNCTURE 70189 ENCOUNTER FOR OTHER PROFESSIONAL OFFICE $1.80 $12.00 MALE SPOUSE 1 BCC SPECIFIED SPECIAL EXAMINATIONS 3/6/2017 2/21/2017 2/28/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR Z01810 ENCOUNTER FOR PROFESSIONAL OFFICE $0.00 $20.00 MALE SPOUSE 1 BCC BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, PREPROCEOURAL LEUKOCY9ES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, CARDIOVASCULAR UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; EXAMINATION AUTOMATED, WITHOUT MICROSCOPY 3/6/2017 2/21/2017 212812017 93000 ELECTROCARD I OG RAM, ROUTINE ECG WITH AT LEAST 12 Z01810 ENCOUNTER FOR PROFESSIONAL OFFICE 3559 LEADS; WITH INTERPRETATION AND REPORT $78.91 PREPROCEDURAL 3559 3559 $252.72 $684.67 MALE CARDIOVASCULAR 1 BCC OR $640.46 $1,950.68 MALE EXAMINATION 1 BCC 3/6/2017 2/21/2017 2/28/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z01810 ENCOUNTER FOR PROFESSIONAL OFFICE 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PREPROCEDURAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY CARDIOVASCULAR $0.00 $164.00 MALE SPOUSE 1 BCC COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION fl EXAMINATION; MEDICAL DECISION MAKING OF } fl MODERATE COMPLEXITY. COUNSELING AND /OR CL i® $20.92 $125.00 MALE SPOUSE 1 BCC COORDINATION OF CARE WITH OTHER Q 3/8/2017 2/20/2017 3/3/2017 71020 RADIOLDGIC EXAMINATION, CHEST, TWO VIEWS, 701811 ENCOUNTER FOR OTHER MEDICAL FRONTAL AND LATERAL; PREPROCEDURAL RESPIRATORY EXAMINATION 3/9/2017 111012017 3/3/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H10413 CHRONIC GIANT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PAPILLARY PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY CONJUNCTIVITIS, COMPONENTS: AN EXPANDED PROBLEM FOCUSED BILATERAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 3/17/2017 3/1/2017 3/8/2017- - R221 LOCALIZED SWELLING, HOSPITAL OUTPATIENT MASS AND LUMP, NECK 3/24/2017 3/1/2017 3/22/2017 - - C8331 DIFFUSE LARGE B-CELL HOSPITAL OUTPATIENT LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 3/27/2017 3/22/2017 3/24/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, LYMPHOMA, LYMPH WHICH REQUIRES THESE 3 KEY COMPONENTS:A NODES OF HEAD, FACE, COMPREHENSIVE HISTORY; A COMPREHENSIVE AND NECK EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY, COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE 3/30/2017 3/25/2017 3/29/2017 - - C9331 DIFFUSE LARGE B -CELL HOSPITAL OUTPATIENT LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/4/2017 3/1/2017 4/3/2017 320 ANESTHESIA FORALL PROCEDURES ON ESOPHAGUS, 8221 LOCALIZED SWELLING, PROFESSIONAL THYROID, LARYNX, TRACHEA AND LYMPHATIC SYSTEM OF MASS AND LUMP, NECK OUTPATIENT /HOSPITAL NECK; NOT OTHERWISE SPECIFIED, AGE 1 YEAR OR OLDER 4/4/2017 3/1/2017 4/3/2017 320 ANESTHESIA FOR ALL PROCEDURES ON ESOPHAGUS, R221 LOCALIZED SWELLING, PROFESSIONAL THYROID, LARYNX, TRACHEA AND LYMPHATIC SYSTEM OF MASS AND LUMP, NECK OUTPATIENT /HOSPITAL NECK; NOT OTHERWISE SPECIFIED, AGE 1 YEAR OR OLDER 4/5/2017 3/24/2017 3/31/2017 - - C8331 DIFFUSE LARGE B-CELL HOSPITAL OUTPATIENT LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/5/2017 3/25/2017 4/4/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET)WITH C8330 DIFFUSE LARGE B -CELL PROFESSIONAL CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL SITE LOCALIZATION IMAGING; SKULL BASE TO MID -THIGH C.7.f $0.00 $75.00 MALE SPOUSE 1 BCC 3559 $2,037.66 $5,163.00 MALE 4) 1 BCC 3559 OR $78.91 $461.00 MALE SPOUSE 1 BCC 3559 3559 $252.72 $684.67 MALE SPOUSE 1 BCC OR $640.46 $1,950.68 MALE SPOUSE 1 BCC 3559 $145.73 $477.00 MALE SPOUSE i' 3559 $0.00 $164.00 MALE SPOUSE 1 BCC 3559 fl } fl CL i® $20.92 $125.00 MALE SPOUSE 1 BCC 3559 CL Q $2,037.66 $5,163.00 MALE SPOUSE 1 BCC 3559 $1,497.15 $3,327.00 MALE SPOUSE 1 BCC 3559 $252.72 $684.67 MALE SPOUSE 1 BCC 3559 $8,534.25 $16,992.78 MALE SPOUSE 1 BCC 3559 $345.26 $1,400.00 MALE SPOUSE 1 BCC 3559 $345.26 $1,540.00 MALE SPOUSE 1 BCC 3559 $640.46 $1,950.68 MALE SPOUSE 1 BCC 3559 $145.73 $477.00 MALE SPOUSE 1 BCC 3559 4/5/2017 3/27/2017 3/31/2017 - - C8331 DIFFUSE LARGE B -CELL HOSPITAL OUTPATIENT SPOUSE $0.00 $40.00 MALE LYMPHOMA, LYMPH $0.00 $10.00 MALE SPOUSE $18.16 NODES OF HEAD, FACE, SPOUSE $18.16 $28.00 MALE SPOUSE AND NECK $40.00 MALE 4/7/2017 3/24/2017 4/5/2017 80074 ACUTE HEPATITIS PANELTHIS PANEL MUST INCLUDE THE C8331 DIFFUSE LARGE B -CELL PROFESSIONAL FOLLOWING: HEPATITIS A ANTIBODY(HAAB), IGM LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL ANTIBODY (86709), HEPATITIS B CORE ANTIBODY(HBCAB), NODES OF HEAD, FACE, IGM ANTIBODY (96705), HEPATITIS B SURFACE ANTIGEN AND NECK (HBSAG) )87340), HEPATITIS C ANTIBODY (86803) 4/7/2017 3/24/2017 4/5/2017 82232 BETA -2 MICROGLDBULIN C8331 DIFFUSE LARGE B-CELL PROFESSIONAL LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 4/7/2017 3/24/2017 4/5/2017 84155 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, 08331 DIFFUSE LARGE B -CELL PROFESSIONAL PLASMA OR WHOLE BLOOD LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 4/7/2017 3/24/2017 4/5/2017 84165 PROTEIN; ELECTROPHORETIC FRACTIONATION AND C8331 DIFFUSE LARGE B -CELL PROFESSIONAL QUANTITATION, SERUM LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 41712017 3/24/2017 4/5/2017 863341MMUNOFIXATION ELECTROPHORESIS; SERUM C8331 DIFFUSE LARGE B -CELL PROFESSIONAL LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 4/7/2017 3/24/2017 4/5/2017 86803 HEPATITIS C ANTIBODY; C8331 DIFFUSE LARGE B -CELL PROFESSIONAL LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 4/7/2017 4/4/2017 4/5/2017 99204 OFFICE OR OTHER OUTPATIENTVISIT FOR THE N1330 UNSPECIFIED PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, HYDRONEPHROSIS WHICH REQUIRES THESE 3 KEY COMPONENTS :A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 4/10/2017 311/2017 4/6/2017 88307 LEVELV- SURGICAL PATHOLOGY, GROSS AND C8331 DIFFUSE LARGE B -CELL PROFESSIONAL MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENTS) , PATHOLOGIC NODES OF HEAD, FACE, FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR AND NECK RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT 4/10/2017 3/1/2017 4/6/2017 88333 PATHOLOGY CONSULTATION DURING SURGERY; C9331 DIFFUSE LARGE B -CELL PROFESSIONAL CYTOLOGIC EXAMINATION (EG, TOUCH PREP, SQUASH LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL PREP), INITIAL SITE NODES OF HEAD, FACE, AND NECK 4/10/2017 3/1/2017 4/6/2017 883411MMUNOHISTOC HEMISTRY OR IMMUNO CYTOCHEMISTRY, C8331 DIFFUSE LARGE B-CELL PROFESSIONAL PER SPECIMEN; EACH ADDITIONAL SINGLE ANTIBODY LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO NODES OF HEAD, FACE, CODE FOR PRIMARY PROCEDURE) AND NECK 4/10/2017 3/1/2017 4/6/2017 883421MMUNOHISTOC HEMISTRY OR IMMUNO CYTOCHEMISTRY, C8331 DIFFUSE LARGE B -CELL PROFESSIONAL PER SPECIMEN; INITIALSINGLE ANTIBODYSTAIN LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL PROCEDURE NODES OF HEAD, FACE, AND NECK $2,773.67 $3,698.23 MALE SPOUSE $0.00 $131.00 MALE SPOUSE $0.00 $40.00 MALE SPOUSE $0.00 $10.00 MALE SPOUSE $18.16 $113.36 MALE SPOUSE $18.16 $28.00 MALE SPOUSE $0.00 $40.00 MALE SPOUSE $17348 $550.00 MALE SPOUSE 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC $0.00 $531.00 MALE SPOUSE 1 BCC C.7.f 3559 w N 3559 3559 3559 3559 3559 3559 3559 9 1 $0.00 $347.00 MALE SPOUSE 1 BCC 3559 $0.00 $1,331.00 MALE SPOUSE 1 BCC 3559 $0.00 $266.00 MALE SPOUSE 1 BCC 3559 R 4/10/2017 3/27/2017 4/7/2017 78472 CARDIACBLOOD POOLIMAGING, GATED EQUILIBRIUM; C8590 NON-HODGKIN PROFESSIONAL PLANAR, SINGLE STUDY AT REST OR STRESS (EXERCISE LYMPHOMA, OUTPATIENT /HOSPITAL AND /OR PHARMACOLOGIC), WALL MOTION STUDY PLUS UNSPECIFIED, EJECTION FRACTION, WITH OR WITHOUT ADDITIONAL UNSPECIFIED SITE QUANTITATIVE PROCESSING 4/10/2017 4/4/2017 4/6/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, LYMPH PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY NODES OF HEAD, FACE, COMPONENTS: A DETAILED HISTORY; A DETAILED AND NECK EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/11/2017 4/3/2017 4/10/2017 88184 FLOW CYTOMETRY, CELLSURFACE, CYTOPLASMIC, OR C8519 UNSPECIFIED B -CELL OTHER MEDICAL NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; FIRST LYMPHOMA, MARKER EXTRANODAL AND SOLID ORGAN SITES 4/11/2017 4/3/2017 4/10/2017 88185 FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR C8519 UNSPECIFIED B -CELL OTHER MEDICAL NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH LYMPHOMA, ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO EXTRANODAL AND SOLID CODE FOR FIRST MARKER) ORGAN SITES 4/11/2017 4/3/2017 4/10/2017 88189 FLOWCYTOMETRY /READ, 16 &: C8519 UNSPECIFIED B -CELL OTHER MEDICAL LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES 4/11/2017 4/3/2017 4/10/2017 88305 LEVELIV- SURGICAL PATHOLOGY, GROSS AND C8331 DIFFUSE LARGE B -CELL PROFESSIONAL MICROSCOPIC EXAMINATION ABORTION- LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE NODES OF HEAD, FACE, MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, AND NECK OTHER THAN FORTUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION 4/11/2017 4/3/2017 4/10/2017 88311 DECALCIFICATION PROCEDURE(LISTSEPARATELY IN C8331 DIFFUSE LARGE B -CELL PROFESSIONAL ADDITION TO CODE FOR SURGICAL PATHOLOGY LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL EXAMINATION) NODES OF HEAD, FACE, AND NECK 4/11/2017 4/3/2017 4/10/2017 88313 SPECIAL STAIN INCLUDING INTERPRETATION AND REPORT; C9331 DIFFUSE LARGE B -CELL PROFESSIONAL GROUP II, ALL OTHER)EG, IRON, TRICHROME), EXCEPT LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL STAIN FOR MICROORGANISMS , STAINS FOR ENZYME NODES OF HEAD, FACE, CONSTITUENTS, OR IMMUNOCYTOCHEMISTRY AND AND NECK IMMUNOHISTOCH EMISTRY 4/12/2017 4/4/2017 4/8/2017 - - N1330 UNSPECIFIED HOSPITAL OUTPATIENT HYDRONEPHROSIS 4/13/2017 4/6/2017 4/10/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE OR DIAGNOSIS (SPECIFY SUBSTANCE DR DRUG); LYMPHOMA, LYMPH ADDITIONAL SEQUENTIAL INFUSION OF A NEW NODES OF HEAD, FACE, DRUG/ SUBSTANCE, UP TO I HOUR (LIST SEPARATELY IN AND NECK ADDITION TO CODE FOR PRIMARY PROCEDURE) 4/13/2017 4/6/2017 4/10/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE INFUSION TECHNIQUE; UP TO I HOUR, SINGLE OR INITIAL LYMPHOMA, LYMPH SUBSTANCE /DRUG NODES OF HEAD, FACE, AND NECK 4113/2017 4/6/2017 4/10/2017 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE TO CODE FOR PRIMARY PROCEDURE) LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK $58.82 $194.00 MALE SPOUSE 1 BCC $116.30 $348.35 MALE SPOUSE 1 BCC $19.96 $222.56 MALE SPOUSE $352.61 $3,516.55 MALE SPOUSE $31.15 $353.89 MALE SPOUSE $77.46 $850.00 MALE SPOUSE $13.09 $95.00 MALE SPOUSE $74.38 $750.00 MALE SPOUSE $214.06 $285.41 MALE SPOUSE $66.93 $219.98 MALE SPOUSE $15034 $494.20 MALE SPOUSE $126.99 $417.44 MALE SPOUSE 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC C.7.f 3559 w Z N Q! 3559 19 } 3559 CL CL Q 3559 v 3559 3559 3559 3559 Fk }1'1 3559 3559 4/13/2017 4/6/2017 411012017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $2.40 $6.40 MALE SPOUSE 1 BCC LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/13/2017 4/6/2017 4/10/201711200 INJECTION, DIPHENHVDRAMINE HILL, UPT050MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $0.65 $3.35 MALE SPOUSE 1 BCC LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/13/2017 4/6/2017 4/10/2017 19310 INJECTION, RITUXIMAB, 100 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $6,671.52 $21,365.19 MALE SPOUSE 1 BCC LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/13/2017 4/7/2017 4/11/2017 96372 Therapeutic, prophylactic, ordiagnostic injection (specify C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $2156 $77.44 MALE SPOUSE 1 BCC substance or drug); subcutaneous or Intramuscular LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/13/2017 41712017 411112017 J2505 INJECTION, PEGFILGRASTIVI C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $4,117.23 $8,449.85 MALE SPOUSE 1 BCC LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/13/2017 4/7/2017 4/11/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $33.46 $109.99 MALE SPOUSE 1 BCC ORDIAGNOSIS(SPECIFY SUBSTANCE ORDRUG); LYMPHOMA, LYMPH ADDITIONAL SEQUENTIAL INFUSION OF A NEW NODES OF HEAD, FACE, DRUG /SUBSTANCE, UP TO I HOUR (LIST SEPARATELY IN AND NECK ADDITION TO CODE FOR PRIMARY PROCEDURE) 4/13/2017 4/7/2017 4/11/2017 96375 Therapeutic, prophylactic, ordiagnostic injection (specify C8331 DIFFUSE LARGE B-CELL PROFESSIONAL OFFICE $46.75 $153.70 MALE SPOUSE 1 BCC substance ordrug); each additional sequential intravenous LYMPHOMA, LYMPH push of a new substance /drug(List separately in addition NODES OF HEAD, FACE, to cadc for primary procedure( AND NECK 4/13/2017 4/7/2017 4/11/2017 96411 CHEMOTHERAPY ADMINISTRATION ; INTRAVENOUS, PUSH C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $130.42 $428.76 MALE SPOUSE 1 BCC TECHNIQUE, EACH ADDITIDNALSUBSTAN CE /DRUG(LIST LYMPHOMA, LYMPH SEPARATELY IN ADDITION TO CODE FOR PRIMARY NODES OF HEAD, FACE, PROCEDURE) AND NECK 4/13/2017 41712017 4/11/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C8331 DIFFUSE LARGE B -CELL PROFE55IONAL OFFICE $150.34 $494.20 MALE SPOUSE 1 BCC INFUSION TEC HNIQUE ; LETO I HOUR, SINGLEOR INITIAL LYMPHOMA, LYMPH SUBSTANCE /DRUG NODES OF HEAD, FACE, AND NECK 4/13/2017 4/7/2017 4/11/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $132 $6.40 MALE SPOUSE 1 BCC LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/13/2017 4/7/2017 4/11/2017 J1200 INJECTION, DIPHENHYDRAMINE HCL, UPTO50MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $0.52 $3.35 MALE SPOUSE 1BCC LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/13/2017 4/7/2017 4/11/2017 12469 PALONOSETRON HCL C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $192.60 $594.40 MALE SPOUSE 1 BCC LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/13/2017 4/712017 4/11/2017 J9000 INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $20.40 $149.00 MALE SPOUSE 1 BCC LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/13/2017 4/7/2017 4/11/2017 19070 CYCLOPHOSPHAMIDE, 100 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $357.60 $892.20 MALE SPOUSE 1 BCC LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/13/2017 4/7/2017 4/11/2017 J9370 VINCRISTINE SULFATE, I MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $7.57 $24.28 MALE SPOUSE 1BCC LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/13/2017 4/10/2017 411212017 96360 Intravenous infusl on, hydration; in itia 1, 31 minutes to 1 E860 DEHYDRATION PROFESSIONAL OFFICE $2,500.00 MALE SPOUSE $8,865.43 hau SPOUSE $725.86 $725.86 MALE 4/13/2017 4/10/2017 4/12/201717030 INFUSION, NORMAL SALINE SOLUTION, 1000 CC E860 DEHYDRATION PROFESSIONAL OFFICE 4/14/2017 3/1/2017 4/13/2017 38510 BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP R220 LOCALIZED SWELLING, PROFESSIONAL $70.00 MALE SPOUSE $141.30 CERVICAL NODE(S) SPOUSE MASS AND LUMP, HEAD OUTPATIENT /HOSPITAL 4/18/2017 4/3/2017 4/7/2017 *' * ** * * * ** ° " * ** * * * ** * * * ** 4/18/2017 4/4/2017 4112/2017 - - C8331 DIFFUSE LARGE B -CELL HOSPITAL OUTPATIENT LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/18/2017 4/5/2017 4/8/2017 - - N1330 UNSPECIFIED HOSPITAL OUTPATIENT HYDRONEPHROSIS 4/18/2017 4/10/2017 4/13/2017 * * * ** * * * ** ` * * ** * * * ** * * * ** 4/20/2017 413/2017 4/19/2017 88271 MOLECULAR CYTOGENETICS; DNA PROBE, EACH )EG, FISH) C8331 DIFFUSE LARGE B -CELL OTHER MEDICAL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 412012017 4/3/2017 4/19/2017 88275 MOLECULAR CYTOGENETICS; INTERPHASE IN SITU C8331 DIFFUSE LARGE B -CELL OTHER MEDICAL HYBRIDIZATION, ANALYZE 100 -300 CELLS LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 4/21/2017 4/4/2017 4/20/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 N1330 UNSPECIFIED PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY HYDRONEPHROSIS OUTPATIENT/HOSPITAL 4/24/2017 4/19/2017 4/21/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, LYMPH PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY NODES OF HEAD, FACE, COMPONENTS: A DETAILED HISTORY; A DETAILED AND NECK EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/25/2017 4/5/2017 4/8/2017 - - C8590 NON- HODGKIN HOSPITAL OUTPATIENT LYMPHOMA, UNSPECIFIED, UNSPECIFIED SITE 4/26/201] 4/1]/201] 4/20/201] * " ** * * * ** * * * ** ` * * ** * * * ** 4/2]/201] 4/21/201] 4/26/2017 81002 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR N1330 UNSPECIFIED PROFESSIONAL OFFICE BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, HYDRONEPHROSIS LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON - AUTOMATED, WITHOUT MICROSCOPY 4/27/2017 4/21/2017 4/26/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N1330 UNSPECIFIED PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYDRONEPHROSIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 5/2/2017 4/5/2017 5/1/2017 52332 CYSTOURETHROSCOPY , WITH INSERTION OF INDWELLING N1330 UNSPECIFIED PROFESSIONAL URETERAL STENT)EG, GIBBONS OR DOUBLE -1 TYPE) HYDRONEPHROSIS INPATIENT /HOSPITAL 5/2/2017 4/24/2017 4/27/2017 * * * ** * * * ** ... * ***** **< ** $78.81 $194.27 MALE SPOUSE $1.96 $3.59 MALE SPOUSE $634.25 $2,500.00 MALE SPOUSE $8,865.43 $8,865.43 MALE SPOUSE $725.86 $725.86 MALE SPOUSE $15,179.52 $28,682.60 MALE SPOUSE $854.00 $1,001.99 MALE SPOUSE $59.58 $864.00 MALE SPOUSE $82.65 $612.00 MALE SPOUSE $11.07 $70.00 MALE SPOUSE $141.30 $348.35 MALE SPOUSE 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC C.7.f 3559 w 3559 N 3559 Q! 3559 3559 7 3559 fl } 3559 3559 CL CL Q 3559 4 F 3559 LIJ h D 3559 $12,620.23 $16,098.08 MALE SPOUSE 1 BCC 3559 $854.00 $1,001.99 MALE SPOUSE 1 BCC 3559 $2.10 $20.00 MALE SPOUSE 1 BCC 3559 $86.79 $240.00 MALE SPOUSE 1 BCC 3559 $199.02 $550.00 MALE SPOUSE 1 BCC 3559 $854.00 $1,001.99 MALE SPOUSE 1 BCC 3559 5/3/2017 4/27/2017 5/1/2017 963671 NTRAVENO US IN FUSION, FORTH ERAPY, PRO PHYLAX IS, R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $6.40 MALE SPOUSE 1 BCC OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); $0.65 UNSPECIFIED SPOUSE 1 BCC 3559 $192.60 ADDITIONAL SEQUENTIAL INFUSION OF ANEW SPOUSE 1 BCC 3559 $173.90 $428.76 MALE SPOUSE DRUG /SUBSTANCE, UP TO 1 HOUR )LIST SEPARATELY IN 3559 $200.46 $494.20 MALE SPOUSE 1 BCC 3559 ADDITION TO CODE FOR PRIMARY PROCEDURE) $208.72 MALE SPOUSE 1 BCC 5/3/2017 4/27/2017 51112017 96375 Therapeutic, prophylactic, ordiagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $149.00 MALE SPOUSE 1 BCC su Est ance or drug); each add itio na l seque rut l i nt —enous $447.00 UNSPECIFIED SPOUSE 1 BCC 3559 $6,671.52 push of a new substance /drug (List separately in addition SPOUSE 1 BCC 3559 $9.46 $24.28 MALE SPOUSE to code for primary procedure) 3559 $31.41 $77.44 MALE 5/3/2017 4/27/2017 5/1/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE 3559 UNSPECIFIED 5/3/2017 4/27/2017 5/1/201711200 INJECTION, DIPHENHYDRAMINE HCL, UPTO50MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 5/3/2017 4/27/2017 5/1/201712469 PALONOSETRON HCL 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 5/3/2017 4/27/2017 5/1/2017 96411 CHEMOTHERAPY ADMINISTRATION ; INTRAVENOUS, PUSH C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE TECHNIQUE, EACH ADDITIONAL SUBSTANCE /DRUG(LIST LYMPHOMA, LYMPH SEPARATELY IN ADDITION TO CODE FOR PRIMARY NODES OF HEAD, FACE, PROCEDURE) AND NECK 5/3/2017 4/27/2017 5/1/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE INFUSION TECHNIQUE; UP TO I HOUR, SINGLE OR INITIAL LYMPHOMA, LYMPH SUBSTANCE /DRUG NODES OF HEAD, FACE, AND NECK 5/3/2017 4/27/2017 5/1/2017 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE TO CODE FOR PRIMARY PROCEDURE) LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 5/3/2017 4/27/2017 5/1/2017 96417 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE INFUSION TECHNIQUE; EACH ADDITIONAL SEQUENTIAL LYMPHOMA, LYMPH INFUSION (DIFFERENT SUBSTANCE /DRUG), UP TO I HOUR NODES OF HEAD, FACE, (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY AND NECK PROCEDURE) 5/3/2017 4/27/2017 5/1/2017 19000 INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 5/3/2017 4/27/2017 51112017 19070 CYCLOPHOSPHAMIDE, 100 MG 08331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 5/3/2017 412712017 5/1/2017 19310 INJECTION, RITUXIMAB, 100 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 5/3/2017 4/27/2017 5/1/201719370 VINCRISTINE SULFATE, I MG 08331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 5/4/2017 4/28/2017 5/2/2017 96372 Therapeutic, prophylactic, or diagnostic Injection (specify C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE substance or drug); subcutaneous or l ntramuscular LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 5/4/2017 4/28/2017 5/2/201712505 INJECTION, PEGFILGRASTIM,6MG 08331 DIFFUSE LARGE &CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK $0.00 $219.98 MALE SPOUSE 1 BCC C.7.f 3559 $0.00 $76.85 MALE SPOUSE 1 BCC 3559 $2.40 $6.40 MALE SPOUSE 1 BCC 3559 $0.65 $3.35 MALE SPOUSE 1 BCC 3559 $192.60 $594.40 MALE SPOUSE 1 BCC 3559 $173.90 $428.76 MALE SPOUSE 1 BCC 3559 $200.46 $494.20 MALE SPOUSE 1 BCC 3559 $84.66 $208.72 MALE SPOUSE 1 BCC 3559 $9918 $244.77 MALE SPOUSE 1 BCC 3559 $25.50 $149.00 MALE SPOUSE 1 BCC 3559 $447.00 $892.20 MALE SPOUSE 1 BCC 3559 $6,671.52 $15,538.32 MALE SPOUSE 1 BCC 3559 $9.46 $24.28 MALE SPOUSE 1 BCC 3559 $31.41 $77.44 MALE SPOUSE 1 BCC 3559 $4,117.23 $8,44935 MALE SPOUSE 1 BCC 3559 5/24/2017 5/13/2017 5/23/2017 78815 POSITRON EMISSION TOMOGRAPHY(PET)WITH C8330 DIFFUSE LARGE B -CELL PROFESSIONAL $194.31 CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY SPOUSE LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL $48.47 (CT( FORATTENUATION CORRECTION AND ANATOMICAL SPOUSE SITE Al $0.00 LOCALIZATION IMAGING; SKULL BASE TO MID -THIGH SPOUSE 1 BCC N 5/24/2017 5/13/2017 5/23/2017 * * " $348.35 MALE SPOUSE 1 BCC m 6/8/2017 6/5/2017 6/7/2017 81002 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR N1330 UNSPECIFIED PROFESSIONAL OFFICE $2.10 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, SPOUSE HYDRONEPHR05IS 3559 LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON AUTOMATED, WITHOUT MICROSCOPY i' 6/8/2017 6/5/2017 6/7/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N1330 UNSPECIFIED PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYDRONEPHROSIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $8639 COMPONENTS: AN EXPANDED PROBLEM FOCUSED SPOUSE 1 BCC 3559 HISTORY; AN EXPANDED PROBLEM FOCUSED W EXAMINATION; MEDICAL DECISION MAKING OF LOW } COMPLEXITY. COUNSELING AND COORD fl i® 6/13/2017 31 5/24/2017 88307 LEVELV- SURGICAL PATHOLOGY, GROSS AND C8331 DIFFUSE LARGE B -CELL PROFESSIONAL MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENTS( , PATHOLOGIC NODES OF HEAD, FACE, Q $113.79 FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR SPOUSE AND NECK 3559 RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OFSURGICAL MARGINS BREAST, MASTECT 6/13/2017 3/1/2017 5/24/2017 88333 PATHOLOGY CONSULTATION DURING SURGERY; C8331 DIFFUSE LARGE B -CELL PROFESSIONAL CYTOLOGIC EXAMINATION (EG, TOUCH PREP, SQUASH LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL PREP), INITIAL SITE NODES OF HEAD, FACE, AND NECK 6/13/2017 3/1/2017 5124/2017 883411MMUNOHISTOC HEMISTRY OR IMMUNO CYT0CHEMISTRY, C8331 DIFFUSE LARGE B -CELL PROFESSIONAL PER SPECIMEN; EACH ADDITIONAL SINGLE ANTIBODY LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO NODES OF HEAD, FACE, CODE FOR PRIMARY PROCEDURE) AND NECK 6113/2017 3/1/2017 5/24/2017 883421MMUNOHISTOC HEMISTRY OR IMMUNOCYTOCHEMISTRY , C8331 DIFFUSE LARGE B -CELL PROFESSIONAL PER SPECIMEN; INITIALSINGLE ANTIBODY STAIN LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL PROCEDURE NODES OF HEAD, FACE, AND NECK 6/14/2017 5/13/2017 6/13/2017 83615 LACTATE DEHYDROGENASE(ED),(LDH); C9331 DIFFUSE LARGE &CELL PROFESSIONAL LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL NODES OF HEAD, FACE, AND NECK 6/15/2017 5/18/2017 6/14/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, LYMPH PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY NODES OF HEAD, FACE, COMPONENTS: A DETAILED HISTORY; A DETAILED AND NECK EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/15/2017 6/8/2017 6114/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, LYMPH PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY NODES OF HEAD, FACE, COMPONENTS: A DETAILED HISTORY; A DETAILED AND NECK EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER $85.91 $347.00 MALE SPOUSE 1 RICE C.7.f $194.31 $477.00 MALE SPOUSE 1 BCC 3559 w $48.47 $266.00 MALE SPOUSE 1 BCC Al $0.00 $16.00 MALE SPOUSE 1 BCC N $141.30 $348.35 MALE SPOUSE 1 BCC m $11,379.00 $18,236.70 MALE SPOUSE 1 BCC 3559 $2.10 $20.00 MALE SPOUSE 1 BCC 3559 i' $8639 $240.00 MALE SPOUSE 1 BCC 3559 W } fl i® CL CL Q $113.79 $531.00 MALE SPOUSE 1 BCC 3559 $85.91 $347.00 MALE SPOUSE 1 RICE 3559 $421.08 $1,331.00 MALE SPOUSE 1 BCC 3559 $48.47 $266.00 MALE SPOUSE 1 BCC 3559 $0.00 $16.00 MALE SPOUSE 1 BCC 3559 $141.30 $348.35 MALE SPOUSE 1 BCC 3559 $141.30 $348.35 MALE SPOUSE 1 BCC ma 6/19/2017 5/18/2017 6/14/2017 963671 NTRAVENO US IN FUSION, FORTH ERAPY, PRO PHYLAX IS, R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $6.40 MALE SPOUSE 1 BCC OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); $0.65 UNSPECIFIED SPOUSE 1 BCC 3559 $192.60 ADDITIONAL SEQUENTIAL INFUSION OF ANEW SPOUSE 1 BCC 3559 $173.90 $428.76 MALE SPOUSE DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN 3559 $200.46 $494.20 MALE SPOUSE 1 BCC 3559 ADDITION TO CODE FOR PRIMARY PROCEDURE) $313.08 MALE SPOUSE 1 BCC 6/19/2017 5/18/2017 6/14/2017 96375 Therapeutic, prophylactic, or diagnostic Infection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $149.00 MALE SPOUSE 1 BCC subs tanc eo rdr ug); eachadditi onalsequentialintravenous $670.50 UNSPECIFIED SPOUSE 1 BCC 3559 $6,671.52 push of a new substance /drug (USt separately in addition SPOUSE 1 BCC 3559 $9.46 $24.28 MALE SPOUSE to code for primary procedure( 3559 $3141 $77.44 MALE 6/19/2017 5/18/2017 6/14/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE 3559 $854.00 $1,24330 MALE SPOUSE 1 BCC UNSPECIFIED 6/19/2017 5/18/2017 6/14/201711200 INJECTION, DIPHENHYDRAMINE HCL, UPTO50MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 6/19/2017 5/18/2017 6/14/201712469 PALONOSETRON HCL 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 6/19/2017 5/18/2017 6/14/2017 96411 CHEMOTHERAPY ADMINISTRATION ; INTRAVENOUS, PUSH C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE TECHNIQUE, EACH ADDITIONAL SUBSTANCE /DRUG(LIST LYMPHOMA, LYMPH SEPARATELY IN ADDITION TO CODE FOR PRIMARY NODES OF HEAD, FACE, PROCEDURE) AND NECK 6/19/2017 5/18/2017 6/14/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE INFUSION TECHNIQUE; UP TO I HOUR, SINGLE OR INITIAL LYMPHOMA, LYMPH SUBSTANCE /DRUG NODES OF HEAD, FACE, AND NECK 6/19/2017 5/18/2017 6114/2017 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE TO CODE FOR PRIMARY PROCEDURE) LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 5/18/2017 6/14/2017 96417 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE INFUSION TECHNIQUE; EACH ADDITIONAL SEQUENTIAL LYMPHOMA, LYMPH INFUSION (DIFFERENT SUBSTANCE /DRUG(, UP TO I HOUR NODES OF HEAD, FACE, (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY AND NECK PROCEDURE) 6/19/2017 5118/2017 6/14/2017 19000 INJECTION, DOKORUBICIN HYDROCHLORIDE, 10 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 5/18/2017 6/14/2017 19070 CYCLOPHOSPHAMIDE, 100 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 5/18/2017 6/14/2017 19310 INJECTION, RITUXIMAB, 100 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 5/18/2017 6/14/2017 J9370 VINCRISTINE SULFATE, 1 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 5/19/2017 6/14/2017 96372 Therapeutic, prophylactic, ordiagnostic Injection (specify C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE substance or drug); subcutaneous or l intramuscular LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 5/19/2017 6/14/201712505 INJECTION, PEGFILGRASTIM,6MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 6/5/2017 6/13/2017 * * * ** $0.00 $219.98 MALE SPOUSE 1 BCC C.7.f 3559 $0.00 $76.85 MALE SPOUSE 1 BCC 3559 $2.40 $6.40 MALE SPOUSE 1 BCC 3559 $0.65 $3.35 MALE SPOUSE 1 BCC 3559 $192.60 $594.40 MALE SPOUSE 1 BCC 3559 $173.90 $428.76 MALE SPOUSE 1 BCC 3559 $200.46 $494.20 MALE SPOUSE 1 BCC 3559 $126.99 $313.08 MALE SPOUSE 1 BCC 3559 $9918 $244.77 MALE SPOUSE 1 BCC 3559 $25.50 $149.00 MALE SPOUSE 1 BCC 3559 $670.50 $1,338.30 MALE SPOUSE 1 BCC 3559 $6,671.52 $15,538.32 MALE SPOUSE 1 BCC 3559 $9.46 $24.28 MALE SPOUSE 1 BCC 3559 $3141 $77.44 MALE SPOUSE 1 BCC 3559 $4,117.23 $8,44935 MALE SPOUSE 1 BCC 3559 $854.00 $1,24330 MALE SPOUSE 1 BCC 3559 6/19/2017 6/8/2017 6/14/2017 963671 NTRAVENO US IN FUSION, FORTH ERAPY, PRO PHYLAX IS, R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $6.40 MALE SPOUSE 1 BCC OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); $0.65 UNSPECIFIED SPOUSE 1 BCC 3559 $192.60 ADDITIONAL SEQUENTIAL INFUSION OF ANEW SPOUSE 1 BCC 3559 $173.90 $428.76 MALE SPOUSE DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN 3559 $200.46 $494.20 MALE SPOUSE 1 BCC 3559 ADDITION TO CODE FOR PRIMARY PROCEDURE) $313.08 MALE SPOUSE 1 BCC 6/19/2017 6/8/2017 6/14/2017 96375 Therapeutic, prophylactic, or diagnostic Infection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $149.00 MALE SPOUSE 1 BCC subs tanc eo rdr ug); eachadditi onalsequentialintravenous $447.00 UNSPECIFIED SPOUSE 1 BCC 3559 $6,671.52 push of a new substance /drug (USt separately in addition SPOUSE 1 BCC 3559 $9.46 $24.28 MALE SPOUSE to code for primary procedure( 3559 $3131 $77.44 MALE 6/19/2017 6/8/2017 6/14/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE 3559 UNSPECIFIED 6/19/2017 6/8/2017 6/14/201711200 INJECTION, DIPHENHYDRAMINE HCL, UPTO50MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 6/19/2017 618/2017 6/14/201712469 PALONOSETRON HCL 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 6/19/2017 6/8/2017 6/14/2017 96411 CHEMOTHERAPY ADMINISTRATION ; INTRAVENOUS, PUSH C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE TECHNIQUE, EACH ADDITIONAL SUBSTANCE /DRUG(LIST LYMPHOMA, LYMPH SEPARATELY IN ADDITION TO CODE FOR PRIMARY NODES OF HEAD, FACE, PROCEDURE) AND NECK 6/19/2017 6/8/2017 6/14/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE INFUSION TECHNIQUE; UP TO I HOUR, SINGLE OR INITIAL LYMPHOMA, LYMPH SUBSTANCE /DRUG NODES OF HEAD, FACE, AND NECK 6/19/2017 6/8/2017 6114/2017 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE TO CODE FOR PRIMARY PROCEDURE) LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 6/8/2017 6/14/2017 96417 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE INFUSION TECHNIQUE; EACH ADDITIONAL SEQUENTIAL LYMPHOMA, LYMPH INFUSION (DIFFERENT SUBSTANCE /DRUG(, UP TO I HOUR NODES OF HEAD, FACE, (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY AND NECK PROCEDURE) 6/19/2017 6/8/2017 6/14/2017 19000 INJECTION, DOKORUBICIN HYDROCHLORIDE, 10 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 6/8/2017 6/14/2017 19070 CYCLOPHOSPHAMIDE, 100 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 6/8/2017 6/14/2017 19310 INJECTION, RITUXIMAB, 100 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 6/8/2017 6/14/2017 J9370 VINCRISTINE SULFATE, 1 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 6/9/2017 6/14/2017 96372 Therapeutic, prophylactic, or diagnostic Injection (specify C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE substance or drug); subcutaneous or l intramuscular LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 6/19/2017 6/9/2017 6/14/201712505 INJECTION, PEGFILGRASTIM,6MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK $0.00 $109.99 MALE SPOUSE 1 BCC C.7.f 3559 $0.00 $153.70 MALE SPOUSE 1 BCC 3559 $2.40 $6.40 MALE SPOUSE 1 BCC 3559 $0.65 $3.35 MALE SPOUSE 1 BCC 3559 $192.60 $594.40 MALE SPOUSE 1 BCC 3559 $173.90 $428.76 MALE SPOUSE 1 BCC 3559 $200.46 $494.20 MALE SPOUSE 1 BCC 3559 $126.99 $313.08 MALE SPOUSE 1 BCC 3559 $9918 $244.77 MALE SPOUSE 1 BCC 3559 $25.50 $149.00 MALE SPOUSE 1 BCC 3559 $447.00 $892.20 MALE SPOUSE 1 BCC 3559 $6,671.52 $15,538.32 MALE SPOUSE 1 BCC 3559 $9.46 $24.28 MALE SPOUSE 1 BCC 3559 $3131 $77.44 MALE SPOUSE 1 BCC 3559 $4,117.23 $8,44935 MALE SPOUSE 1 BCC 3559 6/27/2017 4/5/2017 6/26/2017 74000 RADIOLOGIC EXAM I NATION, ABDOMEN; SINGLE Z0189 ENCOUNTER FOR OTHER PROFESSIONAL $11,379.00 ANTEROPOSTERIOR VIEW SPOUSE SPECIFIED SPECIAL OUTPATIENT /HOSPITAL $124.30 $292.00 MALE SPOUSE EXAMINATIONS 6/30/2017 6/24/2017 6/29/2017 ..... . » ».. ..... ... »r 71712017 4/3/2017 7/6/2017 38221 BONE MARROW; BIOPSY, NEEDLE OR TROCAR C9510 UNSPECIFIED B -CELL PROFESSIONAL $14.41 $48.00 MALE SPOUSE LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL $616.81 $1,399.00 MALE SPOUSE SITE 7/7/2017 4/3/2017 7/6/2017 77002 FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT(EG, C8510 UNSPECIFIED B -CELL PROFESSIONAL $31.75 BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) SPOUSE LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL SITE 71712017 4/3/2017 7/6/2017 99152 Moderate sedation services provided bythe same 08510 UNSPECIFIED B -CELL PROFESSIONAL physician or other qualified health care professional LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL performingthe diagnostic or therapeutic service that SITE 7/7/2017 413/2017 7/6/2017 G0364 BONE MARROW ASPIRATE &BIOPSY C8510 UNSPECIFIED B -CELL PROFESSIONAL LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL SITE 71712017 4/5/2017 7/6/2017 36561 INSERTION OFTUNNELED CENTRALLY INSERTED CENTRAL C8510 UNSPECIFIED B -CELL PROFESSIONAL VENOUS ACCESS DEVICE, W ITH SUBCUTANEOUS PORT; LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL AGE 5 YEARS OR OLDER SITE 7/7/2017 4/5/2017 7/6 /2017 76937 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS C8510 UNSPECIFIED B -CELL PROFESSIONAL REQUIRING ULTRASOUND EVALUATION OF POTENTIAL LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL ACCESS SITES, DOCUMENTATION OF SELECTEDVESSEL SITE PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION OF VASCULAR NEEDLE ENTRY, 7/7/2017 4/S/2017 7/6/2017 77001 FLUOROSCDPIC GUIDANCE FOR CENTRAL VENOUS ACCESS C8510 UNSPECIFIED B -CELL PROFESSIONAL DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR LYMPHOMA, UNSPECIFIED INPATIENT /HOSPITAL COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC SITE GUIDANCE FORVASCULAR ACCESS AND CATHETER MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER W ITH RELATED VENOGRAPHYR 7/7/2017 6/30/2017 7/4/2017 96372 Therapeutic, prophylactic, ordiagnostic injection (specify C8331 DIFFUSE LARGE B-CELL PROFESSIONAL OFFICE substance or drug); subcutaneous or Intramuscular LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 71712017 6/30/2017 7/4/2017 J2505 INJECTION, PEGFILGRASTIM,6MG C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 7/11/2017 6/24/2017 7/10/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET) WITH C8330 DIFFUSE LARGE B -CELL PROFESSIONAL CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL (CT)FORATTENUATION CORRECTION AND ANATOMICAL SITE LOCALIZATION IMAGING; SKULL BASE TD MID THIGH 7/12/2017 6/29/2017 7/11/2017 99215 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, LYMPH PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY NODES OF HEAD, FACE, COMPONENTS: A COMPREHENSIVE HISTORY; A AND NECK COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 7/14/2017 6/29/2017 7/11/2017 96375 Therapeutic, prophylactic, or diagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE substance or drug); each a dditi... l sequential ntravenous UNSPECIFIED push of a new substance /drug (List separately In addition to c.de for primary procedure) $14.94 $36.00 MALE SPOUSE 1 BCC $11,379.00 $18,236.70 MALE SPOUSE 1 BCC $124.30 $292.00 MALE SPOUSE 1 BCC $46.72 $100.00 MALE SPOUSE 1 BCC $20.62 $48.00 MALE SPOUSE 1 BCC $14.41 $48.00 MALE SPOUSE 1 BCC $616.81 $1,399.00 MALE SPOUSE 1 BCC $23.87 $64.00 MALE SPOUSE 1 BCC $31.75 $71.00 MALE SPOUSE 1 BCC C.7.f 3559 w Z N 3559 3559 3559 7 3559 fl } fl 3559 CL CL Q 3559 v Q 3559 M I $3141 $77.44 MALE SPOUSE 1 BCC 3559 $4,117.23 $8,449.85 MALE SPOUSE 1 BCC 3559 $194.31 $477.00 MALE SPOUSE 1 BCC 3559 $190.28 $469.12 MALE SPOUSE 1 BCC 3559 $0.00 $76.85 MALE SPOUSE 1 BCC Em 7/14/2017 6/29/2017 7/11/201712469 PALONOSETRON DEL R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $494.20 MALE SPOUSE 1 BCC 3559 $84.66 UNSPECIFIED SPOUSE 7/17/2017 6/29/2017 7/11 /2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C8331 DIFFUSE LARGE B-CELL PROFESSIONAL OFFICE $2.40 $6.40 MALE SPOUSE OR DIAGNOSIS ISPECIFY SUBSTANCE OR DRUG); 3559 LYMPHOMA, LYMPH $3.35 MALE SPOUSE 1 BCC 3559 ADDITIONAL SEQUENTIAL INFUSION OF A NEW $149.00 MALE NODES OF HEAD, FACE, 1 BCC 3559 $670.50 $1,338.30 MALE DRUG /SUBSTANCE, UP TO I HOUR (LIST SEPARATELY IN 1 BCC AND NECK $6,671.52 $15,53832 MALE SPOUSE 1 BCC ADDITION TO CODE FOR PRIMARY PROCEDURE) $9.46 $24.28 MALE SPOUSE 7/17/2017 6/29/2017 7111/2017 96411 CHEMOTHERAPY ADMINISTRATION ; INTRAVENOUS, PUSH C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $0.00 $164.00 MALE SPOUSE TECHNIQUE, EACH ADDITIONAL SUBSTANCE /DRUG(LIST 3559 LYMPHOMA, LYMPH $36.00 MALE SPOUSE 1 BCC 3559 SEPARATELY IN ADDITION TO CODE FOR PRIMARY NODES OF HEAD, FACE, PROCEDURE) AND NECK 7/17/2017 6/29/2017 7/11/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE INFUSION TECHNIQUE; UP TO I HOUR, SINGLE OR INITIAL LYMPHOMA, LYMPH SUBSTANCE /DRUG NODES OF HEAD, FACE, AND NECK 7117/2017 6/29/2017 7/11/2017 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE TO CODE FOR PRIMARY PROCEDURE) LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 711712017 6/29/2017 7/11/2017 96417 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE INFUSION TECHNIQUE; EACH ADDITIONAL SEQUENTIAL LYMPHOMA, LYMPH INFUSION (DIFFERENT SUBSTANCE /DRUG), UP TO I HOUR NODES OF HEAD, FACE, (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY AND NECK PROCEDURE) 7/17/2017 6/29/2017 7/11/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 7/17/2017 6/29/2017 7/11/201711200 INJECTION, DIPHENHYDRAMINE HCL, UPTOSOMG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 7/17/2017 6/29/2017 7/11/2017 19000 INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 M6 C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 7/17/2017 6/29/2017 7/11/2017 19070 CYCLOPHOSPHAMIDE, 100 MG C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 7/17/2017 6/29/2017 7/11/201719310 INJECTION, RITUXIMAB, 100 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 7/17/2017 6/29/2017 7/11/2017 19370 VINCRISTINE SULFATE, 1 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 7/17/2017 7/6/2017 7/14/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION D709 NEUTROPENIA, OTHER MEDICAL AND PRESUMPTIVE IDENTIFICATION OF ISOLATES UNSPECIFIED (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) 7/17/2017 7/6/2017 7/14/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, D709 NEUTROPENIA, OTHER MEDICAL FRONTAL AND LATERAL; UNSPECIFIED 7117/2017 7/6/2017 7/14/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR D709 NEUTROPENIA, OTHER MEDICAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, UNSPECIFIED LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UR0BILINDGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY $192.60 $594.40 MALE SPOUSE $89.24 $219.98 MALE SPOUSE C.7.f 1 BCC 3559 w 1 BCC 3559 N $173.90 $428.76 MALE SPOUSE 1 BCC 3559 $200.46 $494.20 MALE SPOUSE 1 BCC 3559 $84.66 $208.72 MALE SPOUSE 1 BCC 3559 $99.28 $244.77 MALE SPOUSE 1 BCC 3559 $2.40 $6.40 MALE SPOUSE 1 BCC 3559 $0.65 $3.35 MALE SPOUSE 1 BCC 3559 $25.50 $149.00 MALE SPOUSE 1 BCC 3559 $670.50 $1,338.30 MALE SPOUSE 1 BCC 3559 $6,671.52 $15,53832 MALE SPOUSE 1 BCC 3559 $9.46 $24.28 MALE SPOUSE 1 BCC 3559 $14.16 $156.00 MALE SPOUSE 1 BCC 3559 $0.00 $164.00 MALE SPOUSE 1 BCC 3559 $0.00 $36.00 MALE SPOUSE 1 BCC 3559 rl 7/17/2017 7/6/2017 7/14/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, D709 NEUTROPENIA, OTHER MEDICAL $2.10 HCf, RISC, WBC AND PLATELET COUNT) AND AUTOMATED SPOUSE UNSPECIFIED 3559 $127.40 DIFFERENTIAL W BC COUNT SPOUSE 1 BCC 3559 7/17/2017 7/6/2017 7/14/2017 963651rtravenous infusion, for therapy, p rophyla,is, or diagnosis D709 NEUTROPENIA, OTHER MEDICAL $84.66 (specify substance or drug); initial, up to 1 hour SPOUSE UNSPECIFIED 3559 7/17/2017 7/6/2017 7/14/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D709 NEUTROPENIA, OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 7/17/2017 7/6/2017 7/14/2017 11956 INJECTION, LEVOFLOXACIN, 250 MG D709 NEUTROPENIA, OTHER MEDICAL UNSPECIFIED 7124/2017 7/19/2017 7/21/2017 81002 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR N1330 UNSPECIFIED PROFESSIONAL OFFICE BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, HYDRONEPHROSIS LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINDGEN, ANY NUMBER OF THESE CONSTITUENTS; NON AUTOMATED, WITHOUT MICROSCOPY 7/24/2017 7/19/2017 7/21/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N1330 UNSPECIFIED PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYDRONEPHROSIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 7/25/2017 7/20/2017 7/24/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, LYMPH PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY NODES OF HEAD, FACE, COMPONENTS: A DETAILED HISTORY; A DETAILED AND NECK EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 7/27/2017 7/20/2017 7/24/201712469 PALONOSETRON HCL R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 7/27/2017 7/20/2017 7/24/2017 96375 Therapeutic, prophylactic, ordlagnostic Infection (specify C9331 DIFFUSE LARGE &CELL PROFESSIONAL OFFICE substance or drug); each additional sequential intravenous LYMPHOMA, LYMPH push of a new substance /drug(List separately In addition NODES OF HEAD, FACE, to code for prlmaP procedure) AND NECK 712712017 712012017 7/24/2017 96411 CHEMOTHERAPY ADMINISTRATION ; INTRAVENOUS, PUSH C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE TECHNIQUE, EACH ADDITIONAL SUBSTANCE /DRUG(LIST LYMPHOMA, LYMPH SEPARATELY IN ADDITION TO CODE FOR PRIMARY NODES OF HEAD, FACE, PROCEDURE) AND NECK 7/27/2017 7/20/2017 7/24/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE INFUSION TEC HNIQUE ; UP TO I HOUR, SINGLE OR INITIAL LYMPHOMA, LYMPH SUBSTANCE /DRUG NODES OF HEAD, FACE, AND NECK 7/27/2017 7/20/2017 7/24/2017 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE TO CODE FOR PRIMARY PROCEDURE) LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK $0.00 $58.00 MALE SPOUSE $0.00 $314.00 MALE SPOUSE $225.00 $300.00 MALE SPOUSE 1 BCC 1 BCC 1 BCC C.7.f 3559 w Z 3559 OR m Q! 3559 $0.00 $38.00 MALE SPOUSE 1 BCC 3559 $2.10 $20.00 MALE SPOUSE 1 BCC 3559 $127.40 $350.00 MALE SPOUSE 1 BCC 3559 $141.30 $348.35 MALE SPOUSE 1 BCC 3559 $192.60 $594.40 MALE SPOUSE 1 BCC 3559 $93.51 $230.55 MALE SPOUSE 1 BCC 3559 $173.90 $428.76 MALE SPOUSE 1 BCC 3559 $200.46 $494.20 MALE SPOUSE 1 BCC 3559 $84.66 $208.72 MALE SPOUSE 1 BCC 3559 E 712712017 7/20/2017 7/24/2017 96417 CHEMOTHERAPY ADM IN ISTRATION, INTRAVENOUS C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE 1 BCC $0.76 $3.35 MALE INFUSION TEC HNIQUE; EACH ADDITIONAL SEQUENTIAL 1 BCC LYMPHOMA, LYMPH $149.00 MALE SPOUSE 1 BCC $670.50 INFUSION (DIFFERENT SUBSTANCE /DRUG), UP TO I HOUR SPOUSE NODES OF HEAD, FACE, $6,670.00 $15,538.32 MALE SPOUSE 1 BCC (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY $24.28 MALE AND NECK 1 BCC $3141 $77.44 MALE SPOUSE PROCEDURE) $4,191.34 $8,449.85 MALE SPOUSE 712712017 712012017 7/24/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE SPOUSE 1 BCC $0.00 $77.00 MALE SPOUSE LYMPHOMA, LYMPH $225.00 $300.00 MALE SPOUSE 1 BCC NODES OF HEAD, FACE, AND NECK 7/27/2017 7/20/2017 7/24/201711200 INJECTION, DIPHENHYDRAMINE HOT, UPTO50MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 7/27/2017 712012017 7/24/2017 19000 INJECTION, DOXORUBICIN HYDROCHLORIDE, 30 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 7/27/2017 7/20/2017 7/24/2017 19070 CYCLOPHOSPHAMIDE, 100 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 712712017 712012017 7/24/2017 19310 INJECTION, RITUXIMAB, 100 MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 7/27/2017 7/20/2017 7/24/201719370 VINCRISTINE SULFATE, I MG C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 712712017 7/21/2017 7/25/2017 96372 Therapeutic, prophylactic, ordiagnostic Infection (specify C9331 DIFFUSE LARGE B-CELL PROFESSIONAL OFFICE substance or drug); s ubcutane.ue or l ntramuscular LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 7/27/2017 7/21/2017 7/25/201712505 INJECTION, PEGFILGRASTIM, 6 MG C9331 DIFFUSE LARGE &CELL PROFESSIONAL OFFICE LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 712812017 711212017 711812017 7/31/2017 7/12/2017 7/25/2017 * * ° ** 8/4/2017 7/27/2017 8/2/2017 96372 Therapeutic, prophylactic, ordi.gii is injection (specify 1069 ACUTE UPPER OTHER MEDICAL substance or drug); subcutaneous or Intramuscular RESPIRATORY INFECTION, UNSPECIFIED 8/4/2017 7/27/2017 81212017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1069 ACUTE UPPER OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED RESPIRATORY INFECTION, PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY UNSPECIFIED COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 8/4/2017 7/27/2017 8/2/2017 10696 INJECTION, CEFTRIAXONE SODIUM, PER 250 MG 1069 ACUTE UPPER OTHER MEDICAL RESPIRATORY INFECTION, UNSPECIFIED 8/9/2017 8/2/2017 8/8/2017 52000 C/5TOURETHROSCOPY(SEPARATE PROCEDURE) N1330 UNSPECIFIED PROFESSIONAL OFFICE HYDRONEPHROSIS $99.28 $244.77 MALE SPOUSE 1 BCC $2.20 $6.40 MALE SPOUSE 1 BCC $0.76 $3.35 MALE SPOUSE 1 BCC $52.20 $149.00 MALE SPOUSE 1 BCC $670.50 $1,338.30 MALE SPOUSE 1 BCC $6,670.00 $15,538.32 MALE SPOUSE 1 BCC $9.44 $24.28 MALE SPOUSE 1 BCC $3141 $77.44 MALE SPOUSE 1 BCC $4,191.34 $8,449.85 MALE SPOUSE 1 BCC $3,698.00 $3,698.00 MALE SPOUSE 1 BUT $7843 $194.00 MALE SPOUSE 1 BCC $0.00 $77.00 MALE SPOUSE 1 BCC $225.00 $300.00 MALE SPOUSE 1 BCC $0.00 $8.00 MALE SPOUSE $198.66 $675.00 MALE SPOUSE 1 BCC 1 BCC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 8/9/2017 8/2/2017 81812017 81002 URINALYSIS, BY D I P STICK OR TABLET REAGENT FOR N1330 UNSPECIFIED PROFESSIONAL OFFICE $980.21 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, SPOUSE HYDRONEPHROSIS 3559 $119.91 LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, SPOUSE 1 BCC 3559 ($113.79) UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; SPOUSE 1 BCC 3559 NON AUTOMATED, WITHOUT MICROSCOPY 811512017 81712017 8/14/2017 • « « »+ ..... » « » +» .. vwr ... ». 8/23/2017 8/10/2017 8/22/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, LYMPH PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY NODES OF HEAD, FACE, COMPONENTS: A DETAILED HISTORY; A DETAILED AND NECK EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 8/25/2017 7/17/2017 8/15/2017 `k "`* ... " "' `.... ' « "+ 8128/2017 8/24/2017 8/25/2017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE N1330 UNSPECIFIED PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYDRONEPHROSIS PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 8/31/2017 8/21/2017 8/30/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C8510 UNSPECIFIED B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, UNSPECIFIED PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY SITE COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 9/6/2017 3/1/2017 5124/2017 88307 LEVELV - SURGICAL PATHOLOGY, GROSS AND C8331 DIFFUSE LARGE B-CELL PROFESSIONAL MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENTS) , PATHOLOGIC NODES OF HEAD, FACE, FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR AND NECK RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT 9/6/2017 3/1/2017 5/24/2017 88333 PATHOLOGY CONSULTATION DURING SURGERY; C8331 DIFFUSE LARGE B -CELL PROFESSIONAL CYTOLOGIC EXAMINATION (EG, TOUCH PREP, SQUASH LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL PREP), INITIAL SITE NODES OF HEAD, FACE, AND NECK 9/6/2017 31 5/24/2017 883411MMUNOHISTOC HEMISTRY OR IMMUNO CYTOCHEMISTRY, C8331 DIFFUSE LARGE B -CELL PROFESSIONAL PER SPECIMEN; EACH ADDITIONAL SINGLE ANTIBODY LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO NODES OF HEAD, FACE, CODE FOR PRIMARY PROCEDURE) AND NECK 9/6/2017 3/1/2017 5/24/2017 983421MNIUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY , C9331 DIFFUSE LARGE B -CELL PROFESSIONAL PER SPECIMEN; INITIALSINGLE ANTIBODYSTAIN LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL PROCEDURE NODES OF HEAD, FACE, AND NECK 9/6/2017 3/1/2017 5124/2017 88307 LEVELV - SURGICAL PATHOLOGY, GROSS AND C8331 DIFFUSE LARGE B-CELL PROFESSIONAL MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENTS) , PATHOLOGIC NODES OF HEAD, FACE, FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR AND NECK RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OFSURGICAL MARGINS BREAST. MASTECT $2.10 $20.00 MALE SPOUSE 1 BCC $854.00 $905.00 MALE SPOUSE 1 BCC $141.30 $348.35 MALE SPOUSE 1 BCC $706.00 $706.00 MALE SPOUSE 1 BCC $86.79 $240.00 MALE SPOUSE 1 BCC $103.91 $461.00 MALE SPOUSE 1 BCC $280.41 $531.00 MALE SPOUSE 1 BCC C.7.f 3559 0 IN ®' mw $211.42 $347.00 MALE SPOUSE 1 BCC 3559 $980.21 $1,331.00 MALE SPOUSE 1 BCC 3559 $119.91 $266.00 MALE SPOUSE 1 BCC 3559 ($113.79) {5531001 MALE SPOUSE 1 BCC 3559 C.7.f 91 3/1/2017 5/24/2017 88333 PATH OLOGYCONSULTATI ON DURING SURGERY; 08331 DIFFUSE LARGE B -CELL PROFESSIONAL ($85011 ($347.00) MALE SPOUSE 1 BCC 3559 CYTOLOGIC EXAMINATION (EG, TOUCH PREP, SQUASH LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL y� PREP), INITIAL SITE NODES OF HEAD, FACE, AND NECK N 91 3/1/2017 5/24/2017 883411MMUNOHISTOC HEMISTRY OR IMMUNO CYTOCHEMISTRY, C8331 DIFFUSE LARGE B -CELL PROFESSIONAL {$121.081 1$1,311' 0111 MALE SPOUSE 1BCC 3559 PERSPECIMEN; EACH ADDITIONAL SINGLE ANTIBODY LYMPHOMA, LYMPH OUTPATIENT/HOSPIFAL STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO NODES OF HEAD, FACE, CODE FOR PRIMARY PROCEDURE) AND NECK 91 3/1/2017 5124/2017 883421MMUNOHISTO CHEMISTRY ORIMMUNOCYiOCHEMISTRV, 08331 DIFFUSE LARGE B -CELL PROFESSIONAL ($48.471 ($266.001 MALE SPOUSE 1 BCC 3559 � PERSPECIMEN; INITIAL SINGLE ANTIBODY STAIN LYMPHOMA, LYMPH OUTPATIENT /HOSPITAL PROCEDURE NODES OF HEAD, FACE, a�.r AND NECK 91 4/27/2017 8/28/2017 %367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $219.98 MALE SPOUSE 1 BCC 3559 } OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); UNSPECIFIED ADDITIONAL SEQUENTIAL INFUSION OF ANEW A. CL DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN Q, ADDITION TO CODE FOR PRIMARY PROCEDURE) 9/6/2017 4/27/2017 8/28/2017 96375 Therapeutic, prophylactic, ordlagnostic Injection (specify 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $76.85 MALE SPOUSE 1 BCC 3559 substance ordrug); each additional sequential intravenous UNSPECIFIED pusher, new substance /drug (List separately in addition to code for primary procedure( W 91 4/27/2017 8/28/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $6.40 MALE SPOUSE 1 BCC 3559 IE UNSPECIFIED 9/6/2017 4/27/2017 8/28/201]11200 INJECTION, DIPHENHYDRAMINE HCL, UPT050MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $3.35 MALE SPOUSE 1BCC 3559 UNSPECIFIED 91 4/27/2017 8/28/201]12469 PALONOSETRON HCL 8112 NAUSEA WITH VOMITING, PROFE55IONAL OFFICE $0.00 $594.40 MALE SPOUSE 1BCC 3559 UNSPECIFIED Q W 91 5/18/2017 8/28/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $219.98 MALE SPOUSE 1 BCC 3559 OR DIAGNOSIS (SPECIFY SUBSTANCE ORDRUG); UNSPECIFIED UJ ADDITIONAL SEQUENTIAL INFUSION OF A N EW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) e °✓ 91 5/18/2017 812812017 96375 Therapeutic, prophylactic, ordiagnostic injection (specify 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $76.85 MALE SPOUSE 1 BCC 3559 su bstance or drug); each a did itio na l seq ue ntia l i nt —onous UNSPECIFIED push of a new substance /drug (List separately In addition J to code for primary procedure( v 91 5/18/2017 8/28/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $6.40 MALE SPOUSE 1 BCC 3559 r UNSPECIFIED Z W 91 5/18/2017 8/28/201711200 INJECTION, DIPHENHYDRAMINE HCL, UPT050MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $3.35 MALE SPOUSE 1BCC 3559 UNSPECIFIED U 91 5/18/2017 8/28/201]12469 PALONOSETRON HCL R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $594.40 MALE SPOUSE 1BCC 3559 UNSPECIFIED 91 6/8/2017 8/28/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $109.99 MALE SPOUSE 1 BCC 3559 OR DIAGNOSIS (SPECIFY SUBSTANCE ORDRUG); UNSPECIFIED hl ADDITIONAL SEQUENTIAL INFUSION OF A N EW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN = ADDITION TO CODE FOR PRIMARY PROCEDURE) W 9/7/2017 6/8/2017 812812017 96375 Therapeutic, prophylactic, or diagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE C! substance or drug); each addICono l sequential intravenous UNSPECIFIED SO push of a new substance /drug (List separately In addition M $0.00 $6.40 MALE to code for primary procedure) 1 BCC 3559 91 6/8/2017 812812017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 9/7/2017 6/8/2017 8/28/201711200 INJECTION, DIPHENHYDRAMINE HCL, UPTOSDMG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE 7 UNSPECIFIED 9/7/2017 6/8/2017 8/28/201712469 PALONOSETRON HCL R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $594.40 MALE SPOUSE 1 BCC UNSPECIFIED 911112017 412712017 9/1/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, R112 NAUSEA WITH VOMITING, PR0FE55IONAL OFFICE fl $0.00 $219.98 MALE OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); 1 BCC UNSPECIFIED } ADDITIONAL SEQUENTIAL INFUSION OF ANEW iL CL DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN CL ADDITION TO CODE FOR PRIMARY PROCEDURE) 9/11/2017 4/27/2017 9/1/2017 96375Th eap,,rc,prophylactic,,,diagnos to Injection (specify R112 NAUSEAWITH VOMITING, PROFESSIONAL OFFICE $0.00 $76.85 MALE substance or drug); each additional sequential intravenous 1 BCC UNSPECIFIED push of a new substance /drug (List separately In addition to code for primary procedure) 9/11/2017 4/27/2017 91 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE W UNSPECIFIED 9/11/2017 4/27/2017 9/1/201711200 INJECTION, DIPHENHYDRAMINE HCL, UPTOSOMG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $6.40 MALE SPOUSE 1 BCC UNSPECIFIED 9/11/2017 4/27/2017 9/1/201712469 PALONOSETRON HCL R112 NAUSEA WITH VOMITING, PROFESSIONALDFFICE $0.00 $3.35 MALE SPOUSE 1 BCC UNSPECIFIED 9/11/2017 6/29/2017 9/1/2017 96375 Therapeutic, prophylactic, ordiagnostl, fnjectlon (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE x substance or drug); each additional sequential intravenous UNSPECIFIED O $0.00 $594.40 MALE push of a new substance /drug (USt separately In addition 1 BCC 3559 Q to code for primary procedure) 9/11/2017 6/29/2017 9/1/201712469 PALONOSETRON HCL 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE IX $0.OD $76.85 MALE SPOUSE 1 BCC UNSPECIFIED 9/14/2017 8/4/2017 9/13/2017 76770 ULTRASOUND, RETROPERITONEAL(EG, RENAL, AORTA, N1330 UNSPECIFIED OTHER MEDICAL NODES), REALTIME WITH IMAGE DOCUMENTATION; HYDRONEPHROSIS O COMPLETE 9/15/2017 4/27/2017 5/1/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE ILLJ OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); UNSPECIFIED en $0.00 $594.40 MALE ADDITIONAL SEQUENTIAL INFUSION OF A NEW 1 BCC 3559 DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN Q � ADDITION TO CODE FOR PRIMARY PROCEDURE) 9/15/2017 4/27/2017 5/1/2017 96375 Therapeutic, prophylactic, or diagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFE55IONAL OFFICE substance or drug); each additional sequential intravenous UNSPECIFIED v push ,f a new substance /drug (List sepaately In addition $89.24 $219.98 MALE to code for primary procedure) 1 BCC 3559 9/15/2017 4/27/2017 5/1/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE W UNSPECIFIED 9/15/2017 4/27/2017 5/1/201711200 INJECTION, DIPHENHYDRAMINE HCL, UPT050MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED C.7.f $0.00 $153.70 MALE SPOUSE 1 BCC 3559 C! SO M $0.00 $6.40 MALE SPOUSE 1 BCC 3559 $0.00 $3.35 MALE SPOUSE 1 BCC 3559 7 $0.00 $594.40 MALE SPOUSE 1 BCC 3559 fl $0.00 $219.98 MALE SPOUSE 1 BCC 3559 } iL CL CL Q $0.00 $76.85 MALE SPOUSE 1 BCC 3559 F W u $0.00 $6.40 MALE SPOUSE 1 BCC 3559 $0.00 $3.35 MALE SPOUSE 1 BCC 3559 x O $0.00 $594.40 MALE SPOUSE 1 BCC 3559 Q W IX $0.OD $76.85 MALE SPOUSE 1 BCC 3559 UJ O J ILLJ en $0.00 $594.40 MALE SPOUSE 1 BCC 3559 Q � J $125.00 $537.00 MALE SPOUSE 1 BCC 3559 v $89.24 $219.98 MALE SPOUSE 1 BCC 3559 W U Q $31.17 $76.85 MALE SPOUSE 1 BCC 3559 Q N N $240 $6.40 MALE SPOUSE 1 BCC 3559 = E $0.65 $3.35 MALE SPOUSE 1 BCC 3559 ._ C.7.f 9/15/2017 4/27/2017 5/1/2017 12469 PALONOSETRDN HCL R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $192.60 $594.40 MALE SPOUSE 1 BCC 3559 UNSPECIFIED W 9/15/2017 4/27/2017 5/1/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 (52^ -9.98) MALE SPOUSE 1 BCC 3559 N ORDIAGNOSIS ISPECIFY SUBSTANCE ORDRUG); UNSPECIFIED ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9/15/2017 4/27/2017 5/1/2017 96375 Therapeutic, prophylactic, ordiagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 ($76.291 MALE SPOUSE 1 BCC 3559 "a substance ordrug); each additional sequential intravenous UNSPECIFIED push of a new substance /drug (List separately In addition to code for primary procedure( fO 9/15/2017 4/27/2017 5/1/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE 152.491 156.401 MALE SPOUSE 1 BCC 3559 } UNSPECIFIED U. CL CL 9/15/2017 4/27/2017 5/1/2017 J1200 INJECTION, DIPHENHYDRAMINE HCL, UPTO50MG 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE (.$0.65) ($135) MALE SPOUSE 1 BCC 3559 'Q UNSPECIFIED v 9/15/2017 4/27/2017 5/1/201712469 PALONOSETRDN HCL R112 NAUSEAWITH VOMITING, PROFESSIONAL OFFICE ($192.601 ($594,401 MALE SPOUSE 1 BCC 3559 Q 'W UNSPECIFIED F 9/19/2017 5/18/2017 6/14/2017 96367 INTRAVENOUS INFUSION, FORTHERAPY, PROPHYLAXIS, R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $89.24 $219.98 MALE SPOUSE 1 BCC 3559 W ORDIAGNOSIS(SPECIFY SUBSTANCE ORDRUG); UNSPECIFIED IE ADDITIONAL SEQUENTIAL INFUSION OF A NEW W DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) _ 9/19/2017 5/18/2017 6/14/2017 96375 Therapeutic, prophylactic, ordiagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $31.17 $76.85 MALE SPOUSE 1 BCC 3559 substance ordrug); each additional sequential intravenous UNSPECIFIED push of a new substance /drug (List separately In addition Q to code for primary procedure) 9/19/2017 5/18/2017 6/14/2017 J1100 INJECTION, DEXAMETHASONESODIUM PHOSPHATE, I MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $240 $6.40 MALE SPOUSE IBCC 3559 UJ UNSPECIFIED 9/19/2017 5/18/2017 6/14/2017 J1200 INJECTION, DIPHENHYDRAMINE HCL, UPTO50MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.65 $3.35 MALE SPOUSE 1BCC 3559 UNSPECIFIED p W V 9/19/2017 5/18/2017 6/14/2017 12469 PALONOSETRDN HCL 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $192.60 $594.40 MALE SPOUSE 1 BCC 3559 UNSPECIFIED J 9/19/2017 5/18/2017 6/14/2017 96367 INTRAVENOUS INFUSION, FORTHERAPY, PROPHYLAXIS, R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 ($219.98) MALE SPOUSE 1 BCC 3559 V ORDIAGNOSIS(SPECIFY SUBSTANCE ORDRUG); UNSPECIFIED r ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN W ADDITION TO CODE FOR PRIMARY PROCEDURE) 9/19/2017 5 /18 /2017 6/14/2017 96375 Therapeutic, prophylactic, ordiagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 (.$76.351 MALE SPOUSE 1 BCC 3559 substance or drug); each addit1ono l seq uential intravenous UNSPECIFIED Q push of a new substance /drug (List separately In addition F to code for primary procedure) N 9/19/2017 5/18/2017 6/14/2017 J1100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE ($2.401 ($fi 401 MALE SPOUSE 1 BCC 3559 N UNSPECIFIED C 9119/2017 5/18/2017 6/14/201711200 INJECTION, DIPHENHYDRAMINE HCL, UP TO SO MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE (54.651 ($3.35) MALE SPOUSE 1 BCC 3559 {y UNSPECIFIED C.7.f 9/19/2017 5/18/2017 6/14/201712469 PALONOSETRDN HCL R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE ($192.601 (.$594,40) MALE SPOUSE 1 BCC 3559 UNSPECIFIED W 9/19/2017 5/18/2017 91 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $219.98 MALE SPOUSE 1 BCC 3559 N ORDIAGNOSIS ISPECIFY SUBSTANCE ORDRUG); UNSPECIFIED ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 9/19/2017 5/18/2017 91 96375 Therapeutic, prophylactic, ordiagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $76.85 MALE SPOUSE 1 BCC 3559 "a substance ordrug); each additional sequential intravenous UNSPECIFIED push of a new substance /drug (List separately In addition to code for primary procedure( fO 9/19/2017 5/18/2017 91 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $6.40 MALE SPOUSE 1 BCC 3559 } UNSPECIFIED U. CL CL 9/19/2017 5/18/2017 9/1/201711200 INJECTION, DIPHENHYDRAMINE HCL, UPTO50MG 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $3.35 MALE SPOUSE 1 BCC 3559 UNSPECIFIED 9/19/2017 5/18/2017 9/1/2017 12469 PALONOSETRON HCL R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $594.40 MALE SPOUSE 1 BCC 3559 UNSPECIFIED F 9/20/2017 6/8/2017 6/14/2017 96367 INTRAVENOUS INFUSION, FORTHERAPY, PROPHYLAXIS, R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $O.OD $109.99 MALE SPOUSE 1 BCC 3559 W ORDIAGNOSIS(SPECIFY SUBSTANCE ORDRUG); UNSPECIFIED IE ADDITIONAL SEQUENTIAL INFUSION OF A NEW W DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) _ 9/20/2017 6/8/2017 6/14/2017 96375 Therapeutic, prophylactic, ordiagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $153.70 MALE SPOUSE 1 BCC 3559 substance ordrug); each additional sequential intravenous UNSPECIFIED push of a new substance /drug (List separately In addition Q to code for primary procedure( 9/20/2017 6/8/2017 6/14/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $6.40 MALE SPOUSE 1 BCC 3559 UJ UNSPECIFIED 9/20/2017 6/8/2017 6/14/201711200 INJECTION, DIPHENHYDRAMINE HCL, UPTO50MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $3.35 MALE SPOUSE 1 BCC 3559 UNSPECIFIED p W V 9/20/2017 6/8/2017 6/14/2017 12469 PALONOSETRON HCL 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $594.40 MALE SPOUSE 1 BCC 3559 UNSPECIFIED J 9/20/2017 6/8/2017 6/14/2017 96367 INTRAVENOUS INFUSION, FORTHERAPY, PROPHYLAXIS, R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 ($109.99) MALE SPOUSE 1 BCC 3559 V ORDIAGNOSIS(SPECIFY SUBSTANCE ORDRUG); UNSPECIFIED r ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN W ADDITION TO CODE FOR PRIMARY PROCEDURE) 9/20/2017 6/8/2017 6/14/2017 96375 Therapeutic, prophylactic, ordiagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 (.$153.701 MALE SPOUSE 1 BCC 3559 substance or drug); each addit1ono l seq uential intravenous UNSPECIFIED Q push of a new substance /drug (List separately In addition F to code for primary procedure) N 9/20/2017 61 6/14/201711100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE ($2.401 ($6,40J MALE SPOUSE 1 BCC 3559 N UNSPECIFIED C 9120/2017 6/8/2017 6/14/201711200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE (54.651 ($3.35) MALE SPOUSE 1 BCC 3559 {y UNSPECIFIED 9/20/2017 6/8/2017 6/14/201712469 PALONOSETRDN HCL R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $6.40 MALE SPOUSE 1 BCC 3559 $0.00 UNSPECIFIED 9/20/2017 6/8/2017 9/1/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE 1 BCC 3559 $31.17 OR DIAGNOSIS ISPECIFY SUBSTANCE OR DRUG); SPOUSE UNSPECIFIED 3559 $192.60 $594.40 MALE ADDITIONAL SEQUENTIAL INFUSION OF A NEW 1 BCC 3559 $0.00 ($76.85] MALE SPOUSE DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN 3559 ($192.607 ($594 ,ET MALE SPOUSE 1 BCC ADDITION TO CODE FOR PRIMARY PROCEDURE) $375.20 $903.00 MALE 9/20/2017 6/8/2017 9/1/2017 96375 Therapeutic, prophylactic, ,,diagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE 1 BCC 3559 $145.73 substance ordrug); each additional sequential intravenous SPOUSE UNSPECIFIED 3559 $706.00 $]06.00 MALE push of a new substance /drug (List separately In addition 1 BCC 3559 $11,379.00 $16,993 -00 MALE SPOUSE Ed cede for primary procedure( 3559 $194.31 9/20/2017 6/8/2017 9/1/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE SPOUSE 1 BCC 3559 UNSPECIFIED 912012017 618/2017 9/1/201711200 INJECTION, DIPHENHYDRAMINE HCL, UPT050MG 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 9/20/2017 6/8/2017 9/1/201712469 PALONDSETRON HCL R112 NAUSEAWITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 9/21/2017 6/29/2017 ]/11/201] 96375 Therapeutic, prophylactic, or diagnostic Infection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE substance Dr drug); each addltlone l sequential intravenous UNSPECIFIED push of a new substance /drug (List separately In addition to code for primary procedure( 9/21/2017 6/29/2017 ]/11/201]12469 PALONOSETRON HCL R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 9/21/2017 6/29/2017 7111/2017 96375 Therapeutic, prophylactic, .,diagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL DFFICE substance or drug); each additional sequential intravenous UNSPECIFIED push of a new substance /drug (List separately In addition to code for primary procedure( 9/21/2017 6/29/2017 7/11/201712469 PALONOSETRON HCL R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 9/27/2017 4/5/2017 9/26/2017 910 ANESTHESIA FO R TRAIN S U R ETH RAE P ROCEDU R ES N1330 UNSPECIFIED OTHER MEDICAL (INCLUDING URETHROCYSTOSCOPY ); NOTOTHERWISE HYDRONEPHROSIS SPECIFIED 10/13/2017 9/5/2017 10/12/2017 * * * ** xxxxx . *w.x xxxxx xxxxx 1011712017 811012017 10/16/2017 99203 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C8338 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, LYMPHOMA, LYMPH WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED NODES OF MULTIPLE HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION SITES MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE P 10/26/2017 10/19/2017 10/25/2017 *x' ** * * * ** * * * ** * * * ** * * * ** 10/31/2017 10/21/2017 10/26/201] 10/31/2017 10121/2017 10/30/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET)WITH C8330 DIFFUSE LARGE B -CELL PROFESSIONAL CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY LYMPHOMA, UNSPECIFIED OUTPATIENT /HOSPITAL (CT) FORATTENUATION CORRECTION AND ANATOMICAL SITE LOCALIZATION IMAGING; SKULL BASE TO MID -THIGH 111812017 10/25/2017 11/6/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 140 BRONCHITIS, NOT OTHER MEDICAL FRONTALAND LATERAL; SPECIFIED ASACUTE OR CHRONIC $3.05 $0.00 MALE SPOUSE $44.62 $109.99 MALE SPOUSE C.7.f 1 BCC 3559 w 1 BCC 3559 N $62.34 $153.70 MALE SPOUSE 1 BCC 3559 $0.00 $6.40 MALE SPOUSE 1 BCC 3559 $0.00 $3.35 MALE SPOUSE 1 BCC 3559 $0.00 $594.40 MALE SPOUSE 1 BCC 3559 $31.17 $76.85 MALE SPOUSE 1 BCC 3559 $192.60 $594.40 MALE SPOUSE 1 BCC 3559 $0.00 ($76.85] MALE SPOUSE 1 BCC 3559 ($192.607 ($594 ,ET MALE SPOUSE 1 BCC 3559 $375.20 $903.00 MALE SPOUSE 1 BCC 3559 $706.00 $706.00 MALE SPOUSE 1 BCC 3559 $145.73 $392.87 MALE SPOUSE 1 BCC 3559 $706.00 $]06.00 MALE SPOUSE 1 BCC 3559 $11,379.00 $16,993 -00 MALE SPOUSE 1 BCC 3559 $194.31 $477.00 MALE SPOUSE 1 BCC 3559 $0.00 $164.00 MALE SPOUSE 1 BCC 3559 111812017 10/25/2017 11/6/2017 87804 INFECTIOUS AGENT ANTIGEN DETECTION BY 140 BRONCHITIS, NOT OTHER MEDICAL 3559 IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; $348.35 MALE SPECIFIED A5ACUTE OR 1 BCC INFLUENZA $93.75 CHRONIC 11/8/2017 10/25/2017 11/6/2017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 140 BRONCHITIS, NOT OTHER MEDICAL $149.37 MALE EVALUATION AND MANAGEMENTOFAN ESTABLISHED 1 BCC SPECIFIED AS ACUTE OR $25.56 PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY SPOUSE CHRONIC 3559 COMPONENTS: AN EXPANDED PROBLEM FOCUSED $446.82 MALE SPOUSE 1 DEC HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 11/17/2017 11/1/2017 11/16/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C8510 UNSPECIFIED B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, UNSPECIFIED PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY SITE COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 1112212017 6/8/2017 6/14/201712469 PALONOSETRON HCL 8112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE UNSPECIFIED 11/27/2017 10/30/2017 11/24/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C8331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, LYMPH PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY NODES OF HEAD, FACE, COMPONENTS: A DETAILED HISTORY; A DETAILED AND NECK EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/11/2017 12/4/2017 12/8/2017 76775 ULTRASOUND, RETROPERITONEAL(EG, RENAL, AORTA, C8590 NON- HODGKIN OTHER MEDICAL NODES), REALTIME WITH IMAGE DOCUMENTATION; LYMPHOMA, LIMITED UNSPECIFIED, UNSPECIFIED SITE 12/11/2017 12/6/2017 12/8/2017 20600 ARTHROCENTESIS , ASPIRATION AND /OR INJECTION, M10071 IDIOPATHIC GOUT, RIGHT PROFESSIONAL OFFICE SMALL JOINT OR BURSA(EG, FINGERS, TOES); WITHOUT ANKLE AND FOOT ULTRASOUND GUIDANCE 12111/2017 12/6/2017 12/8/2017 73630 RADIOLOGIC EXAMINATION, FOOT; COMPLETE, M10071 IDIOPATHIC GOUT, RIGHT PROFESSIONAL OFFICE MINIMUM OF THREE VIEWS ANKLE AND FOOT 12/11/2017 1216/2017 121812017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N110071 IDIOPATHIC GOUT, RIGHT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, ANKLE AND FOOT WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 12/11/2017 12/6/2017 12/8/201711030 INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG M10071 IDIOPATHICGOUT, RIGHT PROFESSIONAL OFFICE ANKLE AND FOOT 12/15/2017 12/8/2017 12114/2017 81002 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR N1330 UNSPECIFIED PROFESSIONAL OFFICE BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, HYDRONEPHROSIS LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINDGEN, ANY NUMBER OF THESE CONSTITUENTS; NON AUTOMATED, WITHOUT MICROSCOPY $0.00 $83.00 MALE SPOUSE $225.00 $300.00 MALE SPOUSE C.7.f 1 BCC 3559 w 1 BCC 3559 N $103.91 $461.00 MALE SPOUSE 1 BCC i] ($195.651 $594.40 MALE SPOUSE 1 BCC 3559 $141.30 $348.35 MALE SPOUSE 1 BCC 3559 $93.75 $444.00 MALE SPOUSE 1 BCC 3559 $35.65 $149.37 MALE SPOUSE 1 BCC 3559 $25.56 $100.00 MALE SPOUSE 1 BCC 3559 $108.33 $446.82 MALE SPOUSE 1 DEC 3559 $6.34 $7.00 MALE SPOUSE 1 BCC 3559 $2.10 $20.00 MALE SPOUSE 1 DEC 3559 rl 12/15/2017 121812017 12/14/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N1330 UNSPECIFIED PROFESSIONAL OFFICE $240.00 MALE SPOUSE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 3559 w HYDRONEPHROSIS 3559 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY N COMPONENTS: AN EXPANDED PROBLEM FOCUSED m HISTORY; AN EXPANDED PROBLEM FOCUSED w EXAMINATION; MEDICAL DECISION MAKING OF LOW F_n COMPLEXITY. COUNSELING AND COORD $3115 $444.00 MALE 12/27/2017 12/4/2017 12/22/2017 76775 ULTRASOUND, RETROPERITONEAL(EG, RENAL, AORTA, C8590 NON-HODGKIN OTHER MEDICAL NODES), REALTIME WITH IMAGE DOCUMENTATION; LYMPHOMA, LIMITED UNSPECIFIED, $103.91 $461.00 MALE SPOUSE 1 BCC UNSPECIFIED SITE $14130 12/27/2017 12/20/2017 12/23/2017 * * * ** * * * 3559 } 12/28/2017 9/21/2017 12/27/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE CL EVALUATION AND MANAGEMENT OF AN ESTABLISHED LYMPHOMA, LYMPH CL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY NODES OF HEAD, FACE, Q COMPONENTS: A DETAILED HISTORY; A DETAILED AND NECK EXAMINATION; MEDICAL DECISION MAKING OF $35.02 $86.33 MALE SPOUSE 1 BCC MODERATE COMPLEXITY. COUNSELING AND /OR F COORDINATION OF CARE WITH OTHER 1212812017 1211812017 12/27/2017 96523 IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR C9331 DIFFUSE LARGE B -CELL PROFESSIONAL OFFICE $181,667.59 $92.94 $369,710.32 $146.00 FEMALE DRUG DELIVERY SYSTEMS 1 OSO LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK Sub Total 4.375E +10 1/30/2017 1/9/2017 1/13/2017 99202 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 8938 ABNORMAL FINDINGS ON PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF ANEW PATIENT, DIAGNOSTIC IMAGING OF WHICH REQUIRES THESE 3 KEYCOMP0NENTS: AN OTHER SPECIFIED BODY EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED STRUCTURES PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WITH 0 1/30/2017 1/23/2017 1/24/2017 58100 ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT M25551 PAIN IN RIGHT HIP PROFESSIONAL OFFICE EN DOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DIUITION, ANY METHOD (SEPARATE PROCEDURE) 2/20/2017 2/9/2017 2/16/2017 57455 COLPOSCOPY OF THE CERVIX INCLUDING C539 MALIGNANT NEOPLASM PROFESSIONAL OFFICE UPPER /ADIACE NT VAG I NA; WITH B IO PSY(S) O F TH E OF CERVIX UTERI, CERVIX UNSPECIFIED 212012017 2/9/2017 211612017 99243 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED C539 MALIGNANT NEOPLASM PROFESSIONAL OFFICE PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS :A OF CERVIX UTERI, DETAILED HISTORY; A DETAILED EXAMINATION; AND UNSPECIFIED MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE 2/20/2017 2/10/2017 2/13/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C539 MALIGNANT NEOPLASM OTHER MEDICAL OF CERVIX UTERI, UNSPECIFIED 3/6/2017 2/16/2017 2/27/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C539 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF CERVIX UTERI, PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY UNSPECIFIED COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD $153.65 $325.00 FEMALE SUBSCRIBER 1 050 3559 C.7.f $86.79 $240.00 MALE SPOUSE 1 BCC 3559 w 1 0SO 3559 O1 N m w F_n $3115 $444.00 MALE SPOUSE 1 BCC 3559 7 $103.91 $461.00 MALE SPOUSE 1 BCC 3559 $14130 $348.35 MALE SPOUSE 1 BCC 3559 } fl i® CL CL Q $35.02 $86.33 MALE SPOUSE 1 BCC 3559 F W $181,667.59 $92.94 $369,710.32 $146.00 FEMALE SUBSCRIBER 1 OSO D 3559 $153.65 $325.00 FEMALE SUBSCRIBER 1 050 3559 $260.70 $481.00 FEMALE SUBSCRIBER 1 OSO 3559 $204.35 $278.00 FEMALE SUBSCRIBER 1 0SO 3559 $0.00 $56.00 FEMALE SUBSCRIBER 1050 3559 $93.27 $240.00 FEMALE SUBSCRIBER l OSO 3559 3/6/2017 2/24/2017 212812017 72197 MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; C539 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $529.00 FEMALE SUBSCRIBER 1050 WITHOUT CONTRAST MATERIAL(SE FOLLOWED BY OF CERVIX UTERI, OUTPATIENT /HOSPITAL CONTRAST MATERIAL(S) AND FURTHER SEQUENCES UNSPECIFIED 3/9/2017 2/27/2017 3/4/2017 72197 MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; C539 MALIGNANT NEOPLASM PROFESSIONAL $148.17 $458.00 FEMALE SUBSCRIBER 1050 WITHOUTCONTRAST MATERIAL(SE FOLLOWED BY OF CERVIX UTERI, OUTPATIENT /HOSPITAL CONTRAST MATERIAL(S) AND FURTHER SEQUENCES UNSPECIFIED 3/13/2017 2/24/2017 3/1/2017- - C539 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,511.48 $4,738.00 FEMALE SUBSCRIBER 1050 OF CERVIX UTERI, UNSPECIFIED 3/17/2017 2/27/2017 3/6/2017- - C539 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $2,129.40 $4,732.00 FEMALE SUBSCRIBER 1050 OF CERVIX UTERI, UNSPECIFIED 3/17/2017 3/2/2017 3/10/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET)WITH C539 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $2,981.70 $6,626.00 FEMALE SUBSCRIBER 3050 CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY OF CERVIX UTERI, (CTS FORATTENUATION CORRECTION AND ANATOMICAL UNSPECIFIED LOCALIZATION IMAGING; SKULL BASE TO MID -THIGH 3/17/2017 3/2/2017 3/10/2017 A9552 FLUORODEOXYGLUCOSE F -18 FDG, DIAGNOSTIC, PER C539 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $310.50 $690.00 FEMALE SUBSCRIBER 1050 STUDY DOSE, UP TO 45 MILLICU RIES OF CERVIX UTERI, UNSPECIFIED 3/22/2017 3/17/2017 3/21/2017 77263 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $172.06 $565.54 FEMALE SUBSCRIBER 1050 COMPLEX OF EXOCERVIX 3/29/2017 3/23/2017 3/28/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $252.72 $684.67 FEMALE SUBSCRIBER 1050 EVALUATION AND MANAGEMENTOF A NEW PATIENT, OF ENDOCERVIX WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY, COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS GRACE 3/30/2017 3/24/2017 3/29/2017 77300 BASIC RADIATION D0SIMETRY CALCULATION, CENTRAL C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $358.61 $1,137.55 FEMALE SUBSCRIBER 1050 AXIS DEPTH DOSE CALCULATION, TDF, NSD, GAP OF EXOCERVIX CALCULATION, OFF AXIS FACTOR, TISSUE INHOMOGENEITY FACTORS, CALCULATION OF NON - IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN PRESCRIBED BY THE TREATING 3/30/2017 3/24/2017 3/29/2017 77301 INTENSITY MODULATED RADIOTHERAPY PLAN, C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $2,129.62 $6,769.90 FEMALE SUBSCRIBER 1050 INCLUDING DOSE- VDLUME HISTOGRAMS FOR TARGET OF EXOCERVIX AND CRITICAL STRUCTURE PARTIAL TOLERANCE SPECIFICATIONS 3/30/2017 3/24/2017 3/29/2017 77338 Multi leaf collimator(MLC) device(s) for intensity C531 MALIGNANT N EOPLASM PROFESSIONAL OFFICE $490.93 $1,557.76 FEMALE SUBSCRIBER 1050 modulated radiation therapy (IMRT), design and OF EXOCERVIX a nstruction per IMRT plan 4/3/2017 3/28/2017 3/31/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 OF RADIATION THERAPY FIELDS OF EXOCERVIX 4/3/2017 3/28/2017 3/31/2017 66015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $56518 $1,259.04 FEMALE SUBSCRIBER 1050 OF EXOCERVIX 41 3/29/2017 4/3/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT CS31 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 OF RADIATION THERAPY FIELDS OF EXOCERVIX 4/4/2017 3/29/2017 4/3/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $565.28 $1,259.04 FEMALE SUBSCRIBER 1050 OF EXOCERVIX 4/5/2017 3130/2017 4/4/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 OF RADIATION THERAPY FIELDS OF EXOCERVIX C.7.f 4/5/2017 3/30/2017 4/4/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $565.28 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX W 4/6/2017 3/17/2017 4/4/2017 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $120.73 $341.63 FEMALE SUBSCRIBER 1OSO 3559 N EVALUATION AND MAN.AGEMENTOF A NEW PATIENT, OF EXOCERVIX WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 7 AGENCIES ARE P "a 4/7/2017 3/17/2017 4/5/2017 77334 TREATMENT DEVICES, DESIGN AND CONSTRUCTION; C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $155.95 $496.62 FEMALE SUBSCRIBER 1(50 3559 COMPLEX IRREGULAR BLOCKS, SPECIAL SHIELDS, OF EXOCERVIX COMPENSATORS, WEDGES, MOLDS DR CASTS) W } 0 4/7/2017 3/27/2017 4/5/2017 77280 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $191.67 $610.61 FEMALE SUBSCRIBER 1 0S 3559 N. CL SETTING; SIMPLE OF EXOCERVIX Q, Q 4/7/2017 3/31/2017 4/5/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $219.98 FEMALE SUBSCRIBER 1050 3559 v OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); OF ENDOCERVIX ADDITIONAL SEQUENTIAL INFUSION OF A NEW rf DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) W 4/7/2017 3/31/2017 4/5/201711100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, I MG C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.15 $3.84 FEMALE SUBSCRIBER 1 OSO 3559 OF ENDOCERVIX 4/7/2017 3/31/2017 4/5/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 3559 _ OF RADIATION THERAPY FIELDS OF EXOCERVIX 4/7/2017 3/31/2017 4/5/201766015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFE55IONAL OFFICE $565.28 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX Q W 4/10/2017 3/28/2017 4/6/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $191.02 $597.63 FEMALE SUBSCRIBER 1050 3559 TREATMENTS OF EXOCERVIX UJ 4/10/2017 3131/2017 4/5/2017 96375 Therapeutic, prophylactic, or dlagnostic Injection (specify C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $23.38 $76.85 FEMALE SUBSCRIBER 1OSO 3559 substance ordrug); each additional sequential intravenous OF ENDOCERVIX Q push of a new substance /drug (List separately In addition LLJ to code for primary procedure) 4/10/2017 3/31/2017 4/5/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $150.34 $494.20 FEMALE SUBSCRIBER 1 OSO 3559 INFUSION TECHNIQUE; UPTO I HOUR, SINGLE OR INITIAL OF ENDOCERVIX SUBSTANCE /DRUG v 4/10/2017 3/31/2017 4/5/2017 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $31.75 $104.36 FEMALE SUBSCRIBER 1050 3559 TO CODE FOR PRIMARY PROCEDURE) OF ENDOCERVIX W 4/10/2017 3/31/2017 4/5/2017 J2469 PALONOSETRON HCL C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $154.08 $594.40 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX U 4/10/2017 3/31/2017 4/5/201719060 INJECTION, CISPLATIN,POWDER OR SOLUTION, 10 MG C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $12.26 $46.62 FEMALE SUBSCRIBER IOSO 3559 OF ENDOCERVIX 4/10/2017 4/3/2017 4/6/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 3559 CEJ OF RADIATION THERAPY FIELDS OF EXOCERVIX hl 4/10/2017 4/3/2017 4/6/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $53.47 $169.84 FEMALE SUBSCRIBER IOSO 3559 = INCLUDING A55ESSMENT OF TREATMENT PARAMETERS, OF EXOCERVIX Qj QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF ._ THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY �, C.7.f 4/10/2017 4/3/2017 4/6/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $565.28 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX W 4/11/2017 3/23/2017 3/29/2017- - C530 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $456.86 $609.15 FEMALE SUBSCRIBER 1050 3559 OR OF ENDOCERVIX Q! 4/11/2017 4/4/2017 4/10/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX i 4/11/2017 4/4/2017 4/10/2017 66015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $56518 $1,259.04 FEMALE SUBSCRIBER 1050 3559 "a OF EXOCERVIX 4/11/2017 4/5/2017 4110/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT CS31 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX } fl 4/11/2017 4/5/2017 4/10/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $565.28 $1,259.04 FEMALE SUBSCRIBER 1050 3559 N. CL OF EXOCERVIX CL Q 4/12/2017 4/3/2017 4/11/2017 * * * ** * * "* * * * ** F # *' * * *" $13,855.13 $17,88157 FEMALE SUBSCRIBER 1 RISC 3559 v 4/12/2017 41712017 4/11/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $116.30 $348.35 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF ENDOCERVIX PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF h MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/13/2017 4/6/2017 4/12/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 4/13/2017 4/6/2017 4/12/201766015 RADIATION TX DELIVERY IMRT CS31 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX Q ® Lli 4/13/2017 4/7 /2017 4/12/2017- - C530 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $609.15 $609.15 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX J 4/13/2017 417/2017 4/12/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 0 OF RADIATION THERAPY FIELDS OF EXOCERVIX LLJ 4/13/2017 4/7/2017 4/12/201766015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $75331 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX 4 J 4/13/2017 4/10/2017 4/12/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $89.24 $219.98 FEMALE SUBSCRIBER 1050 3559 OR DIAGNOSIS ISPECIFY SUBSTANCE OR DRUG); OF ENDOCERVIX v ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) LLJ 4/13/2017 4/10/2017 4/12/201711100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG CS30 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.44 $3.84 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX U 4/14/2017 4/4/2017 4/13/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $254.69 $597.63 FEMALE SUBSCRIBER 1050 3559 TREATMENTS OF EXOCERVIX {V 4/14/2017 4/10/2017 4/13/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $7119 $169.84 FEMALE SUBSCRIBER 1050 3559 N INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF EXOCERVIX QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF C PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF Qj THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY C.7.f 4/14/2017 4/10/2017 4/13/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX 4/14/2017 4/10/2017 4/13/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 4/14/2017 4/11/2017 4/13/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX 4/14/2017 4/11/2017 4/13/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1 0S 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 4/17/2017 4/10/2017 4112/2017 96375 Therapeutic, prophylactic, or diagnostic injection (specify CS30 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $31.17 $76.85 FEMALE SUBSCRIBER 1050 3559 substance ordrug); each additional sequential intravenous OF ENDOCERVIX push of a new substance /drug (List separately In addition to code for primary procedure) 4/17/2017 4/10/2017 4/12/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $200.46 $494.20 FEMALE SUBSCRIBER 1050 3559 INFUSION TEC HNIQUE ; UPTO I HOUR, SINGLE OR INITIAL OF ENDOCERVIX SUBSTANCE /DRUG 4/17/2017 4/10/2017 4/12/2017 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $42.33 $104.36 FEMALE SUBSCRIBER 1050 3559 TO CODE FOR PRIMARY PROCEDURE) OF ENDOCERVIX 4/17/2017 4/10/2017 4/12/201712469 PALONOSETRON HCL C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $192.60 $594.40 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX 4/17/2017 4/10/2017 4/12/2017 J9060 INJECTION, CISPLATIN,POWDER OR SOLUTION, 10 MG C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $15.33 $46.62 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX 4/18/2017 4/12/2017 4/17/201766015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX 4/18/2017 4/12/2017 4/17/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 412012017 4/11/2017 4/19/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C531 MALIGNANT NEOPLASM PROFE55IONAL OFFICE $254.69 $597.63 FEMALE SUBSCRIBER 1050 3559 TREATMENTS OF EXOCERVIX 4/20/2017 4/13/2017 4/19/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 4/20/2017 4/13/2017 4/19/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX 4/20/2017 4/14/2017 4/19/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 4/20/2017 4/14/2017 4/19/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX 4/20/2017 4/14/2017 4/19/2017- - C530 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $609.15 $609.15 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX 4/20/2017 4/17/2017 4/19/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $141.30 $348.35 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF ENDOCERVIX PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS : A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER C.7.f 4/20/2017 4/17/2017 4/19/2017 96367 I NTRAVENO US IN FUSION, FORTH ERAPY, PRO PHYLAX IS, C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $89.24 $219.98 FEMALE SUBSCRIBER 1050 3559 OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); OF ENDOCERVIX ADDITIONAL SEQUENTIAL INFUSION OF A NEW Z DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN (n ADDITION TO CODE FOR PRIMARY PROCEDURE) Q! 412012017 411712017 4/19/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $200.46 $494.20 FEMALE SUBSCRIBER 1 0S 3559 INFUSION TECHNIQUE; UPTO I HOUR, SINGLE OR INITIAL OF ENDOCERVIX SUBSTANCE /DRUG i 4/20/2017 4/17/2017 4119/2017 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION CS30 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $42.33 $104.36 FEMALE SUBSCRIBER 1050 3559 "a TO CODE FOR PRIMARY PROCEDURE) OF ENDOCERVIX 4/20/2017 4/17/2017 4/19/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $144 $3.84 FEMALE SUBSCRIBER 1 OSO 3559 OF ENDOCERVIX } fl 4/20/2017 4117/2017 4/19/201719060 INJECTION, CISPLATIN,POWDER OR SOLUTION, 10 MG CS30 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $15.33 $46.62 FEMALE SUBSCRIBER 1050 3559 N. CL OF ENDOCERVIX Q, Q 4/24/2017 4/17/2017 4/19/2017 96375 Therapeutic, prophylactic, or diagnostic injection (specify R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $0.00 $76.85 FEMALE SUBSCRIBER 1 OSO 3559 v substance or drug); each addli ono l sequential intravenous UNSPECIFIED push of a new substance /drug (List separately In addition to code for primary procedure) F 4/24/2017 411712017 4/19/201712469 PALONOSETRON HCL R112 NAUSEA WITH VOMITING, PROFESSIONAL OFFICE $192.60 $594.40 FEMALE SUBSCRIBER 1050 3559 UNSPECIFIED D 4/24/2017 4/17/2017 4/21/2017 77014 COMPUTED TDMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER IOSO 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX _ 4/24/2017 4/17/2017 4/21/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $7119 $169.84 FEMALE SUBSCRIBER 1050 3559 INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF EXOCERVIX QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF Q PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY U 4/24/2017 411712017 412112017 66015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1 OSO 3559 OF EXOCERVIX 4/24/2017 4/18/2017 4/21/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 een OF RADIATION THERAPY FIELDS OF EXOCERVIX 4/24/2017 4/18/2017 4/21/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1 OSO 3559 OF EXOCERVIX v 4/26/2017 3/29/2017 4/19/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX W 4/26/2017 4/3/2017 4/19/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX U 4/26/2017 4/18/2017 4/25/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $191.02 $597.63 FEMALE SUBSCRIBER 1050 3559 TREATMENTS OF EXOCERVIX 4/26/2017 4/19/2017 4/25/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX N 4/26/2017 4/19/2017 412512017 66015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $56528 $1,259.04 FEMALE SUBSCRIBER 1050 3559 = OF EXOCERVIX y E 4/26/2017 4/20/2017 4/25/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 2 C.7.f 4/26/2017 4/20/2017 4/25/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $741.15 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX 4/26/2017 4/21/2017 4/25/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 4/26/2017 4/21/2017 4/25/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1 OSO 3559 OF EXOCERVIX 4/27/2017 4/19/2017 412212017- - C531 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $3,699.00 $7,664.53 FEMALE SUBSCRIBER 1 0S 3559 OF EXOCERVIX 4/27/2017 4/24/2017 4/26/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $8924 $219.98 FEMALE SUBSCRIBER l OSO 3559 OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); OF ENDOCERVIX ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP T01 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 4/27/2017 4/24/2017 4/26/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $144 $3.84 FEMALE SUBSCRIBER 1 OSO 3559 OF ENDOCERVIX 4/28/2017 4/24/2017 4/27/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 4/28/2017 4/24/2017 4/27/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $53.47 $169.84 FEMALE SUBSCRIBER 1OSO 3559 INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF EXOCERVIX QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY 4/28/2017 4/24/2017 4/27/2017 66915 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $648.11 $1,259.04 FEMALE SUBSCRIBER 1 OSO 3559 OF EXOCERVIX 5/1/2017 3/28/2017 3/31/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $37016 $0.00 FEMALE SUBSCRIBER 10SO 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/1/2017 3/28/2017 3/31/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ;$565.28) (11,259. 04) FEMALE SUBSCRIBER 1 OSO 3559 OF EXOCERVIX 5/1/2017 3/28/2017 4/20/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/1/2017 3/31/2017 4/5/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $370.26 $0.00 FEMALE SUBSCRIBER 1 0S 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/1/2017 3/31/2017 4/5/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE (.$56528) ($1,259.04) FEMALE SUBSCRIBER l OSO 3559 OF EXOCERVIX 5/1/2017 3/31/2017 4/20/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1OSO 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/1/2017 4/21/2017 4/25/2017- - C530 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $609.15 $609.15 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX 5/1/2017 4/24/2017 4/26/2017 96375 Therapeutic, prophylactic, or diagnostic injection( specify C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $31.17 $76.85 FEMALE SUBSCRIBER 10SO 3559 substance ordrug); each additional sequential intravenous OF ENDOCERVIX push of a new substance /drug (List separately In addition to code for primary procedure( 5/1/2017 4/24/2017 4/26/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $200.46 $494.20 FEMALE SUBSCRIBER 1 OSO 3559 INFUSION TEC HNIQUE ; UPTO I HOUR, SINGLE OR INITIAL OF ENDOCERVIX SUBSTANCE /DRUG C.7.f 5/1/2017 4/24/2017 4/26/2017 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $42.33 $104.36 FEMALE SUBSCRIBER 1 0S 3559 TO CODE FOR PRIMARY PROCEDURE) OF ENDOCERVIX Z 5/1/2017 4/24/2017 4/26/2017 J2469 PALONOSETRON BEL C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $192.60 $594.40 FEMALE SUBSCRIBER 1050 3559 N OF ENDOCERVIX Q! 5/1/2017 4/24/2017 4/26/201719060 INJECTION, CISPLATIN,POWDER OR SOLUTION, 10 MG C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $15.33 $46.62 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX i 5/1/2017 4/25/2017 4/28/2017 ]]014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $261103 $620.96 FEMALE SUBSCRIBER 1050 3559 "a OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/1/2017 4/25/2017 4/28/201766015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX } fl 5/2/2017 4/26/2017 5/1/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 N. CL OF RADIATION THERAPY FIELDS OF EXOCERVIX Q, Q 5/2/2017 4/26/2017 5/1/201766015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1050 3559 v OF EXOCERVIX 5/4/2017 4/24/2017 5/3/2017 77290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $1,711.37 FEMALE SUBSCRIBER 1050 3559 SETTING; COMPLEX OF EXOCERVIX W 5/4/2017 4/25/2017 5/3/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $254.69 $597.63 FEMALE SUBSCRIBER 1 0S 3559 IY TREATMENTS OF EXOCERVIX 5/4/2017 4/26/2017 5/3/2017 772953 - DIMENSIONAL RADIOTHERAPY PLAN, INCLUDING DOSE- C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $769.43 $1,832.73 FEMALE SUBSCRIBER 1050 3559 _ VOLUME HISTOGRAMS OF EXOCERVIX 5/4/2017 4/26/2017 5/3/2017 77300 BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $19116 $455.02 FEMALE SUBSCRIBER 1 0S 3559 AXIS DEPTH DOSE CALCULATION, TDF, NSD, GAP OF EXOCERVIX IL CALCULATION, OFF AXIS FACTOR, TISSUE uj INHOMOGENEITY FACTORS, CALCULATION OF NON - IONIZING RADIATION SURFACE AND DEPTH DOSE, AS U`J REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN 5/4/2017 4/26/2017 5/3/2017 PRESCRIBED BY THE TREATING 77334 TREATMENT DEVICES, DESIGN AND CONSTRUCTION; C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $415.85 $993.24 FEMALE SUBSCRIBER 1050 3559 COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, OF EXOCERVIX een COMPENSATORS, WEDGES, MOLDS OR CASTS) 5/4/2017 4/27/2017 5/3/201766015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX v 5/4/2017 4/27/2017 5/3/2017 ]]014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX W 5/4/2017 4/28/2017 5/3/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX U 5/4/2017 4/28/2017 5/3/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/4/2017 5/1/2017 5/3/2017 963661ntravenous infusion, for therapy, prophylaxis, or diagnosis C530 MALIGNANT N EOPLASM PROFESSIONAL OFFICE $29.55 $72.85 FEMALE SUBSCRIBER 1050 3559 (specify substance or drug); each additional hour (List separately in addition to code for primary Procedure) OF ENDOCERVIX N C.7.f 5/4/2017 5/1/2017 5/3/2017 963671 NTRAVEN0 US IN FUSION, FORTH ERAPY, PRO PHYLAX IS, C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $439.96 FEMALE SUBSCRIBER 1050 3559 0R DIAGNOSIS (SPECIFY SUBSTANCE 0R DRUG); OF ENDOCERVIX ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 5/4/2017 5/1/2017 5/3/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.44 $3.84 FEMALE SUBSCRIBER 1 0SO 3559 OF ENDOCERVIX S/4/2017 5/1/2017 5/3/201713475 INJECTION, MAGNESIUM SULFATE, PERSOO MG CS30 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $2.00 $5.96 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX 5/4/2017 5/1/2017 5/3/201713480 INJECTION, POTASSIUM CHLORIDE, PER2 MEQ C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $4.25 $5.75 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX 5/5/2017 511/2017 5/3/2017 96375 Therapeutic, prophylactic, or diagnostic injection (specify CS30 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $31.17 $76.85 FEMALE SUBSCRIBER 1050 3559 substance or drug); each additional sequential intravenous OF ENDOCERVIX push of a new substance /drug (List separately In addition to cade for primary procedure( 5/5/2017 5/1/2017 5/3/2017 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $150.34 $494.20 FEMALE SUBSCRIBER 1050 3559 INFUSION TEC HNIQUE ; UPTO I HOUR, SINGLE OR INITIAL OF ENDOCERVIX SUBSTANCE /DRUG 5/5/2017 5/1/2017 5/3/2017 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $31.75 $104.36 FEMALE SUBSCRIBER 1050 3559 TO CODE FOR PRIMARY PROCEDURE) OF ENDOCERVIX 5/5/2017 5/1/2017 5/3/201712469 PALONOSETRDN HILL C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $191.36 $594.40 FEMALE SUBSCRIBER l OSO 3559 OF ENDOCERVIX 5/5/2017 5/1/2017 5/3/201719060 INJECTION, CISPLATIN,P0WDER 0R SOLUTION, 10 MG C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1216 $46.62 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX 5/8/2017 3/28/2017 3/31/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ( <n93.68'! $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/8/2017 3/28/2017 4/20/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($195.02) (.$620,96) FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/8/2017 3/28/2017 4/20/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $688.70 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX 5/8/2017 4/24/2017 4/27/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($195.021 (5620.961 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/8/2017 4/24/2017 5/3/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/8/2017 4/24/2017 5/3/2017 77290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $715.65 $1,711.37 FEMALE SUBSCRIBER 1 0S 3559 SETTING; COMPLEX OF EXOCERVIX 5/8/2017 4/27/2017 5/3/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/8/2017 4/28/2017 5/3/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/10/2017 3/31/2017 4/19/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $565.28 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX 5/11/2017 3/29/2017 4/3/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX C.7.f 5/11/2017 3/29/2017 4/3/2017 77014 COMPUTED TOM OG RAP HYGU I DANCE FOR PLACE ME NT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $370.26 $0.00 FEMALE SUBSCRIBER 1O50 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/11/2017 3/29/2017 4/3/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($565.281 1$1,259.041 FEMALE SUBSCRIBER 1050 3559 N OF EXOCERVIX w 5/11/2017 3/31/2017 4/5/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($493.68] $620.96 FEMALE SUBSCRIBER 1OSO 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX i 5/11/2017 3/31/2017 412012017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT 0531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($195.02i (.$620.961 FEMALE SUBSCRIBER 1050 3559 � OF RADIATION THERAPY FIELDS OF EXOCERVIX m O 5/11/2017 3/31/2017 4/20/201766015 RADIATION TX DELIVERY IMRT CS31 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $688.70 $1,259.04 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX } fl 5/11/2017 4/3/2017 4/6/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1050 3559 N. CL OF RADIATION THERAPY FIELDS OF EXOCERVIX Q, Q 5/11/2017 4/3/2017 4/6/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($'195.0'21 ($620.96 FEMALE SUBSCRIBER 1050 3559 v OF RADIATION THERAPY FIELDS OF EXOCERVIX 5/11/2017 4/3/2017 4/6/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $565.28 $0.00 FEMALE SUBSCRIBER 1OSO 3559 INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF EXOCERVIX QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF F PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF 511112017 4/3/2017 4/6/2017 G6015 THERAPY RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($565)81 (51,259.047 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX 5/11/2017 5/9/2017 5110/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z01818 ENCOUNTER FOR OTHER PROFESSIONAL OFFICE $325.28 $440.00 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOF A NEWPATIENT, PREPROCEDURAL Q WHICH REQUIRES THESE 3 KEY COMPONENTS :A EXAMINATION ui COMPREHENSIVE HISTORY; A CDMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF UJ MODERATE COMPLEXITY. COUNSELING .AND /OR cn COORDINATION OF CARE WITH OTHER PROVIDERS OR J 5/12/2017 5/8/2017 5/10/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $141.30 $348.35 FEMALE SUBSCRIBER 1OSO 3559 e LLJ EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF ENDOCERVIX PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED J EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR v COORDINATION OF CARE WITH OTHER 5/15/2017 4/28/2017 5/9/2017- - C530 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $609.15 $609.15 FEMALE SUBSCRIBER 1050 3559 LLJ OF ENDOCERVIX 5/15/2017 5/11/2017 5/12/2017 57155 INSERTION OF UTERINE TANDEM AND /OR VAGINAL C539 MALIGNANT NEOPLASM PROFESSIONAL $37339 $1,239.00 FEMALE SUBSCRIBER 1050 3559 (' OVOIDS FOR CLINICAL BRACHYTHERAPY OF CERVIX UTERI, OUTPATIENT /HOSPITAL UNSPECI LIED 5/16/2017 5/1/2017 5/10/201766015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,447.90 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX N N 5/16/2017 5/1/2017 5/10/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $714.10 FEMALE SUBSCRIBER l OSO 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX n 5/16/2017 5/1/2017 5/10/2017 77336 CONTINUING ME DICALPHYSICSCONSULTATION, 0531 3559 OF EXOCERVIX INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, MALIGNANT NEOPLASM QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF PROFESSIONAL OFFICE $380.74 $973.96 FEMALE SUBSCRIBER PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF 3559 OF EXOCERVIX THE RADIATION DNCOLOGIST, REPORTED PER WEEK OF MALIGNANT NEOPLASM PROFESSIONAL OFFICE $4.25 MALIGNANT NEOPLASM THERAPY $25536 5/16/2017 5/2/2017 5/10/2017 77427 RADIATION TREATMENT MANAGEMENT, FIVE C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE TREATMENTS $677.58 FEMALE SUBSCRIBER 5/16/2017 5/2/2017 5110/2017 06013 RADIATION TREATMENT DELIVERY CS31 5/16/2017 5/2/2017 5/10/2017 77280 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD C531 $31.17 $76.85 FEMALE SUBSCRIBER 1050 SETTING; SIMPLE OF ENDOCERVIX 5/16/2017 513/2017 5/10/2017 G6013 RADIATION TREATMENT DELIVERY C531 5/16/2017 5/3/2017 5/10/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 OF RADIATION THERAPY FIELDS MALIGNANT NEOPLASM 5/16/2017 5/4/2017 5/10/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C531 3559 OF EXOCERVIX INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF PROFESSIONAL OFFICE $380.74 $973.96 FEMALE SUBSCRIBER PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF 3559 OF EXOCERVIX THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF MALIGNANT NEOPLASM THERAPY $260.03 5/16/2017 5/4/2017 5/10/2017 G6013 RADIATION TREATMENT DELIVERY CS31 5/16/2017 5/4/2017 5/10/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF RADIATION THERAPY FIELDS $7185 FEMALE 5/16/2017 5/8/2017 5/10/2017 96366 Intraveno. sinfusion, for th era py, prophylaxis, or diagnos is CS30 (specify substance or drug); each additional hour (List MALIGNANT NEOPLASM PROFESSIONAL OFFICE $178.48 separately in addition to code for primary procedure) SUBSCRIBER 5/16/2017 5/8/2017 5/10/2017 96367 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, C530 OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG /SUBSTANCE, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 5/16/2017 5/8/2017 5/10/2017 11100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG C530 5/16/2017 5/8/2017 5/10/2017 13475 INJECTION, MAGNESIUM SULFATE, PER SOO MG CS30 5/16/2017 5/8/2017 5/10/2017 13480 INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ C530 5/17/2017 3/17/2017 5/16/2017 77470 SPECIAL TREATMENT PROCEDURE( EG,TOTALBODY C531 IRRADIATION, HEMIBODY RADIATION, PER ORALOR ENDOCAVITARY IRRADIATION) 5/17/2017 5/8/2017 5/10/2017 96375 Therapeutic, prophylactic, ordi.gnosE, injection (specify C530 substance or drug); each additional sequential intravenous push of a new substance /drug (List separately In addition to code for primary procedure) MALIGNANT NEOPLASM PROFESSIONAL OFFICE $71.29 $195.32 FEMALE SUBSCRIBER 1050 OF EXOCERVIX C.7.f 3559 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $254.69 $687.27 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX MALIGNANT NEOPLASM MALIGNANT NEOPLASM PROFESSIONAL OFFICE $380.74 $973.96 FEMALE SUBSCRIBER l OSO 3559 OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $4.25 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $25536 $702.20 FEMALE SUBSCRIBER 1 USE) 3559 OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $274.85 $677.58 FEMALE SUBSCRIBER 1050 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $380.74 $973.96 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX PROFESSIONAL OFFICE $31.17 $76.85 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $714.10 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $71.29 $195.32 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $380.74 $973.96 FEMALE SUBSCRIBER 1 OSO 3559 OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $714.10 FEMALE SUBSCRIBER 1 OSO 3559 OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $2935 $7185 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $178.48 $439.96 FEMALE SUBSCRIBER 1 OSO 3559 OF ENDOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.44 $3.84 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $2.00 $5.96 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $4.25 $5.75 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $274.85 $677.58 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE $31.17 $76.85 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX C.7.f 5/17/2017 5/8/2017 5/10/2017 5/17/2017 5/8/2017 5/10/2017 5/17/2017 5/8/2017 5/10/2017 12469 5/17/2017 5/8 /2017 5/10/2017 19060 5/18/2017 S/12/2017 5117/2017 5/22/2017 5/12/2017 5/16/2017 5/23/2017 3/31/2017 4/5/2017 5/23/2017 3/31/2017 412012017 G6015 5/24/2017 5/12/2017 5/18/2017 5/24/2017 5/12/2017 5/18/2017 5/25/2017 5/12/2017 5/24/2017 - 5/25/2017 S/19/2017 5124/2017 - 5/25/2017 5/22/2017 5/24/2017 - 5/26/2017 5/10/2017 5/25/2017 5/30/2017 5/5/2017 5/23/2017 - 5/30/2017 5/17/2017 5/24/2017 - 5/30/2017 5/21/2017 5/24/2017 5/30/2017 5/21/2017 5/24/2017 5/30/2017 S/22/2017 5126/2017 5/30/2017 5/25/2017 5/26/2017 - 96413 CHEMOTHERAPY ADM IN INTRATION ,INTRAVENOUS C530 INFUSION TECHNIQUE; UP TO 1 HOUR, SINGLE OR INITIAL 3559 SUBSTANCE /DRUG C531 96415 EACH ADDITIONAL HOUR, (LIST SEPARATELY IN ADDITION C530 TO CODE FOR PRIMARY PROCEDURE) $594.40 FEMALE SUBSCRIBER PALONOSETRON HEL C530 INJECTION, CISPLATIN,POWDER OR SOLUTION, 10 MG C530 940 ANESTHESIA FOR VAGINAL PROCEDURES (INCLUDING CS31 BIOPSY OF LABIA, VAGINA, CERVIX OR ENDOMETRIUM); C539 NOT OTHERWISE SPECIFIED 3559 77290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD C531 SETTING; COMPLEX 3559 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 OF RADIATION THERAPY FIELDS 3559 RADIATION TX DELIVERY IMRT C531 57155 INSERTION OF UTERINE TANDEM AND /OR VAGINAL C531 OVOIDS FOR CLINICAL BRACHYTHERAPY $1,23913 FEMALE SUBSCRIBER 77771 Remote afterb.ding high dose rate radionuclide C531 interstitial o mtracavitary brachytherapy,includes basic $2,186.29 FEMALE SUBSCRIBER dosimetry, when performed; 2 -12 channels 3559 $81634 C539 1050 CS39 $81634 C539 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, Z4682 FRONTAL AND LATERAL; $10,423.00 FEMALE SUBSCRIBER C530 C530 57155 INSERTION OF UTERINE TANDEM AND /OR VAGINAL C531 OVOIDS FOR CLINICAL BRACHYTHERAPY 3559 77771 Remote afterloadmg high dose rate radionuclide C531 interstitial or intracavitary brachytherapy, includes basic 3559 dosimetry, when performed; 2 -12 channels $594.40 FEMALE SUBSCRIBER 940 ANESTHESIA FOR VAGINAL PROCEDURES (INCLUDING CS39 BIOPSY OF LABIA, VAGINA, CERVIX OR ENDOMETRIUM); $46.62 FEMALE SUBSCRIBER NOT OTHERWISE SPECIFIED 3559 $0.00 C539 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF ENDOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF ENDOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF ENDOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF ENDOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OF EXOCERVIX OUTPATIENT /HOSPITAL MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF EXOCERVIX MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF CERVIX UTERI, UNSPECIFIED MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF CERVIX UTERI, UNSPECIFIED MALIGNANT NEOPLASM HOSPITA L OUTPATIENT OF CERVIX UTERI, UNSPECIFIED ENCOUNTER FOR FITTING PROFESSIONAL AND ADJUSTMENT OF OUTPATIENT /HOSPITAL NON- VASCULAR CATHETER MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF ENDOCERVIX MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF ENDOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF EXOCERVIX MALIGNANT NEOPLASM PROFESSIONAL OF CERVIX UTERI, OUTPATIENT /HOSPITAL UNSPECIFIED MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF CERVIX UTERI, UNSPECIFIED $200.46 $494.20 FEMALE SUBSCRIBER 1 050 3559 $42.33 $104.36 FEMALE SUBSCRIBER 1 OSO 3559 $192.60 $594.40 FEMALE SUBSCRIBER 1 OSO 3559 $1533 $46.62 FEMALE SUBSCRIBER 1050 3559 $0.00 $875.00 FEMALE SUBSCRIBER l OSO 3559 $715.65 $1,968.08 FEMALE SUBSCRIBER 1050 3559 $688.70 $620.96 FEMALE SUBSCRIBER 1 OSO 3559 ($688.70) (51,259.04) FEMALE SUBSCRIBER 1 050 3559 $456.21 $1,23913 FEMALE SUBSCRIBER 1 OSO 3559 $687.45 $2,186.29 FEMALE SUBSCRIBER 1 OSO 3559 $81634 $10,423.00 FEMALE SUBSCRIBER 1050 3559 $81634 $10,42100 FEMALE SUBSCRIBER l OSO 3559 $816.34 $10,423.00 FEMALE SUBSCRIBER 1050 3559 $17.64 $42.00 FEMALE SUBSCRIBER 1 OSO 3559 $625.70 $625.70 FEMALE SUBSCRIBER 1 OSO 3559 $602.70 $602.70 FEMALE SUBSCRIBER 1 OSO 3559 $456.21 $1,239.23 FEMALE SUBSCRIBER 1 OSO 3559 $752A6 $2,186.29 FEMALE SUBSCRIBER 1050 3559 $312.00 $750.00 FEMALE SUBSCRIBER 1 OSO 3559 $816.34 $10,423 -00 FEMALE SUBSCRIBER 1050 3559 C.7.f 5/31/2017 5/22/2017 5/26/2017 571551 NSERTI ON OF UTERINE TANDEM AN D /OR VAGINAL C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $456.21 $1,239.23 FEMALE SUBSCRIBER 1050 3559 OVOIDS FOR CLINICAL BRACHYTHERAPY OF EXOCERVIX 5/31/2017 5/22/2017 5/26/2017 77771 Remote afterloading high dose rate radionuclide C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $752.46 $2,186.29 FEMALE SUBSCRIBER 1 OSO 3559 OR interstitial or intracavitary brachytherapy, includes basic OF EXOCERVIX OR dasimetry, when performed; 2 -12 channels tu 5/31/2017 5/22/2017 5/30/2017- - C539 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $204.00 $204.00 FEMALE SUBSCRIBER 1 0S 3559 OF CERVIX UTERI, UNSPECIFIED 6/1/2017 5/26/2017 5/31/2017- - C531 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $204.00 $204.00 FEMALE SUBSCRIBER 1050 3559 OF EXOCERVIX 6/2/2017 5/25/2017 6/1/2017 940 ANESTHESIA FOR VAGINAL PROCEDURES (INCLUDING C531 MALIGNANT NEOPLASM PROFESSIONAL $312.00 $750.00 FEMALE SUBSCRIBER 1050 3559 BIOPSY OF LABIA, VAGINA, CERVIX OR ENDOMETRIUM); OF EXOCERVIX OUTPATIENT /HOSPITAL } NOT OTHERWISE SPECIFIED { j 6/5/2017 5/19/2017 5/31/2017 77290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $715.65 $1,968.08 FEMALE SUBSCRIBER 1050 3559 N. CL SETTING; COMPLEX OF EXOCERVIX Q. Q 6/5/2017 5/22/2017 5/31/2017 77290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $715.65 $1,968.08 FEMALE SUBSCRIBER 1 0S 3559 v SETTING; COMPLEX OF EXOCERVIX 6/5/2017 5/25/2017 5/31/2017 57155 INSERTION OF UTERINE TANDEM AND /OR VAGINAL C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $456.21 $1,239.23 FEMALE SUBSCRIBER 1050 3559 OVOIDS FOR CLINICAL BRACHYTHERAPY OF EXOCERVIX W 6/5/2017 5/25/2017 5/31/2017 77290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $715.65 $1,968.08 FEMALE SUBSCRIBER 1050 3559 IE SETTING; COMPLEX OF EXOCERVIX 6/5/2017 5/25/2017 5/31/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $71.29 $195.32 FEMALE SUBSCRIBER 1 0S 3559 _ INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF EXOCERVIX QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF a. THERAPY Ind 6/S/2017 5/25/2017 5/31/2017 77771 Remote after)oading high dose rate radionuclide C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $752.46 $2,186.29 FEMALE SUBSCRIBER 1 OSO 3559 interstitial or intracavitary brachyth —py, includes basic OF EXOCERVIX dosimetry, when performed; 2 -12 channels 6/8/2017 616/2017 6/7/2017 20670 REMOVAL OF IMPLANT; SUPERFICIAL(EG, BURIED WIRE, C539 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $770.60 $1,003.00 FEMALE SUBSCRIBER 1050 3559 PIN OR ROD) (SEPARATE PROCEDURE( OF CERVIX UTERI, Q UNSPECIFIED ILLJ 6/15/2017 5/23/2017 6/14/2017- - C539 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $10,746.99 $13,787.49 FEMALE SUBSCRIBER 1050 3559 U OF CERVIX UTERI, .A UNSPECIFIED J 6/16/2017 3/29/2017 4/3/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($195.02) i$620.96j FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX U 6/16/2017 3/29/2017 4/3/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1OSO 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX uj 6/16/2017 3/29/2017 4/3/2017 G6015 RADIATION TX DELIVERY HURT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1 0S 3559 OF EXOCERVIX U 6/16/2017 3/29/2017 4/3/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT CS31 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($565.28) $0.00 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX Q N 6/16/2017 3/29/2017 4/3/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM OF EXOCERVIX PROFESSIONAL OFFICE $0.00 61,2!:39.04! FEMALE SUBSCRIBER 1 OSO 3559 N 6/16/2017 5/18/2017 6/14/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE 1050 $565.28 $1,259.04 FEMALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1050 OF ENDOCERVIX ,620.961 FEMALE SUBSCRIBER 1 OSO 1$565.28) PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SUBSCRIBER 1 OSO $620.96 FEMALE SUBSCRIBER 1050 COMPONENTS: A DETAILED HISTORY; A DETAILED $1,537.00 FEMALE SUBSCRIBER 1050 $616.81 $1,399.00 FEMALE SUBSCRIBER EXAMINATION; MEDICAL DECISION MAKING OF $57.62 $156.52 FEMALE SUBSCRIBER 1 OSO MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/20/2017 5/11/2017 6/15/2017- - C539 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF CERVIX UTERI, UNSPECIFIED 6/29/2017 3/30/2017 4/4/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF RADIATION THERAPY FIELDS OF EXOCERVIX 6/29/2017 3/30/2017 4/4/2017 66015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF EXOCERVIX 6/29/2017 3/30/2017 4/4/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF RADIATION THERAPY FIELDS OF EXOCERVIX 6/29/2017 3/30/2017 4/4/2017 66015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF EXOCERVIX 7/5/2017 3/28/2017 3/31/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF RADIATION THERAPY FIELDS OF EXOCERVIX 7/6/2017 5/10/2017 6/28/2017 - - Z01810 ENCOUNTER FOR HOSPITAL OUTPATIENT PREPROCEDURAL CARDIOVASCULAR EXAMINATION 71712017 4/3/2017 7/6/2017 36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL Z452 ENCOUNTERFOR PROFESSIONAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; ADIUSTMENTAND INPATIENT / HDSPITAL AGES YEARS OR OLDER MANAGEMENT OF VASCULAR ACCESS DEVICE 71712017 6/8/2017 7/5/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF EXOCERVIX PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 711212017 4/3/2017 4/6/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF EXOCERVIX QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY 7/17/2017 5/11/2017 7/14/2017 940 ANESTHESIA FOR VAGINAL PROCEDURES (INCLUDING C539 MALIGNANT NEOPLASM OTHER MEDICAL BIOPSY OF LABIA, VAGINA, CERVIX OR ENDOMETRIUM); OF CERVIX UTERI, NOT OTHERWISE SPECIFIED UNSPECIFIED 7/18/2017 7/7/2017 7/11/2017 96523 IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE DRUG DELIVERY SYSTEMS OF ENDOCERVIX 7/19/2017 5/22/2017 5/26/2017 57155 INSERTION OF UTERINE TANDEM AND /OR VAGINAL C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OVOIDS FOR CLINICAL BRACHYTHERAPY OF EXOCERVIX 7119/2017 5/22/2017 5/26/2017 77771 Remote aReLI,rdmg high dose ate radionuclide C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE interstitial or intrac —tart' brachytherapy, includes basic OF EXOCERVIX dosimetry, when performed; 2 -12 channels $141.30 $348.35 FEMALE SUBSCRIBER 1050 $13,513.00 $32,062.45 FEMALE SUBSCRIBER 1050 $195.02 $620.96 FEMALE SUBSCRIBER 1050 $565.28 $1,259.04 FEMALE SUBSCRIBER 1050 5145.021 ,620.961 FEMALE SUBSCRIBER 1 OSO 1$565.28) ($1,259.04) FEMALE SUBSCRIBER 1 OSO $620.96 FEMALE SUBSCRIBER 1050 $923.00 $1,537.00 FEMALE SUBSCRIBER 1050 $616.81 $1,399.00 FEMALE SUBSCRIBER 1050 $57.62 $156.52 FEMALE SUBSCRIBER 1 OSO ($618.751 $169.84 FEMALE SUBSCRIBER 1050 $509.60 $1,290.00 FEMALE SUBSCRIBER 1050 $35.02 $86.33 FEMALE SUBSCRIBER 1050 $45611 $1,239.23 FEMALE SUBSCRIBER 1050 $752.46 $2,186.29 FEMALE SUBSCRIBER 1 OSO C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 ;M IIm Ill 3559 3559 3559 3559 C.7.f 7/19/2017 5/22/2017 5/26/2017 571551 NSERTI ON OF UTERINE TANDEM AN D /OR VAGINAL C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE iE45621I (51,239.237 FEMALE SUBSCRIBER 1050 3559 OVOIDS FOR CLINICAL BRACHYTHERAPY OF EXOCERVIX y� ]/19/201] 5/22/2017 5/26 /2017 77771 Remote afterloading high dose rate radionuclide C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE 52.461 ($2,136.'29) FEMALE SUBSCRIBER 1 OSO 3559 N interstitial or intracavitary brachytherapy, includes basic OF EXOCERVIX OR dasimetry, when performed; 2 -12 channels 7/24/2017 4/3/2017 4/6/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.02 $620.96 FEMALE SUBSCRIBER 1 0S 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX i ]/24/201] 4/3/2017 4/6/2017 66015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $753.71 $1,259.04 FEMALE SUBSCRIBER 1050 3559 "a OF EXOCERVIX 7/26/2017 3/31/2017 4/5/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT CS31 MALIGNANT NEOPLASM PROFESSIONAL OFFICE (576030 $620.96 FEMALE SUBSCRIBER IOSO 3559 OF RADIATION THERAPV FIELDS OF EXOCERVIX } fl ]/31/201] 3/31/2017 7/27/2017 G6015 RADIATION TX DELIVERY IMRT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $1,259.04 FEMALE SUBSCRIBER 1050 3559 N. CL OF EXOCERVIX CL Q 8/2/2017 7/26/2017 8/1/2017- - C530 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $3,413.00 $13,701.00 FEMALE SUBSCRIBER 1 0S 3559 v OF ENDOCERVIX 6/4/2017 3/31/2017 7/27/2017 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $260.03 $620.96 FEMALE SUBSCRIBER 1050 3559 OF RADIATION THERAPY FIELDS OF EXOCERVIX W 8/8/2017 7/25/2017 8/1/2017- - C530 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $602.70 $602.70 FEMALE SUBSCRIBER 1 0S 3559 OF ENDOCERVIX 8/21/2017 3/31/2017 81 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $620.96 FEMALE SUBSCRIBER 1 0S 3559 _ OF RADIATION THERAPY FIELDS OF EXOCERVIX 8/22/2017 8/2/2017 812112017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $14130 $348.35 FEMALE SUBSCRIBER 1050 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF ENDOCERVIX a. PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY Ind COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF U`J MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER J 8/24/2017 7/26/2017 8/23/2017 74177 Computed tomography, abdomen and pelvis; with C539 MALIGNANT NEOPLASM PROFESSIONAL $149.33 $360.00 FEMALE SUBSCRIBER 1050 3559 ILLJ ca ntrast material7s) OF CERVIX UTERI, OUTPATIENT /HOSPITAL UNSPECIFIED �q 8/25/2017 5/12/2017 8/23/2017 772953 - DIMENSIONAL RADIOTHERAPY PLAN, INCLUDING DOSE- C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $2,107.64 FEMALE SUBSCRIBER 1OSO 3559 J VOLUME HISTOGRAMS OF EXOCERVIX v 8/25/2017 5/19/2017 5/31/2017 77290 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $1,968.08 FEMALE SUBSCRIBER 1050 3559 SETTING; COMPLEX OF EXOCERVIX W 8/25/2017 5/19/2017 5/31/2017 772953 - DIMENSIONAL RADIOTHERAPY PLAN, INCLUDING DOSE- C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $769.43 $2,107.64 FEMALE SUBSCRIBER 1OSO 3559 VOLUME HISTOGRAMS OF EXOCERVIX 8/25/2017 5/19/2017 5/31/2017 77290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD 0531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE i$715.657 {$1,968.03) FEMALE SUBSCRIBER 1 OSO 3559 SETTING; COMPLEX OF EXOCERVIX 8/25/2017 5/19/2017 8/23/2017 77 2953 - DIMENSIONAL RADIOTHERAPY PLAN, INCLUDING DOSE- C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $2,107.64 FEMALE SUBSCRIBER 1050 3559 VOLUME HISTOGRAMS OF EXOCERVIX N 8/25/2017 5/22/2017 5/31/2017 77290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $1,968.08 FEMALE SUBSCRIBER 1050 3559 = SETTING; COMPLEX OF EXOCERVIX Qj E 8/25/2017 5/22/2017 5/31/2017 77 2953 - DIMENSIONAL RADIOTHERAPY PLAN, INCLUDING DOSE- C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $769.43 $2,107.64 FEMALE SUBSCRIBER 1050 3559 VOLUME HISTOGRAMS OF EXOCERVIX 0 C.7.f 8/25/2017 5/22/2017 5/31/2017 ]]290 THE RAP EUTIC RADIOLOGY SIM ULATION -AIDED F ELD C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($715.6511 (51,963.08) FEMALE SUBSCRIBER 1050 3559 SETTING; COMPLEX OF EXOCERVIX y� 8/25/2017 5/22/2017 8/23/2017 ]] 2953 - DIMENSIONAL RADIOTHERAPY PLAN, INCLUDING DOSE- C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $2,107.64 FEMALE SUBSCRIBER 1 0S 3559 N VOLUME HISTOGRAMS OF EXOCERVIX OR Q! 8/25/2017 5/25/2017 5/31/2017 57155 INSERTION OF UTERINE TANDEM AND /OR VAGINAL C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $456.21 $1,239.23 FEMALE SUBSCRIBER l OSO 3559 OVOIDS FOR CLINICAL BRACHYTHERAPY OF EXOCERVIX i 8/25/2017 5/25/2017 5/31/2017 ]]290 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $1,968.08 FEMALE SUBSCRIBER 1050 3559 "a SETTING; COMPLEX OF EXOCERVIX 8/25/2017 5/25/2017 5131/2017 772953 - DIMENSIONAL RADIOTHERAPY PLAN, INCLUDING DOSE- C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $769.43 $2,107.64 FEMALE SUBSCRIBER IOSO 3559 VOLUME HISTOGRAMS OF EXOCERVIX } fl 8/25/2017 5/25/2017 5/31/2017 ]]336 CONTINUING MEDICAL PHYSICS CONSULTATION, C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $71.29 $195.32 FEMALE SUBSCRIBER 1050 3559 N. CL INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF EXOCERVIX Q, QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY 8/25/2017 5/25/2017 5/31/2017 7777 Remote afterloading high dose rate radionuclide C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $752.46 $2,186.29 FEMALE SUBSCRIBER l OSO 3559 interstitial or intracavitary brachytherapy, includes basic OF EXOCERVIX dasimetry, when performed; 2 -12 channels 8/25/2017 5/25/2017 5/31/2017 57155 INSERTION OF UTERINE TANDEM AND /OR VAGINAL C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($456.21) {$1,239.237 FEMALE SUBSCRIBER l OSO 3559 ~ OVOIDS FOR CLINICAL BRACHYTHERAPY OF EXOCERVIX 812512017 5/25/2017 5/31/2017 ]]290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD 0531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($715.651 (51,968.08) FEMALE SUBSCRIBER 1050 3559 _ SETTING; COMPLEX OF EXOCERVIX 8/25/2017 5/25/2017 5131/2017 77336 CONTINUING MEDICAL PHYSICS CONSULTATION, CS31 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($712911 V195.321 FEMALE SUBSCRIBER l OSO 3559 INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, OF EXOCERVIX Q QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF uj PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF UJ THERAPY 8/25/2017 5/25/2017 5/31/2017 77771 Remote afterl .ndl.g high dose rate radionuclide C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ;$752.46) ($2,186.291 FEMALE SUBSCRIBER l OSO 3559 interstitial or intracavitary brachytherapy, includes basic OF EXOCERVIX Q dosimetry, when performed; 2 -12 channels 8/25/2017 8/23/2017 2953 C531 $0.00 $2,107.64 SUBSCRIBER sLLJ 3559 5/25/2017 ]] - DIMENSIONAL RADIOTHERAPY PLAN, INCLUDING DOSE- MALIGNANT NEOPLASM PROFESSIONAL OFFICE FEMALE IOSO VOLUME HISTOGRAMS OF EXOCERVIX J 8/28/2017 5/12/2017 5/16/2017 77290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $1,968.08 FEMALE SUBSCRIBER 1050 3559 SETTING; COMPLEX OF EXOCERVIX v 812812017 5/12/2017 5/16/2017 ]] 2953 - DIMENSIONAL RADIOTHERAPY PLAN, INCLUDING DOSE- C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $769.43 $2,107.64 FEMALE SUBSCRIBER 1050 3559 VOLUME HISTOGRAMS OF EXOCERVIX uJ 8/28/2017 5/12/2017 5/16/2017 77290 THERAPEUTIC RADIOLOGY SIMULATION- AIDED FIELD CS31 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ($715.651 ($1,968.O8% FEMALE SUBSCRIBER l OSO 3559 SETTING; COMPLEX OF EXOCERVIX �..� Q 8/29/2017 8/22/2017 8/28/2017- - C530 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $60230 $602.70 FEMALE SUBSCRIBER 1050 3559 OF ENDOCERVIX Q N 9/7/2017 8/26/2017 8/31/2017- - C531 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $11,379.00 $16,99100 FEMALE SUBSCRIBER 1OSO 3559 N OF EXOCERVIX C 9/13/2017 8/26/2017 9/12/2017 78815 POSITRON EMISSION TOMOGRAPHY (PET) WITH C539 MALIGNANT NEOPLASM PROFESSIONAL $194.31 $477.00 FEMALE SUBSCRIBER 1050 3559 y CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY OF CERVIX UTERI, OUTPATIENT /HOSPITAL (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL UNSPECIFIED LOCALIZATION IMAGING; SKULL BASE TO MID -THIGH m 9/27/2017 8/31/2017 9/26/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C531 MALIGNANT NEOPLASM PROFESSIONAL OFFICE FEMALE SUBSCRIBER EVALUATION AND MANAGEMENT OF AN ESTABLISHED $2,730.98 OF EXOCERVIX FEMALE SUBSCRIBER 1050 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $838.00 FEMALE SUBSCRIBER 1050 $35.02 COMPONENTS: A PROBLEM FOCUSED HISTORY; A FEMALE SUBSCRIBER 1050 $141.30 $348.35 PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD SUBSCRIBER 1050 MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 10/2/2017 5/12/2017 5/17/2017 940 ANESTHESIA FOR VAGINAL PROCEDURES (INCLUDING C531 MALIGNANT NEOPLASM PROFESSIONAL BIOPSY OF LABIA, VAGINA, CERVIX OR ENDOMETRIUM); OF EXOCERVIX OUTPATIENT /HOSPITAL NOT OTHERWISE SPECIFIED 10/2/2017 5/12/2017 9/29/2017 940 ANESTHESIA FOR VAGINAL PROCEDURES (INCLUDING C531 MALIGNANT NEOPLASM PROFESSIONAL BIOPSY OF LABIA, VAGINA, CERVIX OR ENDOMETRIUM); OF EXOCERVIX OUTPATIENT /HOSPITAL NOT OTHERWISE SPECIFIED 11/3/2017 10/26/2017 11/2/2017- - C530 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF ENDOCERVIX 11/13/2017 10/26/2017 11/10/2017 36590 REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS Z452 ENCOUNTER FOR PROFESSIONAL DEVICE, WITH SUBCUTANEOUS PORTOR PUMP, CENTRAL ADJUSTMENT AND OUTPATIENT /HOSPITAL OR PERIPHERAL INSERTION MANAGEMENT OF VASCULAR ACCESS DEVICE 12/28/2017 8/31/2017 12/27/2017 96523 IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE DRUG DELIVERY SYSTEMS OF ENDOCERVIX 12/28/2017 10/13/2017 12/27/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C530 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF ENDOCERVIX PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER Sub Total 5.25E +10 1/3/2017 12/26/2016 12/30/2016 - - BEL HEADACHE HOSPITAL OUTPATIENT 1/4/2017 12/25/2016 1/3/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION D496 NEOPLASM OF PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES UNSPECIFIED BEHAVIOR OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A OF BRAIN DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR 1/6/2017 12/26/2016 1/5/2017 99284 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION R51 HEADACHE OTHER MEDICAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR 1/23/2017 10/19/2016 1/22/2017 1/30/2017 1/4/2017 1/12/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R51 HEADACHE PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR $57.62 $156.52 FEMALE SUBSCRIBER 1050 $0.00 ($875.00) FEMALE SUBSCRIBER 1 050 $280.00 $875.00 FEMALE SUBSCRIBER 1050 $2,730.98 $2,730.98 FEMALE SUBSCRIBER 1050 $346.88 $838.00 FEMALE SUBSCRIBER 1050 $35.02 $86.33 FEMALE SUBSCRIBER 1050 $141.30 $348.35 FEMALE SUBSCRIBER 1050 $127,892.82 $318,626.40 $2,441.15 $2,441.15 FEMALE SUBSCRIBER 1050 $210.83 $994.00 FEMALE SUBSCRIBER 1050 $179.21 $994.00 FEMALE SUBSCRIBER 1050 $225.69 $471.89 FEMALE SUBSCRIBER 1050 $0.00 $994.00 FEMALE SUBSCRIBER 1050 C.7.f 3559 3559 3559 3559 3559 3559 3559 I Lm ®' C.7.f 1/30/2017 1/10/2017 111412017 - - R51 HEADACHE HOSPITAL OUTPATIENT 1/30/2017 1/10/2017 1/17/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R51 HEADACHE PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR 1/31/2017 1/4/2017 1111/2017 - - R51 2/7/2017 1/31/2017 2/3/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE RSI 1050 3559 COMPRESSION OF BRAIN PROFESSIONAL EVALUATION AND MANAGEMENT OF A NEW PATIENT, $10.00 FEMALE SUBSCRIBER 1 OSO 3559 WHICH REQUIRES THESE 3 KEY COMPONENTS ;A COMPREHENSIVE HISTORY; A COMPREHENSIVE COMPRESSION OF BRAIN PROFESSIONAL $4.13 $10.00 FEMALE SUBSCRIBER EXAMINATION; MEDICAL DECISION MAKING OF 3559 INPATIENT /HOSPITAL MODERATE COMPLEXITY. COUNSELING AND /Oft COMPRESSION OF BRAIN PROFESSIONAL $4.13 COORDINATION OF CARE WITH OTHER PROVIDERS OR SUBSCRIBER 2/20/2017 11/19/2016 2/19/2017 * * * ** * * * ** *« « ** 3/1/2017 2/13/2017 2/15/2017 COMPRESSION OF BRAIN PROFESSIONAL $4.13 3/15/2017 2/28/2017 3/11/2017 85014 BLOOD COUNT; HEMATOCRIT (HUT) G935 3/15/2017 2/28/2017 3/11/2017 85018 BLOOD COUNT; HEMOGLOBIN (HGB) G935 3/15/2017 31 3/11/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL G935 3559 INPATIENT /HOSPITAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL COMPRESSION OF BRAIN PROFESSIONAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) $12.00 FEMALE SUBSCRIBER 1 OSO 3559 CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) COMPRESSION OF BRAIN PROFESSIONAL 3/15/2017 3/2/2017 3111/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, G935 INPATIENT /HOSPITAL HCT, BBC, W BC AND PLATELET COUNT) AND AUTOMATED COMPRESSION OF BRAIN PROFESSIONAL $4.13 DIFFERENTIAL W BC COUNT SUBSCRIBER 3/15/2017 3/2/2017 3/11/2017 85610 PROTHROMBIN TIME; 6935 3115/2017 3/2/2017 3/11/2017 85730 THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR G935 $15.00 FEMALE SUBSCRIBER 1 050 WHOLE BLOOD INPATIENT /HOSPITAL 3/15/2017 3/2/2017 3/11/2017 86850 ANTIBODI SCREEN, BBC, EACH SERUM TECHNIQUE G935 3/15/2017 312/2017 3/11/2017 86900 BLOOD TYPING, SEROLOGIC; ABO G935 3/15/2017 3/2/2017 3/11/2017 86901 BLOOD TYPING, SEROLOGIC; RH(D) G935 3/15/2017 3/4/2017 3/11/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL G935 SUBSCRIBER 1 050 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) COMPRESSION OF BRAIN PR0FE55IONAL $4.13 $11.00 FEMALE SUBSCRIBER CREATININE(82565) GLUCOSE (82947) POTASSIUM 3559 INPATIENT /HOSPITAL (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 3/15/2017 3/4/2017 3/11/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, G935 1 OSO 3559 INPATIENT /HOSPITAL HR, RBC, WEE AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL W BC COUNT $1,636.80 3/15/2017 3/4/2017 3/11/2017 85610 PROTHROMBIN TIME; 6935 3/15/2017 3/4/2017 3/11/2017 85730 THROMBOPLASTIN TIME, PARTIAL (PET); PLASMA OR G935 COMPRESSION OF BRAIN PROFESSIONAL $35.04 $402.00 FEMALE WHOLE BLOOD 1 OSO 3/16/2017 3/2/2017 3/14/2017 210 ANESTHESIA FOR INTRACRANIAL PROCEDURES; NOT G935 OTHERWISE SPECIFIED 3/16/2017 3/2/2017 3/14/2017 36620 ARTERIAL CATHETERIZATION OR CANNULATION FOR G935 SAMPLING, MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS $1,760.34 $2,647.12 FEMALE SUBSCRIBER 1050 $158.82 $994.00 FEMALE SUBSCRIBER 1050 ®' HEADACHE HOSPITAL OUTPATIENT $1,278.03 $2,404.05 FEMALE SUBSCRIBER 1050 3559 HEADACHE PROFESSIONAL OFFICE $17133 $513.92 FEMALE SUBSCRIBER 1 050 3559 $154.58 $323.22 FEMALE SUBSCRIBER 1 OSO 3559 $6.07 $65.00 FEMALE SUBSCRIBER 1050 3559 COMPRESSION OF BRAIN PROFESSIONAL $4.13 $10.00 FEMALE SUBSCRIBER 1 OSO 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $4.13 $10.00 FEMALE SUBSCRIBER 1 050 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $4.13 $24.00 FEMALE SUBSCRIBER 1 OSO 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $4.13 $12.00 FEMALE SUBSCRIBER 1 050 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $4.13 $11.00 FEMALE SUBSCRIBER 1 050 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $4.13 $12.00 FEMALE SUBSCRIBER 1 OSO 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $5.19 $17.00 FEMALE SUBSCRIBER 1 050 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $4.13 $9.00 FEMALE SUBSCRIBER 1 OSO 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $4.13 $15.00 FEMALE SUBSCRIBER 1 050 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $4.13 $24.00 FEMALE SUBSCRIBER 1 OSO 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $4.13 $12.00 FEMALE SUBSCRIBER 1 050 3559 INPATIENT / HDSPITAL COMPRESSION OF BRAIN PR0FE55IONAL $4.13 $11.00 FEMALE SUBSCRIBER 1 OSO 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $4.13 $12.00 FEMALE SUBSCRIBER 1 OSO 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $1,636.80 $3,410.00 FEMALE SUBSCRIBER 1 OSO 3559 INPATIENT /HOSPITAL COMPRESSION OF BRAIN PROFESSIONAL $35.04 $402.00 FEMALE SUBSCRIBER 1 OSO 3559 INPATIENT /HOSPITAL C.7.f 3/17/2017 2/28/2017 3/9/2017 - - G935 COMPRESSION OF BRAIN HOSPITAL INPATIENT 3/2/2017 3/4/2017 $52,924.90 $107,753.00 FEMALE SUBSCRIBER 1 050 3559 3/24/2017 3/20/2017 3/23/2017 - - G894 CHRONIC PAIN HOSPITAL OUTPATIENT $2,705.00 $6,526.03 FEMALE SUBSCRIBER 1 OSO 3559 w C! SYNDROME N 3/27/2017 3/2/2017 3/22/2017 20926 TISSUE GRAFTS, OTHER )EG, PARATENDN, FAT, DERMIS) G935 COMPRESSION OF BRAIN PROFESSIONAL $268.79 $1,787.48 FEMALE SUBSCRIBER 1 050 3559 INPATIENT /HOSPITAL 3/27/2017 3/2/2017 3/22/2017 61343 CRANIECTOMY, SUBOCCIPITAL WITH CERVICAL G935 COMPRESSION OF BRAIN PROFESSIONAL $2,724.97 $8,800.64 FEMALE SUBSCRIBER 1 OSO 3559 LAMINECTOMY FOR DECOMPRESSION OF MEDULLAAND INPATIENT /HOSPITAL SPINAL CORD, WITH OR WITHOUT DURAL GRAFT (EG, } ARNOLD- CHIARI MALFORMATION) 3/29/2017 3/20/2017 3128/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION G894 CHRONIC PAIN PROFESSIONAL $266.40 $1,481.00 FEMALE SUBSCRIBER 1050 3559 AND MANAGEMENTOF A PATIENT, WHICH REQUIRES SYNDROME OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY DF THE PATIENT'S CLINICAL } > CONDITION AND /OR MENTAL STATUS: ACOMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND iL CL MEDICAL DECIS Q, Q 3/31/2017 3/20/2017 3/30/2017 * * * "* * * *'" * " " ** sx *xr * * *x. $70.32 $166.00 FEMALE SUBSCRIBER 1 OSO 3559 v 4/10/2017 1/14/2017 4/6/2017 *aa+m * * *.* xxxx. * * * ** * * * ** $154.58 $323.22 FEMALE SUBSCRIBER 1 OSO 3559 4/14/2017 4/10/2017 4/12/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R51 HEADACHE PROFESSIONAL OFFICE $115.82 $150.00 FEMALE SUBSCRIBER 1OSO 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED h EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/19/2017 4/10/2017 4/18/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R51 HEADACHE PROFESSIONAL $313.41 $1,481.00 FEMALE SUBSCRIBER 1 OSO 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL Q CONDITION AND /OR MENTAL STATUS: A CDMPREH ENSIVE ui HISTORY; A COMPREHENSIVE EXAMINATION; AN❑ MEDICAL DECIS UY 4/2U/2017 4/10/2017 4/14/2017 - - R51 HEADACHE HOSPITA L OUTPATIENT $6,248.51 $6,248.51 FEMALE SUBSCRIBER 1 050 3559 0 4/20/2017 4/10/2017 4/19/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT R51 HEADACHE PROFESSIONAL $70.32 $166.00 FEMALE SUBSCRIBER 1050 3559 CONTRAST MATERIAL OUTPATIENT /HOSPITAL een .°✓ 5/3/2017 4/25/2017 5/2/2017 - - G935 COMPRESSION OF BRAIN HOSPITAL OUTPATIENT $1,002.78 $3,695.50 FEMALE SUBSCRIBER 1 OSO 3559 5/4/2017 4/26/2017 5/3/2017- - G971 OTHER REACTION TO HOSPITAL OUTPATIENT $2,206.25 $3,538.75 FEMALE SUBSCRIBER 1050 3559 v SPINAL AND LUMBAR PUNCTURE 5/5/2017 4/25/2017 5/4/2017 82945 GLUCOSE, BODY FLUID, OTHER THAN BLOOD G935 COMPRESSION OF BRAIN PROFE55IONAL $5.50 $13.00 FEMALE SUBSCRIBER 1 OSO 3559 LLJ OUTPATIENT /HOSPITAL 5/5/2017 4/25/2017 5/4/2017 84157 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER G935 COMPRESSION OF BRAIN PROFESSIONAL $5.50 $9.00 FEMALE SUBSCRIBER 1050 3559 (' SOURCE LEG, SYNDVIAL FLUID, CEREBROSPINAL FLUID) OUTPATIENT /HOSPITAL 5/5/2017 4/25/2017 5/4/2017 87070 CULTURE, BACTERIAL, ANY OTHER SOURCE EXCEPT URINE, G935 COMPRESSION OF BRAIN PROFESSIONAL $5.50 $24.00 FEMALE SUBSCRIBER 1050 3559 BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND OUTPATIENT /HOSPITAL PRESUMPTIVE IDENTIFICATION OF ISOLATES f'V 5/5/2017 4/25/2017 5/4/2017 87205 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM G935 COMPRESSION OF BRAIN PROFESSIONAL $550 $13.00 FEMALE SUBSCRIBER 1 OSO 3559 = OR GI EMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES OUTPATIENT /HOSPITAL E 5/5/2017 4/25/2017 5/4/2017 89051 CELL COUNT, MISCELLANEOUS BODY FLUIDS BEG, G935 COMPRESSION OF BRAIN PROFESSIONAL $5.50 $17.00 FEMALE SUBSCRIBER 1 OSO 3559 ._ CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; OUTPATIENT /HOSPITAL WITH DIFFERENTIAL COUNT 5/9/2017 4/25/2017 5/8/2017 62270 SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC G935 COMPRESSION OF BRAIN PROFESSIONAL OUTPATIENT /HOSPITAL 5/9/2017 4/25/2017 5/8/2017 77003 FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF G935 COMPRESSION OF BRAIN PROFESSIONAL NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS OUTPATIENT /HOSPITAL DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) 5/12/2017 4/26/2017 5111/2017 99282 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION G971 OTHER REACTION TO PROFESSIONAL AND MANAGEMENTOF A PATIENT, WHICH REQUIRES SPINALAND LUMBAR OUTPATIENT /HOSPITAL THESE 3 KEYCOMPONENTS: AN EXPANDED PROBLEM PUNCTURE FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5117/2017 5/3/2017 5/16/2017 99285 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION G43909 MIGRAINE, UNSPECIFIED, OTHER MEDICAL AND MANAGEMENTOF A PATIENT, WHICH REQUIRES NOT INTRACTABLE, THESE KEY COMPONENTS WITHIN THE CONSTRAINTS WITHOUTSTATUS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL MIGRAINOSUS CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 5/24/2017 5/17/2017 5/22/2017 76536 ULTRASOUND, SOFTTISSUES OF HEAD AND NECK(EG, R221 LOCALIZED SWELLING, OTHER MEDICAL THYROID, PARATHYROID, PAROTID), REALTIME WITH MASS AND LUMP, NECK IMAGE DOCUMENTATION 5/26/2017 5/3/2017 5/25/2017- - G43909 MIGRAINE, UNSPECIFIED, HOSPITAL OUTPATIENT NOT INTRACTABLE, WITHOUT STATUS MIGRAINOSUS 6/5/2017 5/29/2017 6/1/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE G039 MENINGITIS, UNSPECIFIED OTHER MEDICAL 6/5/2017 5/29/2017 6/1/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST G039 MENINGITIS, UNSPECIFIED OTHER MEDICAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE (82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 6/5/2017 5/29/2017 6/1/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR G039 MENINGITIS, UNSPECIFIED OTHER MEDICAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, W ITHOUT MICROSCOPY 6/5/2017 5/29/2017 6/1/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, G039 MENINGITIS, UNSPECIFIED OTHER MEDICAL HCT, RBC, W BC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL W BC COUNT 6/5/2017 5/29/2017 6/1/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE G039 MENINGITIS, UNSPECIFIED OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 6/6/2017 5129/2017 6/5/2017 - - R51 HEADACHE HOSPITAL OUTPATIENT $72.14 $519.00 FEMALE SUBSCRIBER 1050 $47.66 $144.00 FEMALE SUBSCRIBER 1 OSO $51.43 $150.00 FEMALE SUBSCRIBER l OSO $313.41 $1,481.00 FEMALE SUBSCRIBER 1 OSO $125.00 $441.00 FEMALE SUBSCRIBER l OSO $2,657.35 $2,657.35 FEMALE SUBSCRIBER 1 OSO $0.00 $32.00 FEMALE SUBSCRIBER 1050 $0.00 $99.00 FEMALE SUBSCRIBER l OSO $0.00 $36.00 FEMALE SUBSCRIBER l OSO $0.00 $58.00 FEMALE SUBSCRIBER 1050 $225.00 $300.00 FEMALE SUBSCRIBER l OSO $1,135.68 $4,680.68 FEMALE SUBSCRIBER 1 OSO C.7.f 6/6/2017 5/29/2017 6/5/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT R51 HEADACHE PROFESSIONAL $52.66 $126.00 FEMALE SUBSCRIBER 1O50 3559 CONTRAST MATERIAL OUTPATIENT /HOSPITAL 6/7/2017 5/28/2017 6/6/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 644229 CHRONIC TENSION -TYPE OTHER MEDICAL $211.76 $994.00 FEMALE SUBSCRIBER 1050 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES HEADACHE, NOT THESE KEY COMPONENTS: A DETAILED HISTORY; A INTRACTABLE DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS DR AGENCIES ARE PR 6/7/2017 5/28/2017 6/6/2017 - - 644229 CHRONIC TENSION -TYPE HOSPITAL OUTPATIENT $2,705.00 $4,474.00 FEMALE SUBSCRIBER 1 OSO 3559 HEADACHE,NOT INTRACTABLE 6/21/2017 6/18/2017 6/20/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION H5310 UNSPECIFIED SUBJECTIVE PROFESSIONAL $147.65 $150.00 FEMALE SUBSCRIBER 1050 3559 AND MANAGEMENTOFA PATIENT, WHICH REQUIRES VISUAL DISTURBANCES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR 6/22/2017 6/16/2017 6/21/2017 - - R51 HEADACHE HOSPITAL OUTPATIENT $2,705.00 $5,078.30 FEMALE SUBSCRIBER 1 OSO 3559 6/23/2017 6/16/2017 6/22/2017 99285 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION R51 HEADACHE OTHER MEDICAL $266.40 $1,481.00 FEMALE SUBSCRIBER 1050 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY DF THE PATIENT'S CLINICAL CONDITION AND /OR MENTALSTATUS: ACOMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 6/23/2017 6/18/2017 6122/2017 62270 SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC G935 COMPRESSION OF BRAIN PROFESSIONAL $97.74 $315.20 FEMALE SUBSCRIBER 1 OSO 3559 INPATIENT /HOSPITAL 6/28/2017 6/16/2017 6/27/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT Z98890 OTHER SPECIFIED PROFESSIONAL $7032 $166.00 FEMALE SUBSCRIBER 1 OSO 3559 CONTRAST MATERIAL POSTPROCEDURAL STATES OUTPATIENT /HOSPITAL 6128/2017 6/19/2017 6/27/2017 - - G935 COMPRESSION OF BRAIN HOSPITAL OUTPATIENT $3,850.60 $7,116.25 FEMALE SUBSCRIBER 1 050 3559 6/30/2017 6/18/2017 6/29/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL 6935 COMPRESSION OF BRAIN PROFESSIONAL $5.50 $24.00 FEMALE SUBSCRIBER 1050 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL OUTPATIENT /HOSPITAL (823101 CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (92565) GLUCOSE (92947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN( (84520) 6/30/2017 6/18/2017 6/29/2017 82945 GLUCOSE, BODY FLUID, OTHER THAN BLOOD G935 COMPRESSION OF BRAIN PROFESSIONAL $5.50 $13.00 FEMALE SUBSCRIBER 1 OSO 3559 OUTPATIENT /HOSPITAL 6/30/2017 6/18/2017 6/29/2017 84157 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER G935 COMPRESSION OF BRAIN PROFESSIONAL $5.50 $9.00 FEMALE SUBSCRIBER 1050 3559 SOURCE(EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID) OUTPATIENT /HOSPITAL 6/30/2017 6/18/2017 6129/2017 84702 GONADOTROPIN, CHORIDNIC (TICE); QUANTITATIVE G935 COMPRESSION OF BRAIN PROFESSIONAL $5.50 $22.00 FEMALE SUBSCRIBER 1 OSO 3559 OUTPATIENT /HOSPITAL 6/30/2017 6/18/2017 6/29/2017 85025 BLOOD COUNT; COMPLETE (CDC), AUTOMATED (TIED, G935 COMPRESSION OF BRAIN PROFESSIONAL $5.50 $12.00 FEMALE SUBSCRIBER 1 OSO 3559 HOT, RBC, W BC AND PLATELET COUNT) AND AUTOMATED OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 6/30/2017 6118/2017 6/29/2017 87070 CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, G935 COMPRESSION OF BRAIN PROFESSIONAL $5.50 $24.00 FEMALE SUBSCRIBER 1 OSO 3559 BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND OUTPATIENT/HOSPITAL PRESUMPTIVE IDENTIFICATION OF ISOLATES 6/30/2017 6/18/2017 6/29/2017 87205 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM G935 COMPRESSION OF BRAIN PROFESSIONAL 3559 OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELLTYPES $4,262.16 FEMALE SUBSCRIBER 1050 OUTPATIENT /HOSPITAL 6/30/2017 6/19/2017 6/29/2017 89050 CELL COUNT, MISCELLANEOUS BODY FLUIDS LEG, G935 COMPRESSION OF BRAIN PROFESSIONAL $13.00 FEMALE SUBSCRIBER CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; 3559 $5.50 OUTPATIENT /HOSPITAL 6/30/2017 6/21/2017 6/29/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R51 HEADACHE PROFESSIONAL OFFICE 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED $13.00 FEMALE SUBSCRIBER 1050 3559 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 7/3/2017 6/18/2017 6/29/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION G935 COMPRESSION OF BRAIN PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR 7/12/2017 6/20/2017 7/11/2017 99236 OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE E860 DEHYDRATION PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT OUTPATIENT /HOSPITAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTO RV; A CDM PR EH ENSI VE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELI 7/12/2017 6/20/2017 7/11/2017 - - E860 DEHYDRATION HOSPITAL OUTPATIENT 7/18/2017 7/12/2017 7117/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1329 CHRONIC SINUSITIS, OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED UNSPECIFIED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 7/28/2017 7/25/2017 7/27/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT G919 HYDROCEPHALUS, PROFESSIONAL CONTRAST MATERIAL UNSPECIFIED OUTPATIENT /HOSPITAL 8/2/2017 7/27/2017 81112017 62223 CREATION OF SHUNT; VENTRICULO- PERITONEAL,- G912 (IDIOPATHIC) NORMAL PROFESSIONAL PLEURAL, OTHER TERMINUS PRESSURE INPATIENT /HOSPITAL HYDROCEPHALUS 8/7/2017 7/25/2017 8/4/2017 - - 6912 (IDIOPATHIC) NORMAL HOSPITAL OUTPATIENT PRESSURE HYDROCEPHALUS 8/7/2017 7/25/2017 8/5/2017 82945 GLUCOSE, BODY FLUID, OTHER THAN BLOOD G912 (IDIOPATHIC) NORMAL PROFESSIONAL PRESSURE OUTPATIENT /HOSPITAL HYDROCEPHALUS 8/7 /2017 7 /25/2017 8/5/2017 84157 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER G912 (IDIOPATHIC) NORMAL PROFESSIONAL SOURCE)EG, SYNOVIAL FLUID, CEREBROSPINAL FLUID) PRESSURE OUTPATIENT /HOSPITAL HYDROCEPHALUS 8/7/2017 7/25/2017 8/5/2017 87070 CULTURE, BACTERIAL, ANY OTHER SOURCE EXCEPT URINE, G912 (IDIOPATHIC) NORMAL PROFESSIONAL BLOOD ORSTOOL, AEROBIC, WITH ISOLATION AND PRESSURE OUTPATIENT /HOSPITAL PRESUMPTIVE IDENTIFICATION OF ISOLATES HYDROCEPHALUS 8/7/2017 7/25/2017 8/5/2017 87205 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM G912 (IDIOPATHIC) NORMAL PROFESSIONAL OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELLTYPES PRESSURE OUTPATIENT /HOSPITAL HYDROCEPHALUS $5.50 $13.00 FEMALE SUBSCRIBER $5.50 $15.00 FEMALE SUBSCRIBER $85.52 $199.28 FEMALE SUBSCRIBER 1 050 1 OSO 1 OSO C.7.f 3559 w 3559 N Q! 3559 $147.65 $338.00 FEMALE SUBSCRIBER 1 EGO 3559 $304.82 $1,045.00 FEMALE SUBSCRIBER 1050 3559 $1,890.00 $15,782.00 FEMALE SUBSCRIBER 1050 3559 $225.00 $300.00 FEMALE SUBSCRIBER 1 OSO 3559 $67.06 $205.00 FEMALE SUBSCRIBER 1050 3559 $1,295.08 $4,262.16 FEMALE SUBSCRIBER 1050 3559 $1,011.79 $3,762.00 FEMALE SUBSCRIBER 1050 3559 $5.50 $13.00 FEMALE SUBSCRIBER 1050 3559 $5.50 $9.00 FEMALE SUBSCRIBER 1050 3559 $530 $24.00 FEMALE SUBSCRIBER 1050 3559 $5.50 $13.00 FEMALE SUBSCRIBER 1050 3559 E C.7.f 61712017 7/25/2017 8/5/2017 89050 CELL C0UNT, MISCELLANEOUS BODY FLUIDS(EG, G912 (IDIOPATHIC) NORMAL PROFESSIONAL $5.50 $15.00 FEMALE SUBSCRIBER 1050 3559 CEREBROSPINAL FLUID, JOINT FLUID), EXCEPT BLOOD; PRESSURE OUTPATIENT /HOSPITAL HYDROCEPHALUS 8/7/2017 81112017 8/4/2017 74150 COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT Z982 PRESENCE OF PROFESSIONAL $93.66 $289.00 FEMALE SUBSCRIBER 1050 3559 CONTRAST MATERIAL CEREBROSPINAL FLUID OUTPATIENT /HOSPITAL DRAINAGE DEVICE 8/8/2017 7/27/2017 8/4/2017 - - G910 COMMUNICATING HOSPITAL INPATIENT 7/27/2017 # # # # # # ## $23,562.96 $72,758.50 FEMALE SUBSCRIBER 1 OSO 3559 HYDROCEPHALUS 8/9/2017 7/2S/2017 8/4/2017 - - G919 HYDROCEPHALUS, HOSPITAL OUTPATIENT $539.80 $3,195.00 FEMALE SUBSCRIBER 1 OSO 3559 UNSPECIFIED 8/10/2017 8/1/2017 8/9/2017- - L259 UNSPECIFIED CONTACT HOSPITAL OUTPATIENT $2,621.16 $7,199.00 FEMALE SUBSCRIBER 1050 3559 DERMATITIS, UNSPECIFIED CAUSE 8/11/2017 7/2S/2017 8110/2017 62270 SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC G919 HYDROCEPHALUS, PROFESSIONAL $72.14 $519.00 FEMALE SUBSCRIBER 1 050 3559 UNSPECIFIED OUTPATIENT /HOSPITAL 811112017 7/25/2017 811012017 77003 FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF G919 HYDROCEPHALUS, PROFESSIONAL $47.66 $144.00 FEMALE SUBSCRIBER 1050 3559 NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS UNSPECIFIED OUTPATIENT /HOSPITAL DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) 8/14/2017 8/1/2017 8/11/2017 99282 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION L259 UNSPECIFIED CONTACT PROFESSIONAL $47.70 $150.00 FEMALE SUBSCRIBER 1050 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES DERMATITIS, UNSPECIFIED OUTPATIENT/HOSPITAL THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM CAUSE FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 8/14/2017 8/1/2017 8/11/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL L259 UNSPECIFIED CONTACT PROFESSIONAL $530 $24.00 FEMALE SUBSCRIBER 1050 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL DERMATITIS, UNSPECIFIED OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CAUSE CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 8/14/2017 8/1/2017 8/11/2017 86850 ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE L259 UNSPECIFIED CONTACT PROFESSIONAL $0.00 $17.00 FEMALE SUBSCRIBER 1050 3559 DERMATITIS, UNSPECIFIED OUTPATIENT /HOSPITAL CAUSE 8/14/2017 8/1/2017 811112017 86900 BLOOD TYPING, SEROLOGIC; ADO L259 UNSPECIFIED CONTACT PROFESSIONAL $5.50 $9.00 FEMALE SUBSCRIBER 1 OSO 3559 DERMATITIS, UNSPECIFIED OUTPATIENT /HOSPITAL CAUSE 8/14/2017 8/1/2017 8/11/2017 86901 BLOOD TYPING, SERDLOGIC; RH(D) L259 UNSPECIFIED CONTACT PROFESSIONAL $5.50 $15.00 FEMALE SUBSCRIBER 1050 3559 DERMATITIS, UNSPECIFIED OUTPATIENT/HOSPITAL CAUSE 8/15/2017 5/29/2017 6/5/2017 - - R51 HEADACHE HOSPITAL OUTPATIENT $1,135.68 $4,680.68 FEMALE SUBSCRIBER 1 050 3559 8/15/2017 5/29/2017 6/5/2017 - - R51 HEADACHE HOSPITAL OUTPATIENT ($'- 135,18) ($4,680.68) FEMALE SUBSCRIBER 1 OSO 3559 8/15/2017 8/6/2017 8/14/2017 - - R509 FEVER, UNSPECIFIED HOSPITAL OUTPATIENT $2,705.00 $3,373.74 FEMALE SUBSCRIBER 1 OSO 3559 8/16/2017 7/27/2017 8/14/2017 220 ANESTHESIA FOR INTRACRANIAL PROCEDURES; G910 COMMUNICATING PROFESSIONAL $1,536.00 $2,500.00 FEMALE SUBSCRIBER 1 050 3559 CEREBROSPINAL FLUID SHUNTING PROCEDURES HYDROCEPHALUS INPATIENT /HOSPITAL 8/16/2017 8/6/2017 8/15/2017 99284 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION T8509XA OTHER MECHANICAL PROFESSIONAL $211.76 $994.00 FEMALE SUBSCRIBER 1050 3559 AND MANAGEMENTOF A PATIENT, WHICH REQUIRES COMPLICATION OF OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A VENTRICULAR DETAILED EXAMINATION; AND MEDICAL DECISION INTRACRANIAL MAKING OF MODERATE COMPLEXITY. COUNSELING (COMMUNICATING) AND /OR COORDINATION OF CARE WITH OTHER SHUNT, INITIAL PROVIDERS OR AGENCIES ARE PR ENCOUNTER C.7.f 8/17/2017 8/7/2017 8/16/2017 71010 RADIOLOGIC EXAM I NATION, CHEST; SINGLE VIEW, R509 FEVER, UNSPECIFIED PROFESSIONAL $14.94 $36.00 FEMALE SUBSCRIBER 1 050 3559 FRONTAL OUTPATIENT /HOSPITAL Z 8/18/2017 8/4/2017 8/17/2017- - 8999 UNSPECIFIED INFECTIOUS HOSPITAL OUTPATIENT $204.00 $204.00 FEMALE SUBSCRIBER 1050 3559 N DISEASE 8/22/2017 5/29/2017 812112017 62270 SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC RSl HEADACHE PROFESSIONAL $126.36 $285.00 FEMALE SUBSCRIBER 1 050 3559 OUTPATIENT /HOSPITAL 8/22/2017 5/29/2017 8121/2017 99285 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION R51 HEADACHE PROFESSIONAL $268.82 $665.00 FEMALE SUBSCRIBER 1050 3559 7 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL "a THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND } MEDICAL DECIS L. CL 9/6/2017 8/28/2017 9/5/2017 - - R51 HEADACHE HOSPITAL OUTPATIENT $2,705.00 $4,485.50 FEMALE SUBSCRIBER 1 OSO 3559 Q, Q 9/6/2017 8/31/2017 9/5/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT R51 HEADACHE PROFESSIONAL $0.00 $126.00 FEMALE SUBSCRIBER 1050 3559 v CONTRAST MATERIAL OUTPATIENT/HOSPITAL 9/8/2017 8/28/2017 9/7/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION G8929 OTHER CHRONIC PAIN OTHER MEDICAL $211.76 $994.00 FEMALE SUBSCRIBER 1050 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEYCOMPONENTS: A DETAILED HISTORY; A h DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AG ENCIES ARE PR _ 9/13/2017 8/28/2017 9112/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT FEE HEADACHE PROFESSIONAL $70.32 $166.00 FEMALE SUBSCRIBER 1050 3559 CONTRAST MATERIAL OUTPATIENT /HOSPITAL d 9/22/2017 9/16/2017 9/21/2017 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 50990XA UNSPECIFIED INJURY OF OTHER MEDICAL $155.00 $155.00 FEMALE SUBSCRIBER 1050 3559 {i EVALUATION AND MANAGEMENT OF ANEW PATIENT, HEAD, INITIAL WHICH REQUIRES THESE 3 KEYCOMPONENTS: A DETAILED ENCOUNTER UJ HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE P LLJ 9/22/2017 9/16/2017 9/21/2017- - 50990XA UNSPECIFIED INJURY OF HOSPITAL OUTPATIENT $2,351.27 $9,796.96 FEMALE SUBSCRIBER 1OSO 3559 � HEAD, INITIAL w, J ENCOUNTER 9/26/2017 9/19/2017 9/25/2017- - I820 BUDD- CHIARI SYNDROME HOSPITAL OUTPATIENT $674.96 $2,934.61 FEMALE SUBSCRIBER 1050 3559 v 101212017 8/31/2017 9/29/2017 - - R51 HEADACHE HOSPITAL OUTPATIENT $5,255.08 $7,128.75 FEMALE SUBSCRIBER 1 OSO 3559 W 1D/4/2017 5/10/2017 10/3/2017 * «« «. . » »»w «« «.. w. »rr .. » »» $160.93 $336.56 FEMALE SUBSCRIBER 1 050 3559 10/6/2017 9/16/2017 10/5/2017 99284 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION S098XXA OTHER SPECIFIED OTHER MEDICAL $281.81 $1,311.00 FEMALE SUBSCRIBER 1050 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INJURIES OF HEAD, INITIAL (' THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A ENCOUNTER DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR CN ! C.7.f 10/9/2017 9/19/2017 101 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 1820 BUDD - CHIARI SYNDROME PROFESSIONAL $281.81 $1,311.00 FEMALE SUBSCRIBER 1050 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEYCOMPONENTS: A DETAILED HISTORY; A Z DETAILED EXAMINATION; AND MEDICAL DECISION N MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR.AGENCIES ARE PR 1011012017 4/12/2017 10/9/2017 *` * ** * * * ** * « * ** * * * ** * * * ** $13139 $323.22 FEMALE SUBSCRIBER 1 050 3559 7 10/10/2017 7/27/2017 10/4/2017 44180 LAPAROSCDPY, SURGICAL, ENTEROLYSIS FREEING OF K660 PERITONEAL ADHESIONS PROFESSIONAL $1,178.56 $3,681.00 FEMALE SUBSCRIBER 1 050 3559 "a INTESTINAL ADHESION) (SEPARATE PROCEDURE) (POSTPROCEDURAL) INPATIENT /HOSPITAL (POSTINFECTION) 10/11/2017 4/20/2017 10/10/2017 xxx"s e. **w. $131.39 $323.22 FEMALE SUBSCRIBER 1 050 3559 > 11/6/2017 10/26/2017 11/3/2017 " * * ** 10/26/2017 # # # # # # ## $5,399.45 $15,750.00 FEMALE SUBSCRIBER 1 OSO 3559 11/7/2017 8/31/2017 11/6/2017 99284 EMERGENCY DEPARTMENTVISIT FOR THE EVALUATION SIT HEADACHE PROFESSIONAL $183.33 $443.00 FEMALE SUBSCRIBER 1050 3559 CL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL Q, THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A v DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR F 11/13/2017 11/2/2017 11/10/2017 * * + «* * * * ** *« « ** * * * *« * * * ** $189.04 $2,845.00 FEMALE SUBSCRIBER 1 050 3559 LU 11/20/2017 11/2/2017 11/6/201] * * * ** * * " ** * * * ** * * * "` * * " "* $2,314.05 $6,285.00 FEMALE SUBSCRIBER 1 DID 3559 F 11/22/2017 11/17/2017 11/20/2017 *` * ** * * * "* " « « *" « * * *« * * * ** $0. 00 $5,475.00 FEMALE SUBSCRIBER 1 OSO 3559 D 11/30/2017 11/5/2017 12/4/2017 11/10/2017 11/13/2017 11/30/2017 * *r «r * » »».* r« «rr w *»»r *. » »w $0.00 $0.00 $6, 255.00 FEMALE SUBSCRIBER $1,095.00 FEMALE SUBSCRIBER 1 050 1 050 3559 3559 _ 12/4/2017 11/24/2017 11/30/2017 * * * ** * * * "* ° " * ** « * * ** * * * ** $0.00 $4,380.00 FEMALE SUBSCRIBER COT OSO 3559 12/5/2017 11/28/2017 12/4/2017 * * * "+ $0.00 $2,190.00 FEMALE SUBSCRIBER .1 050 3559 12/6/2017 11/29/2017 12/4/201] * * *«r ». »w.* xsxxx w.*.* »* » * » »* $0,00 $995.00 FEMALE SUBSCRIBER OFF 050 3559 12/6/2017 12/1/201] 12/4/201] * *' ** * * * "* ' * * ** " * * ** * * * ** $0.0C $995.00 FEMALE SUBSCRIBER .1 050 3559 0. 12/11/2017 11/2/2017 11/29/2017 * * * "* * * * "* * * " ** " * * ** * * * »* $108.79 $1,300.00 FEMALE SUBSCRIBER 1 050 3559 LL! 12/12/2017 11/2/2017 11/29/201] xxxss .. +.* xxrsx * + + *a * * * *• $149.03 $2,495.00 FEMALE SUBSCRIBER 1 ISO 3559 12/12/2017 11/10/201] 12/11/201] * * * «` * * * "" * * * *+ " * * *' * * *'" $0.00 $1,095.00 FEMALE SUBSCRIBER 1 ISO 3559 U) 12/12/2017 11/17/2017 12/11/2017 * * * "* *' * "" *` " ** " * *'* *' " *" $0.00 $5 FEMALE SUBSCRIBER 1 050 3559 12/12/2017 11/24/201] 12/11/2017 * * * ** * * *'+ * ** ** • * + *" * * * ** $0 .00 ,475.00 $4,350.00 FEMALE SUBSCRIBER COI ISO 3 9 55 12/12/201] 12/4/201] 12/11/2017 * * "x. +.«+* rrx ++ * * *xx + ***. $0.00 $995.00 FEMALE SUBSCRIBER CO1 OSO 3559 12/12/2017 12/5/2017 12/11/2017 * * * "* * * * ** * * " ** * * * ** * * * ** $0.00 $995.00 FEMALE SUBSCRIBER CO1 ISO 3559 ILLJ 12/12/2017 12/6/201] 12/11/2017 * * * ** + ** *" * ** ** • * * ** * * * ** $0.00 $995.00 FEMALE SUBSCRIBER C OSO 3559 12/12/2017 12/]/2017 12/11/2017 * * *'" * * * ** * *` ** " * * ** * * * ** $0.00 $995.00 FEMALE SUBSCRIBER CO1 ISO 3559 �q 12/12/2017 12/8/2017 12/11/2017 *` * ** $0.00 $995.00 FEMALE SUBSCRIBER CO1 ISO 3559 J 12/15/2017 11/28/2017 12/11/2017 **a +* rr..* r«rrr r *.r« r * * ** $0 .00 C $2,190.00 FEMALE SUBSCRIBER O1 EGO 3559 12/18/201] 12/]/201] 12/15/2017 $0.00 $1,300.00 FEMALE SUBS CRIBER C01 ISO 3559 (, 12/18/2017 12/11/2017 12/15/2017 *` " ** * * * ** * " " ** * * * *« * * * ** $0.00 $1,300.00 FEMALE SUBSCRIBER C01 ISO 3559 r 12/18/2017 12/11/201] 12/15/201] * * " «* * * * *" *« « ** * * " *« * * * »* $9.61 $995.00 FEMALE SUBSCRIBER CO1 ISO 3559 Z 12/18/2017 12/12/2017 12/15/2017 * *r.r *. »».* *«..r w *.»r *. » »w $13.10 $995.00 FEMALE SUBSCRIBER CO1 050 3559 LLJ 12/18/2017 12/13/2017 12/15/2017 "` * ** * + * ** * « « ** * * * *« * + * ** $13.10 $995.00 FEMALE SUBSCRIBER CO1 0 3559 12/19/2017 11/10/2017 12/18/2017 * * * «* " * * ** * « « ** * " * *« " * * »* $0.00 $1,095.00 FEMALE SUBSCRIBER 1 050 3559 12/19/2017 11/17 /2017 12/18/201] * * ».r *. " ** * * * ** * * * »s * * "»* $0.00 $5,4]5.00 FEMALE SUBSCRIBER 1 050 3559 U 12/19/2017 11/24/2017 12/18/2017 *.» ** * * * ** * « « ** " + * ** * * * ** $0.00 $4,380.00 FEMALE SUBSCRIBER C01 0 3559 12/19/2017 11/28/2017 12/18/2017 * *' "* * * * ** * * " "* * * * ** * * * ** $0.00 $2,190.00 FEMALE SUBSCRIBER C01 050 3559 12/19/2017 12/14/2017 12/18/201] xr».r . » »»* xx"xx x *. »* ». » »w $13.10 $995.00 FEMALE SUBSCRIBER C01 050 3559 12/19/2017 12/15/2017 12/18/2017 * * * "+ * * * "* ' * " ** " * * *' * * * ** $13.10 $995.00 FEMALE SUBSCRIBER C01 050 3559 N 12/21/2017 11/5/2017 12/11/2017 * *' "* * * * "* * * " ** " * * "» * * * ** $2,314.05 $6,285.00 FEMALE SUBSCRIBER 1 050 3559 hl 12/21/2017 11/5/2017 12/18/201] xxxss *.x"* xxrsx e. **w. *.*x* $0.00 $6,285.00 FEMALE SUBSCRIBER 1 050 3559 12/27/2017 12/18/2017 12/26/2017 * * * "* * * « ** * * " ** ° # * ** * *' *' $1 3.10 $995.00 FEMALE SUBSCRIBER COT 050 3559 = 12/27/2017 12/18/2017 12/26/2017 * » » "* * * * ** * » " ** ° *. *r * * * «* $48.96 $1,300.00 FEMALE SUBSCRIBER C01 050 3559 93 12/27/2017 12/19/201] 12/26/2017 ' *r** *...* srr.+ x**xr *..r. $13.10 $995.00 FEMALE SUBSCRIBER C01 050 3559 12/2]/2017 12/20/2017 12/26/2017 * * * *' * * * ** * * * ** °k #k * * * ** $13.10 $995.00 FEMALE SUBSCRIBER CO1 ISO 3559 ^� 12/27/2017 12/21/2017 12/26/2017 * * * ** * * * ** * » " ** * * * ** * * * ** $13.10 $995.00 FEMALE SUBSCRIBER CO1 ISO 3559 03 12/27/201] 12/22/201] 12/26/2017 * * * ** * * * ** x*r*r : *r.. * *.r. $13.10 $995.00 FEMALE SUBSCRIBER CO1 EGO 3559 12/29/2017 121112017 12/2812017 * * *`" "` *' " * * ** * *' *' " "• Sub Total $225.00 $1,324.00 MALE SPOUSE $0.00 $99.00 5.375E +10 1/10/2017 12/29/2016 1/9/2017 71D20 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, Z01812 ENCOUNTER FOR OTHER MEDICAL $0.01 MALE SPOUSE 1 ASO FRONTAL AND LATERAL; $0.01 PREPROCEDURAL SPOUSE 1050 3559 $0.01 $0.01 MALE SPOUSE LABORATORY 3559 $0.01 $0.01 MALE SPOUSE 1050 3559 EXAMINATION $0.01 MALE 1/10/2017 12/29/2016 1/9/2017 93000 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 Z01812 ENCOUNTER FOR OTHER MEDICAL LEADS; WITH INTERPRETATION AND REPORT PREPROCEDURAL LABORATORY EXAMINATION 1/30/2017 1/6/2017 1/16/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 201818 ENCOUNTER FOR OTHER OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED PREPROCEDURAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY EXAMINATION COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 1/30/2017 1/19/2017 1/24/2017- - M50223 OTHER CERVICAL DISC HOSPITAL OUTPATIENT DISPLACEMENT AT C6 -C7 LEVEL 2/17/2017 1/25/2017 2/10/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE R05 COUGH OTHER MEDICAL 2/17/2017 1/25/2017 2/10/2017 71250 COMPUTED TOMOGRAPHY, THORAX; WITHOUT R05 COUGH OTHER MEDICAL CONTRAST MATERIAL 2/17/2017 1/25/2017 2/10/2017 80053 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST R05 COUGH OTHER MEDICAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, TOTAL (82247), CALCIUM, TOTAL (82310), CARBON DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, ALKALINE (84075), POTASSIUM (84132), PROTEIN, 2/17/2017 1/25/2017 2/10/2017 84436 THYROXINE; TOTAL R05 COUGH OTHER MEDICAL 2/17/2017 1/25/2017 2/10/2017 84443 THYROID STIMULATING HORMONE(TSH) ROS COUGH OTHER MEDICAL 2/17/2017 1/25/2017 2/10/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, ROS COUGH OTHER MEDICAL HCT, RBC, W BC AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT 2/27/2017 1/19/2017 2/23/2017 72110 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; M549 DORSALGIA, UNSPECIFIED PROFESSIONAL MINIMUM OF FOUR VIEWS OUTPATIENT /HOSPITAL 2/27/2017 1/19/2017 2/23/2017 1036F CURRENTTOBACCO NON - USER (CAD, CAP, CORD, PV) M5020 OTHER CERVICAL DISC PROFESSIONAL 1 DML(IBD) DISPLACEMENT, OUTPATIENT /HOSPITAL UNSPECIFIED CERVICAL REGION 2/27/2017 1/19/2017 2/23/20171101F PATIENT SCREENED FOR FUTURE FALL RISK; M5020 OTHER CERVICAL DISC PROFESSIONAL DOCUMENTATION OF NO FALLS IN THE PASTYEAR OR DISPLACEMENT, OUTPATIENT /HOSPITAL ONLY I FALL WITHOUT INJURY IN THE PAST YEAR(GERI UNSPECIFIED CERVICAL REGION 2/27/2017 1/19/2017 2/23/20171123F ADVANCE CARE PLANNING DISCUSSED AND M5020 OTHER CERVICAL DISC PROFESSIONAL DOCUMENTED ADVANCE CARE PLAN OR SURROGATE DISPLACEMENT, OUTPATIENT /HOSPITAL DECISION MAKER DOCUMENTED IN THE MEDICAL UNSPECIFIED CERVICAL RECORD (DEM) (GER, PALL CR) REGION 2/27/2017 1/19/2017 2/23/2017 1125F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY 'DELAY" N15020 OTHER CERVICAL DISC PROFESSIONAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR DISPLACEMENT, OUTPATIENT /HOSPITAL DIRECT FLAP, AT FOREHEAD, CHEE UNSPECIFIED CERVICAL REGION 212712017 111912017 2/23/20171159F MEDICATION LIST DOCUMENTED IN MEDICAL RECORD M5020 OTHER CERVICAL DISC PROFESSIONAL (COAL DISPLACEMENT, OUTPATIENT /HOSPITAL UNSPECIFIED CERVICAL REGION $0.00 $995.00 FEMALE SUBSCRIBER C01 OSO $153,737.36 $450,27736 $0.00 $164.00 MALE SPOUSE 1050 $0.00 $120.00 MALE SPOUSE 1050 $175.00 $300.00 MALE SPOUSE 1050 $0.00 $1,50038 MALE SPOUSE $0.00 $32.00 MALE SPOUSE $225.00 $1,324.00 MALE SPOUSE $0.00 $99.00 MALE SPOUSE C.7.f 3559 w 3559 OR m Q! 3559 i' 3559 } fl s® CL CL Q 1 OSO 3559 1 OSO 3559 1 050 3559 1 OSO 3559 $0.00 $74.00 MALE SPOUSE 1050 3559 $0.00 $141.00 MALE SPOUSE I OSO 3559 $0.00 $58.00 MALE SPOUSE 3 050 3559 $18.13 $64.00 MALE SPOUSE 1050 3559 $0.01 $0.01 MALE SPOUSE 1 ASO 3559 $0.01 $0.01 MALE SPOUSE 1050 3559 $0.01 $0.01 MALE SPOUSE 1050 3559 $0.01 $0.01 MALE SPOUSE 1050 3559 $0.01 $0.01 MALE SPOUSE I (ISO 3559 2/27/2017 1/19/2017 2/23/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5020 OTHER CERVICAL DISC PROFESSIONAL $170.89 $507.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF ANEW PATIENT, DISPLACEMENT, OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS:A UNSPECIFIED CERVICAL COMPREHENSIVE HISTORY; A COMPREHENSIVE REGION EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 2/27/2017 1/19/2017 2/23/201768420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS M5020 OTHER CERVICAL DISC PROFESSIONAL $0.01 $0.01 MALE SPOUSE 1050 AND NO FOLLOW -UP PLAN IS REQUIRED DISPLACEMENT, OUTPATIENT /HOSPITAL UNSPECIFIED CERVICAL REGION 2/27/2017 1/19/2017 2/23/2017 68427 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN M5020 OTHER CERVICAL DISC PROFESSIONAL SORT $0.01 MALE SPOUSE 1 050 THE MEDICAL RECORD THEYOBTAINED, UPDATED, OR DISPLACEMENT, OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS UNSPECIFIED CERVICAL REGION 2/27/2017 1/19/2017 2/23/2017 G8484 INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, M5020 OTHER CERVICAL DISC PROFESSIONAL $0.01 $0.01 MALE SPOUSE 1050 REASON NOT GIVEN DISPLACEMENT, OUTPATIENT /HOSPITAL UNSPECIFIED CERVICAL REGION 2/27/2017 1/19/2017 2/23/201768730 PAIN ASSESSMENT DOCUMENTED AS POSITIVE USINGA M5020 OTHER CERVICAL DISC PROFESSIONAL $0.00 $0.01 MALE SPOUSE 1050 STANDARDIZED TOOLANDA FOLLOW -UP PLAN IS DISPLACEMENT, OUTPATIENT /HOSPITAL DOCUMENTED UNSPECIFIED CERVICAL REGION 3/1/2017 1/25/2017 2/25/2017 93271 EXTERNAL PATIENT AND, WHEN PERFORMED, AUTO 1484 ATYPICAL ATRIAL FLUTTER PROFESSIONAL OFFICE $0.00 $1,925.00 MALE SPOUSE 1050 ACTIVATED ELECTROCARDIOGRAPHIC RHYTHM DERIVED EVENT RECORDING WITH SYMPTOM- RELATED MEMORY LOOP WITH REMOTE DOWNLOAD CAPABILITY UP TO 30 DAYS, 24 -HDUR ATTENDED MONITORING; TRANSMISSION AND ANALYSIS 3/1/2017 2/15/2017 2/20/2017 840 ANESTHESIA FOR NTRAPERITONEAL PROCEDURES IN K4090 UNILATERAL INGUINAL PROFESSIONAL $425.25 $1,375.00 MALE SPOUSE 1 OSO LOWER ABDOMEN INCLUDING LAPAROSCOPY; NOT HERNIA, WITHOUT OUTPATIENT /HOSPITAL OTHERWISE SPECIFIED OBSTRUCTION OR GANGRENE, NOT SPECI FI ED AS RECURRENT 3/6/2017 2/15/2017 212412017 49585 REPAIR UMBILICAL HERNIA, AGE S YEARS OR OLDER; K4090 UNILATERAL INGUINAL OTHER MEDICAL $652.78 $1,800.00 MALE SPOUSE 1050 REDUCIBLE HERNIA, WITHOUT OBSTRUCTION OR GANGRENE, NOT SPECI FI ED AS RECURRENT 3/6/2017 2/15/2017 2/24/2017 49650 LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL K4090 UNILATERAL INGUINAL OTHER MEDICAL $314.43 $2,350.00 MALE SPOUSE 1 RISE) HERNIA HERNIA, WITHOUT OBSTRUCTION OR GANGRENE, NOT SPECI FI ED AS RECURRENT 3/8/2017 2/21/2017 3/1/2017 72148 MAGNETIC RESONANCE LEG, PROTON) IMAGING, SPINAL M47816 SPONDYLOSIS WITHOUT PROFESSIONAL $92.25 $288.00 MALE SPOUSE 1050 CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MYELOPATHY OR OUTPATIENT /HOSPITAL MATERIAL RADICULOPATHY, LUMBAR REGION 3/8/2017 2/23/2017 2/28/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R066 HICCOUGH PROFESSIONAL OFFICE $58.90 $350,00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENTOFAN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER C.7.f 3/9/2017 2/21/2017 3/2/2017 72146 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL C159 MALIGNANT NEOPLASM PROFESSIONAL $91.84 $310.00 MALE SPOUSE 1050 3559 CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST OF ESOPHAGUS, OUTPATIENT /HOSPITAL MATERIAL UNSPECIFIED Z N 3/13/2017 2/15/2017 2/21/2017 - - K4090 UNILATERAL INGUINAL HOSPITAL OUTPATIENT $4,995.33 $35,920.85 MALE SPOUSE 1 050 3559 HERNIA, WITHOUT OBSTRUCTION OR GANGRENE, NOT SPECI FI ED AS RECURRENT } 3/13/2017 2/21/2017 2124/2017- - M4808 SPINAL STENOSIS, SACRAL HOSPITAL OUTPATIENT $2,774.25 $12,450.66 MALE SPOUSE 1050 3559 AND SACROCOCCYGEAL REGION W 3/17/2017 2/1/2017 3/15/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1480 PAROXYSMAL ATRIAL PROFESSIONAL OFFICE $163.81 $337.00 MALE SPOUSE 1050 } 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED FIBRILLATION A. CL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY Q, COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF v MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER Q 3/1]/201] 3/3/2017 3/7/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C160 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $300.28 $440.00 MALE SPOUSE 1050 3559 EVALUATION AND MANAGEMENTOF A NEW PATIENT, OF CARDIA uj WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 3/17/2017 3/9/2017 3/16/2017 49560 REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; K439 VENTRAL HERNIA OTHER MEDICAL $1,095.68 $2,400.00 MALE SPOUSE 1050 3559 REDUCIBLE WITHOUT OBSTRUCTION Q OR GANGRENE {j 3/17/2017 3/9/2017 3116/2017 495681MPLANT4TION OF MESH OR OTHER PROSTHESIS FOR K439 VENTRAL HERNIA OTHER MEDICAL $405.76 $950.00 MALE SPOUSE 1050 3559 U`J INCISIONAL OR VENTRAL HERNIA REPAIR OR MESH FOR WITHOUT OBSTRUCTION CLOSURE OF DEBRIDEMENT FOR NECROTIZING SOFT OR GANGRENE TISSUE INFECTION (LIST SEPARATELY IN ADDITION TO CODE FOR THE INCISIONAL OR VENTRAL HERNIA REPAIR) W 0 3/17/2017 3/9/2017 3/16/2017 - - K439 VENTRAL HERNIA HOSPITAL INPATIENT 3/9/2017 # # # # # # ## $14,154.90 $61,424.01 MALE SPOUSE 1 050 3559 WITHOUT OBSTRUCTION J OR GANGRENE v 3/27/2017 3/9/2017 3/24/2017 832 ANESTHESIA FOR HERNIA REPAIRS IN LOWER ABDOMEN; K439 VENTRAL HERNIA PROFESSIONAL $744.80 $1,750.00 MALE SPOUSE 1050 3559 VENTRALAND INCISIONAL HERNIAS WITHOUT OBSTRUCTION OUTPATIENT /HOSPITAL OR GANGRENE W 3/28/2017 3/23/2017 3/27/2017- - M5020 OTHER CERVICAL DISC HOSPITAL OUTPATIENT $3,413.00 $5,403.28 MALE SPOUSE 1050 3559 DISPLACEMENT, UNSPECIFIED CERVICAL Q REGION 4/4/2017 1/25/2017 4/3/2017 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 1480 PAROXYSMAL ATRIAL PROFESSIONAL OFFICE $33.01 $66.00 MALE SPOUSE 1050 3559 „p LEADS; WITH INTERPRETATION AND REPORT FIBRILLATION N 4/4/2017 1/25/2017 4/3/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 1480 PAROXYSMAL ATRIAL PROFESSIONAL OFFICE $188.81 $337.00 MALE SPOUSE 1050 3559 N EVALUATION AND MANAGEMENTOFAN ESTABLISHED FIBRILLATION C PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY y COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF ._ MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER C.7.f 4/20/2017 1/25/2017 2/25/2017 93271 EXTER NAL PATIENT AND, WHEN PERFORMED, AUTO 1484 ATYPICAL ATRIAL FLUTTER PROFESSIONAL OFFICE $0.00 jS 1,925.00) MALE SPOUSE 1050 3559 ACTIVATED ELECTROCARDIOGRAPHIC RHYTHM DERIVED EVENT RECORDING WITH SYMPTOM- RELATED MEMORY LOOP WITH REMOTE DOWNLOAD CAPABILITY UP TO 30 N DAYS, 24 -HDUR ATTENDED MONITORING; TRANSMISSION AND ANALYSIS 4/20/2017 1/25/2017 4/19/2017 93271 EXTERNAL PATIENT AND, WHEN PERFORMED, AUTO 1484 ATYPICAL ATRIAL FLUTTER PROFESSIONAL OFFICE $0.00 $1,925.00 MALE SPOUSE 1050 3559 ACTIVATED ELECTROCARDIOGRAPHIC RHYTHM DERIVED } EVENT RECORDING WITH SYMPTOM- RELATED MEMORY "a LOOP WITH REMOTE DOWNLOAD CAPABILITY UP TO 30 DAYS, 24 -HDUR ATTENDED MONITORING; TRANSMISSION AND ANALYSIS W } 4/24/2017 3/23/2017 4/21/2017 72125 COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT C159 MALIGNANT NEOPLASM PROFESSIONAL $87.97 $224.00 MALE SPOUSE 1050 3559 CONTRAST MATERIAL OF ESOPHAGUS, OUTPATIENT /HOSPITAL G. CL UNSPECIFIED Q, Q 4/28/2017 4/20/2017 4/27/2017- - Z4789 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT $22.76 $151.75 MALE SPOUSE 1050 3559 v ORTHOPEDIC AFTERCARE 5/11/2017 5/3/2017 5/9/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL $0.00 $11.00 MALE SPOUSE 1 050 3559 PREPROCEDURAL EXAMINATION h 511112017 5/3/2017 5/9/2017 80053 COMPREHENSIVE METABOLIC PANELTHIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, Z01818 ENCOUNTER FOR OTHER PREPROCEDURAL OTHER MEDICAL $8.27 $50.00 MALE SPOUSE 1 OSO 3559 TOTAL (82247), CALCIUM, TOTAL (8231D), CARBON EXAMINATION _ DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, ALKALINE 184075), POTASSIUM (84132), PROTEIN, d 5/11/2017 5/3/2017 S/9/2017 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR ZO1818 ENCOUNTER FOR OTHER OTHER MEDICAL $248 $15.00 MALE SPOUSE 1050 3559 {i BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, PREPROCEDURAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, EXAMINATION UJ UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; cn AUTOMATED, WITH MICROSCOPY 5/11/2017 5/3/2017 5/9/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED HOPE Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL $6.08 $37.00 MALE SPOUSE 1050 3559 HCT,RBC, WBCAND PLATELETCOUNT ) ANDAUTOMATED PREPROCEDURAL LLJ DIFFERENTIAL WEE COUNT EXAMINATION 5/11/2017 5/3/2017 5/9/2017 85610 PROTHROMBIN TIME; Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL $3.07 $19.00 MALE SPOUSE 1050 3559 PREPROCEDURAL EXAMINATION v 5/11/2017 5/3/2017 5/9/2017 85730 THR0MB0PLASTIN TIME, PARTIAL(PTT); PLASMA OR Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL $4.69 $29.00 MALE SPOUSE 1050 3559 WHOLE BLOOD PREPROCEDURAL LLJ EXAMINATION 5/11/2017 5/3/2017 5/9/2017 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, Z01818 ENCOUNTER FOR OTHER OTHER MEDICAL $6.32 $38.00 MALE SPOUSE 1050 3559 (' URINE PREPROCEDURAL EXAMINATION 5/12/2017 5/3/2017 5/11/2017 87077 CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL 201818 ENCOUNTER FOR OTHER OTHER MEDICAL $632 $39.00 MALE SPOUSE 1050 3559 METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, PREPROCEDURAL hl EACH ISOLATE EXAMINATION 5/12/2017 5/3/2017 5/11/2017 87181 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; AGAR Z01819 ENCOUNTER FOR OTHER OTHER MEDICAL $0.66 $4,00 MALE SPOUSE 1050 3559 DILUTION METHOD, PERAGENT(EG, ANTIBIOTIC PREPROCEDURAL GRADI ENT STRIP) EXAMINATION m 5/12/2017 5/3/2017 5/11/2017 87186 SUSCEPTIBILITY STUD I ES, ANTI MIC ROB IALAGENT; 201818 ENCOUNTER FOR OTHER OTHER MEDICAL MICRODILUTION OR AGAR DILUTION (MINIMUM PREPROCEOURAL INHIBITORY CONCENTRATION AMICA" ORBREAKPOINT), EXAMINATION EACH MULTI - ANTIMICROBIAL, PER PLATE 5/22/2017 3/2/2017 5/19/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 1480 PAROXYSMAL ATRIAL OTHER MEDICAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED FIBRILLATION PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5/22/2017 5/11/2017 5/19/2017- - MS0223 OTHER CERVICAL DISC HOSPITAL OUTPATIENT DISPLACEMENT AT C5 -C7 LEVEL 5122/2017 5/16/2017 5/19/2017 L0460 TLSO, TRIPLANAR CONTROL, MODULAR SEGMENTED M4806 SPINAL STENOSIS, OTHER MEDICAL SPINAL SYSTEM, TWO RIGID PLASTIC SHELLS, POSTERIOR LUMBAR REGION EXTENDS FROM THE SACROCOCCYGEAL JUNCTION AND TERMINATES JUST INFERIOR TO THE SCAPULAR SPINE, ANTERIOR EXTENDS FROM THE SYMPHYSIS PUBIS TO THE STERNAL NOTCH, SOFT LINER, RESTRICTS GROSS TRUNK MOT 5/22/2017 5/18/2017 5/20/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1480 PAROXYSMAL ATRIAL PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH FIBRILLATION INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PO IN ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/17/2017 5/26/2017 72100 RADIOLDGIC EXAM INATION, SPINE, LUMBOSACRAL; TWO M4326 FUSIONOFSPINE, PROFESSIONAL ORTHREEVIEWS LUMBAR REGION INPATIENT /HOSPITAL 5/30/2017 5/24/2017 5/27/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION M4726 OTHER SPONDYLOSIS PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES WITH RADICULOPATHY, INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; LUMBAR REGION A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 5/30/2017 5/25/2017 5/27/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4726 OTHER SPONDYLOSIS PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH WITH RADICULOPATHY, INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN LUMBAR REGION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 5/31/2017 5/11/2017 5/30/2017 72141 MAGNETIC RESONANCE(EG, PROTON) IMAGING, SPINAL M5011 CERVICAL DISC DISORDER PROFESSIONAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST WITH RADICULOPATHY, OUTPATIENT /HOSPITAL MATERIAL HIGH CERVICAL REGION 6/1/2017 5/17/2017 5/25/2017 20931 ALLOGRAFT,STRUCTURAL, FOR SPINE SURGERYONLY(LIST M4727 OTHER SPONDYLOSIS PROFESSIONAL SEPARATELY IN ADDITION TO CODE FOR PRIMARY WITH RADICULOPATHY, INPATIENT /HOSPITAL PROCEDURE) LUMBOSACRAL REGION $0.00 $41.00 MALE SPOUSE 1050 $160.49 $337.00 MALE SPOUSE 1050 $3,699.00 $6,934.00 MALE SPOUSE 1050 $702.24 $702.24 MALE SPOUSE 1050 $148.53 $399.00 MALE SPOUSE 1050 $17.76 $46.00 MALE SPOUSE 1050 $282.08 $783.00 MALE SPOUSE 1050 $103.51 $276.00 MALE SPOUSE 1050 $12245 $310.00 MALE SPOUSE 1050 $262.93 $538,00 MALE SPOUSE 1050 6/1/2017 5/17/2017 5/25/2017 22633 ARTHR0DESIS, COMBINED POSTERIOR OR M4727 OTHER SPONDYLOSIS PROFESSIONAL POSTEROLATERAL TECHNIQUE WITH POSTERIOR WITH RADICULOPATHY, INPATIENT /HOSPITAL INTERBODY TECHNIQUE INCLUDING LAMINECFOMY LUMBOSACRAL REGION AND /OR DISCECTOMY SUFFICIENTTO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; LUMBAR 6/1/2017 5/17/2017 5/25/2017 22634 ARTHR0DESIS, COMBINED POSTERIOR OR M4727 OTHER SPONDYLOSIS PROFESSIONAL POSTEROLATERAL TECHNIQUE WITH POSTERIOR WITH RADICULOPATHY, INPATIENT /HOSPITAL INTERBODY TECHNIQUE INCLUDING LAMINECTOMY LUMBOSACRAL REGION AND /OR DISCECTOMY SUFFICIENTTO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT; EACH ADDITIONAL INT 6/1/2017 5/17/2017 5/25/2017 22842 POSTERIOR SEGMENTAL INSTRUMENTATION LEG, PEDICLE M4727 OTHER SPONDYLOSIS PROFESSIONAL FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND WITH RADICULOPATHY, INPATIENT /HOSPITAL SUBIAMINAR WIRES(; 3TO 6 VERTEBRAL SEGMENTS(LIST LUMBOSACRAL REGION SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 6/1/2017 5/17 /2017 5/25/20174044F DOCUMENTATION THATAN ORDER WAS GIVEN FOR M4727 OTHER SPONDYLOSIS PROFESSIONAL VENOUSTHROMBOEMBOLISM (VTE) PROPHYLAXIS TO BE WITH RADICULOPATHY, INPATIENT /HOSPITAL GIVEN WITHIN 24 HOURS PRI0RT0 INCISION TIME 0R 24 LUMBOSACRAL REGION HOURS AFTER SURGERY END TIME (PERT 2) 6/1/2017 5/17/2017 5/25/20174046F DOCUMENTATION THAT PROPHYLACTIC ANTIBIOTICS M4727 OTHER SPONDYLOSIS PROFESSIONAL WERE GIVEN WITHIN 4 HOURS PRIOR TO SURGICAL WITH RADICULOPATHY, INPATIENT /HOSPITAL INCISION OR GIVEN INTRAOPERATIVELY (PERI 2) LUMBOSACRAL REGION 6/1/2017 5/17/2017 5125/20174049F TRANSECTION OR AVULSION OF OTHER CRANIAL NERVE, M4727 OTHER SPONDYLOSIS PROFESSIONAL EXTRADURAL WITH RADICULOPATHY, INPATIENT /HOSPITAL LUMBOSACRAL REGION 6/1/2017 5/17/2017 5/25/2017 63047 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY M4727 OTHER SPONDYLOSIS PROFESSIONAL (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF WITH RADICULOPATHY, INPATIENT /HOSPITAL SPINALCORD, CAUDA EQUINAAND /OR NERVE ROOTASA ", LUMBOSACRAL REGION AEG, SPINAL OR LATERAL RECESS STENOSISA'), 51 NGLE VERTEBRAL SEGMENT; LUMBAR 6/1/2017 5/17/2017 5/25/2017 63048 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY M4727 OTHER SPONDYLOSIS PROFESSIONAL (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF WITH RADICULOPATHY, INPATIENT /HOSPITAL SPINALCDRD, CAUDA EQUINAAND /OR NERVE ROOT(S), LUMBOSACRAL REGION (EG, SPINAL OR LATERAL RECESS STENOSISH, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 6/1/2017 5/26/2017 5/31/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4726 OTHER SPONDYLOSIS PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH WITH RADICULOPATHY, INPATIENT / HDSPITAL REQUIRESAT LEAST 2 OFTHESE 3 KEYC0MP0NENTS :AN LUMBAR REGION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR $4,286.43 $8,459.00 MALE SPOUSE 1050 $4,732.80 $9,292.00 MALE SPOUSE 1050 $1,780.67 $3,556.00 MALE SPOUSE 1050 $0.00 $0.01 MALE SPOUSE l RISC $0.00 $0.01 MALE SPOUSE 1050 $0.00 $0.01 MALE SPOUSE 1050 $1,175.93 $5,018.00 MALE SPOUSE 1050 $961.20 $1,992.00 MALE SPOUSE 1050 $103.51 $276.00 MALE SPOUSE 1050 C.7.f 3559 w Z N Q! 3559 A u 3SS9 } 0 i® CL CL Q 3559 v 3559 3559 3559 3559 III 6/1/2017 5/27/2017 5/31/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4726 OTHER SPONDYLOSIS PROFESSIONAL $103.51 $276.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH WITH RADICULOPATHY, INPATIENT /HOSPITAL REQUIRESAT LEAST 2 OFTHESE 3 KEY COMPONENT&AN LUMBAR REGION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 6/2/2017 5/30/2017 6/1/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4726 OTHER SPONDYLOSIS PROFESSIONAL $103.51 $276.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH WITH RADICULOPATHY, INPATIENT /HDSPITAL REQUIRESAT LEAST 2 OFTHESE 3 KEYCOMPONENTS :AN LUMBAR REGION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 6/5/2017 5/17/2017 5/30/2017 - - M4806 SPINAL STENOSIS, HOSPITAL INPATIENT 5/17/2017 # # # # # # ## $37,206.09 $299,575.34 MALE SPOUSE 1 050 LUMBAR REGION 6/5/2017 5/31/2017 6/3/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4726 OTHER SPONDYLOSIS PROFESSIONAL $148.53 $399.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH WITH RADICULOPATHY, INPATIENT /HOSPITAL REQU I R ES AT LEAST 2 O F TH ESE 3 KEY COM PO N E NTS:A LUMBAR REGION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/6/2017 5/23/2017 6/5/2017 72100 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO M4806 SPINALSTENOSIS, PROFESSIONAL $17.76 $46.00 MALE SPOUSE 1050 OR THREEVIEWS LUMBAR REGION INPATIENT /HOSPITAL 6/8/2017 S/3/2017 6/7/2017- - 201818 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT $228.00 $1,489.36 MALE SPOUSE 1050 PREPROCEDURAL EXAMINATION 6/12/2017 5/23/2017 6/9/2017 * * * ** * * * ** '• * *+ * * * *' * * * ** $44150 $443.50 MALE SPOUSE 1 OSO 6/14/2017 4/20/2017 5131/2017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE M5020 OTHER CERVICAL DISC PROFESSIONAL $86.98 $193.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENTOFAN ESTABLISHED DISPLACEMENT, OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY UNSPECIFIED CERVICAL COMPONENTS: AN EXPANDED PROBLEM FOCUSED REGION HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 6/16/2017 5/17/2017 6/15/2017 95864 NEEDLE ELECTROMYOGRAPHY, FOUR EXTREMITIES WITH M4727 OTHER SPONDYLOSIS PROFESSIONAL $159.20 $405.00 MALE SPOUSE 1 OSO ORWITHOUT RELATED PARASPINALAREAS WITH RADICULOPATHY, INPATIENT /HOSPITAL LUMBOSACRAL REGION 6/16/2017 5/17/2017 6/15/2017 95938 SHORT - LATENCY SOMATOSENSORY EVOKED POTENTIAL M4727 OTHER SPONDYLOSIS PROFESSIONAL $0.00 $170.00 MALE SPOUSE 1050 STUDY, STIMULATION OF ANY /ALL PERIPHERAL NERVES WITH RADICULOPATHY, INPATIENT /HDSPITAL ORSKIN SITES, RECORDING FROM THE CENTRAL NERVOUS LUMBOSACRAL REGION SYSTEM; IN UPPER AND LOWER LIMBS 6/16/2017 5/17/2017 6/15/2017 95939 CENTRAL MOTOR EVOKED POTENTIAL STUDY M4727 OTHER SPONDYLOSIS PROFESSIONAL $0.00 $455.00 MALE SPOUSE 1 050 (TRANSCRANIAL MOTOR STIMULATION); IN UPPERAND WITH RADICULOPATHY, INPATIENT /HDSPITAL LOWER LIMBS LUMBOSACRAL REGION 6/16/2017 5/17/2017 6/15/2017 95941 CONTINUOUS INTRAOPERATIVE NEUROPHYSIOLOGY M4727 OTHER SPONDYLOSIS PROFESSIONAL $1,996.68 $5,520.00 MALE SPOUSE 1050 MONITORING, FROM OUTSIDETHE OPERATING ROOM WITH RADICULOPATHY, INPATIENT /HOSPITAL (REMOTE OR NEARBY) OR FOR MONITORING OF MORE LUMBOSACRAL REGION THAN ONE CASE WHILE IN THE OPERATING ROOM, PER HOUR (LIST SEPARATELY C.7.f 3559 4) N m Q! 3559 7 fl } fl N. CL 3559 Q, Q 3559 v Q F W h D 3559 3559 O IL 3559 {j 3559 O J W 3559 3559 U Q 3559 Q {hj f'V HSS: C.7.f 6/19/2017 5/29/2017 6/16/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4327 FUSION OF SPINE, PROFESSIONAL $34.21 $100.00 MALE SPOUSE 1050 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBOSACRAL REGION INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A Z PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM N FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 6/19/2017 6/12/2017 6/17/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4726 OTHER SPONDYLOSIS PROFESSIONAL $103.51 $276.00 MALE SPOUSE 1050 3559 7 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH WITH RADICULOPATHY, INPATIENT / HDSPITAL REQUIRESAT LEAST 20FTHESE 3 KEYCOMPONENTS :AN LUMBAR REGION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. } COUNSELING AND /OR N . s. 6/20/2017 5/11/2017 6/19/2017 93000 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 I2510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE $33.01 $66.00 MALE SPOUSE 1050 3559 Q, LEADS; WITH INTERPRETATION AND REPORT DISEASE OF NATIVE CORONARY ARTERY W ITHOUT ANG I NA. PECTORIS rf 6/20/2017 5/11/2017 6/19/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE $188.81 $337.00 MALE SPOUSE 1050 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED DISEASE OF NATIVE PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY CORONARYARTERY Lij COMPONENTS: A DETAILED HISTORY; A DETAILED WITHOUTANGINA EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR PECTORIS COORDINATION OF CARE WITH OTHER _ 6/21/2017 6/13/2017 6/20/2017 99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES M4726 OTHER SPONDYLOSIS PROFESSIONAL $104.45 $279.00 MALE SPOUSE 1050 3559 OR LESS WITH RADICULOPATHY, INPATIENT /HOSPITAL LUMBAR REGION W 6/23/2017 6/1S/2017 6122/2017 E0163 COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED 534139A UNSPECIFIED INIURYTO OTHER MEDICAL $5048 $50.48 MALE SPOUSE 1050 3559 ARMS SACRAL SPINAL CORD, UJ INITIAL ENCOUNTER 6/2]/201] 5/4/2017 6/15/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1493 VENTRICULAR PROFESSIONAL $14.56 $32.00 MALE SPOUSE 1050 3559 LEADS; INTERPRETATION AND REPORT ONLY PREMATURE OUTPATIENT /HOSPITAL � DEPOLARIZATION `✓ 6/28/2017 5/23/2017 6/19/2017- - Z4789 ENCOUNTER FOR OTHER HOSPITAL INPATIENT 5/23 /2017 4####44# $25,809.00 $35,44231 MALE SPOUSE 1050 3559 q . ORTHOPEDIC AFTERCARE J 6/30/2017 6/6/2017 6/27/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4726 OTHER SPONDYLOSIS PROFESSIONAL $103.51 $276.00 MALE SPOUSE 1050 3559 v EVALUATION AND MANAGEMENT OF A PATIENT, WHICH WITH RADICULOPATHY, INPATIENT /HOSPITAL REQUIRESAT LEAST 20FTHESE 3 KEY COMPONENTS: AN LUMBAR REGION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN uj EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR (' 7/3/2017 6/6/2017 6/30/2017- - Z4889 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT $2236 $151.75 MALE SPOUSE 1050 3559 SPECIFIED SURGICAL AFTERCARE N 7/3/2017 6/10/2017 6/29/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4326 FUSIONOFSPINE, PR0FE55IONAL $34.21 $100.00 MALE SPOUSE 1050 3559 N EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PC ENTS: A = PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM Uj FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. .0 COUNSELING AND/ m 71312017 6/11/2017 6/29/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4326 FUSION OF SPINE, PROFESSIONAL $63.96 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH SPOUSE LUMBAR REGION INPATIENT /HOSPITAL $0.00 REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A SPOUSE 1050 3559 $39.76 PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM SPOUSE 1050 3559 $0.00 FOCUSED EXAMINATION; MEDICAL DECISION MAKING SPOUSE 1050 3559 $103.51 THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. SPOUSE 1050 3559 COUNSELING AND/ 7/3/2017 6/21/2017 7/1/2017 E0748 OSTEOOENESIS STIMULATOR, ELECTRICAL, NON- INVASIVE, Z981 ARTHRODESIS STATUS OTHER MEDICAL SPINAL APPLICATIONS 7/12/2017 6/13/2017 7111/2017 E0143 WALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED 534139A UNSPECIFIED INJURYTO OTHER MEDICAL HEIGHT SACRAL SPINAL CORD, INITIAL ENCOUNTER 7/12/2017 6/13/2017 7/11/2017 E1290 HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR 534139A UNSPECIFIED INJURY TO OTHER MEDICAL FULL LENGTH( SWING AWAY DETACHABLE FOOTREST SACRAL SPINAL CORD, INITIAL ENCOUNTER 7/12/2017 6/13/2017 7/11/2017 E2601 GEN W/C CUSHION W DTH 122 IN 534139A UNSPECIFIED INJURYTO OTHER MEDICAL SACRAL SPINAL CORD, INITIAL ENCOUNTER 711712017 7/13/2017 7/14/2017 E1290 HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR 534139A UNSPECIFIED INJURY TO OTHER MEDICAL FULL LENGTH( SWING AWAY DETACHABLE FOOTREST SACRAL SPINAL CORD, INITIAL ENCOUNTER 7/31/2017 6/1/2017 7/28/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4726 OTHER SPONDYLOSIS PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH WITH RADICULOPATHY, INPATIENT /HOSPITAL REQU I R ES AT LEAST 20 F TH ESE 3 KEY COM PO N E MRS AN LUMBAR REGION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 7/31/2017 6/2/2017 7128/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4726 OTHER SPONDYLOSIS PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH WITH RADICULOPATHY, INPATIENT /HOSPITAL REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS AN LUMBAR REGION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 7/31/2017 6/3/2017 7/28/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4726 OTHER SPONDYLOSIS PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH WITH RADICULOPATHY, INPATIENT /HOSPITAL REQU I R ES AT LEAST 20 F TH ESE 3 KEY COM PO N E MRS AN LUMBAR REGION EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 7/31/2017 6/7/2017 7128/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4726 OTHER SPONDYLOSIS PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH WITH RADICULOPATHY, INPATIENT /HOSPITAL REQU I R ES AT LEAST 20 F TH ESE 3 KEY COM PO N E NTS:A LUMBAR REGION DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $34.21 $100.00 MALE SPOUSE 1050 C.7.f 3559 $3,407.69 $3,407.69 MALE SPOUSE 1050 3559 $63.96 $63.97 MALE SPOUSE 1050 3559 $0.00 $45.92 MALE SPOUSE 1050 3559 $39.76 $39.76 MALE SPOUSE 1050 3559 $0.00 $45.92 MALE SPOUSE 1050 3559 $103.51 $276.00 MALE SPOUSE 1050 3559 $10331 $276.00 MALE SPOUSE 1050 3559 $103.51 $276.00 MALE SPOUSE 1050 3559 $148.53 $399.00 MALE SPOUSE 1050 3559 6/3/2017 7/27/2017 81212017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R600 LOCALIZED EDEMA PROFESSIONAL OFFICE SPOUSE 1050 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED $171.00 MALE SPOUSE 1050 3559 $13.34 $54.00 MALE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY 1050 3559 $395.00 $1,352.81 MALE SPOUSE 1050 COMPONENTS: A DETAILED HISTORY; A DETAILED $42.31 $171.00 MALE SPOUSE 1050 3559 $19.82 EXAMINATION; MEDICAL DECISION MAKING OF SPOUSE 1050 3559 $32.91 $114.00 MALE SPOUSE MODERATE COMPLEXITY. COUNSELING AND /OR 3559 $26.68 $108.00 MALE SPOUSE 1050 3559 COORDINATION OF CARE WITH OTHER $78.00 MALE SPOUSE 1050 8/3/2017 7/28/2017 8/2/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $1,696.00 MALE SPOUSE 1050 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP $0.00 $45.92 MALE SPOUSE 1050 3559 $28.21 STRENGTH AND ENDURANCE, RANGE OF MOTION AND SPOUSE 1050 3559 FLEXIBILITY 8/3/2017 7/28/2017 8/2/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE- ON- ONE)PATIENT M545 LOW BACK PAIN OTHER MEDICAL CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 8/3/2017 7/31/2017 81212017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M54S LOW BACK PAIN OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 8/3/2017 7/31/2017 8/2/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 8/4/2017 7/13/2017 8/3/2017- - Z4889 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT SPECIFIED SURGICAL AFTERCARE 8/9/2017 8/4/2017 8/8/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 8/9/2017 8/4/2017 8/8/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT M545 LOW BACK PAIN OTHER MEDICAL CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 8/10/2017 81712017 8/9/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 8/10/2017 8/7/2017 8/9/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), l OR MORE REGIONS, EACH 15 MINUTES 811112017 8/2/2017 8/10/2017 93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING 182402 ACUTE EMBOLISM AND OTHER MEDICAL RESPONSES TO COMPRESSION AND OTHER MANEUVERS; THROMBOSIS OF UNILATERAL OR LIMITED STUDY UNSPECIFIED DEEP VEINS OF LEFT LOWER EXTREMITY 8/11/2017 8/2/2017 8/10/2017 93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING 182402 ACUTE EMBOLISM AND PROFESSIONAL OFFICE RESPONSES TO COMPRESSION AND OTHER MANEUVERS; THROMBOSIS OF UNILATERAL OR LIMITED STUDY UNSPECIFIED DEEP VEINS OF LEFT LOWER EXTREMITY 8/11/2017 8/3/2017 8/9/2017 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST R0602 SHORTNESS OF BREATH OTHER MEDICAL MATERIALS) 8/17/2017 8/13/2017 8/16/2017 E1290 HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR 534139A UNSPECIFIED INIURYTO OTHER MEDICAL FULL LENGTH( SWING AWAY DETACHABLE FOOTREST SACRAL SPINAL CORD, INITIAL ENCOUNTER 8/21/2017 8/11/2017 811812017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY $188.81 $337.00 MALE SPOUSE 1050 C.7.f 3559 $4231 $171.00 MALE SPOUSE 1050 3559 $19.82 $59.00 MALE SPOUSE 1050 3559 $47.01 $171.00 MALE SPOUSE 1050 3559 $13.34 $54.00 MALE SPOUSE 1050 3559 $395.00 $1,352.81 MALE SPOUSE 1050 3559 $42.31 $171.00 MALE SPOUSE 1050 3559 $19.82 $59.00 MALE SPOUSE 1050 3559 $32.91 $114.00 MALE SPOUSE 1050 3559 $26.68 $108.00 MALE SPOUSE 1050 3559 $22.68 $78.00 MALE SPOUSE 1050 3559 $164.64 $499.00 MALE SPOUSE 1050 3559 $350.00 $1,696.00 MALE SPOUSE 1050 3559 $0.00 $45.92 MALE SPOUSE 1050 3559 $28.21 $114.00 MALE SPOUSE 1050 3559 C.7.f 812112017 8/11/2017 811812017 97112 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $19.82 $59.00 MALE SPOUSE 1 050 3559 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING N AND /OR STANDING ACTIVITIES Td tU 812112017 811112017 811812017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $54.00 MALE SPOUSE 1 OSO 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 r MINUTES a 8/24/2017 8/18/2017 8123/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $47.01 $171.00 MALE SPOUSE 1 050 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 8/24/2017 8/18/2017 8/23/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $54.00 MALE SPOUSE 1 050 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, G. CL MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 Q, MINUTES 8/24/2017 8/21/2017 8/23/2017 97110 THERAPEUTIC PROCEDURE, l OR MOREAREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $28.21 $114.00 MALE SPOUSE 1 OSO 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 812412017 8/21/2017 8/23/2017 97112 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $19.82 $59.00 MALE SPOUSE 1 OSO 3559 MINUTES; NEUROMUSCULAR REEDUCATION OF uj MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING AND /OR STANDING ACTIVITIES 8/24/2017 8/21/2017 8/23/2017 97140 MANUALTHERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $54.00 MALE SPOUSE 1 050 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 O MORE REGIONS, EACH 15 MINUTES IL 8/25/2017 7/13/2017 8/24/2017 72110 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; M549 DORSALGIA, UNSPECIFIED PROFESSIONAL $24.18 $64.00 MALE SPOUSE 1 050 3559 {li MINIMUM OF FOUR VIEWS OUTPATIENT /HOSPITAL 8/28/2017 8/23/2017 8/25/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $32.91 $114.00 MALE SPOUSE 1 050 3559 cn MINUTES; THERAPEUTIC EXERCISESTO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY LLJ 8/28/2017 8/23/2017 8/25/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $1334 $54.00 MALE SPOUSE 1 OSO 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, � MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 J MINUTES 8/30/2017 8/25/2017 8/29/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $28.21 $114.00 MALE SPOUSE 1 PAO 3559 v MINUTES; THERAPEUTIC EXERCISES TO DEVELOP r STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY W 8/30/2017 8/25/2017 8/29/2017 97140 MANUAL THERAPY TECH NIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $54.00 MALE SPOUSE 1 OSO 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 (' MINUTES 8/30/2017 8/25/2017 8/29/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE - ON- ONE)PATIENT M545 LOW BACK PAIN OTHER MEDICAL $19.82 $59.00 MALE SPOUSE 1050 3559 CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES Q TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 CW 8/30/2017 10/14/2016 8/29/2017 MINUTES 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R5383 OTHER FATIGUE PROFESSIONAL OFFICE $0.00 $314.00 MALE SPOUSE 1050 3559 N EVALUATION AND MANAGEMENTOFAN ESTABLISHED C PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY y COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED ._ EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 8/31/2017 6/21/2017 8/30/2017 - - Z4789 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT $113.25 $113.26 MALE SPOUSE 1 050 ORTHOPEDIC AFTERCARE 8/31/2017 6/28/2017 8/30/2017 - - Z4789 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT $322.80 $322.80 MALE SPOUSE 1 OSO ORTHOPEDIC AFTERCARE 8/31/2017 6/29/2017 81 - - Z4789 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT $373.74 $373.74 MALE SPOUSE 1 OSO ORTHOPEDIC AFTERCARE 9/1/2017 7/5/2017 8/31/2017 - - Z4789 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT $124.58 $124.58 MALE SPOUSE 1 OSO ORTHOPEDIC AFTERCARE 9/1/2017 7/20/2017 8131/2017 - - Z4789 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT $62190 $622.90 MALE SPOUSE 1 OSO ORTHOPEDIC AFTERCARE 9/1/2017 8/13/2017 813112017 E1290 HEAVY DUTY WHEELCHAIR, DETACHABLE ARMS (DESK OR 534139A UNSPECIFIED INJURYTO OTHER MEDICAL $0.00 $45.92 MALE SPOUSE 1 050 FULL LENGTH( SWING AWAY DETACHABLE FOOTREST SACRAL SPINAL CORD, INITIAL ENCOUNTER 9/13/2017 8/30/2017 9/12/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $28.21 $114.00 MALE SPOUSE 1 DEC MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 9/13/2017 8/30/2017 911212017 97112 THERAPEUTIC PROCEDURE, 1 OR MOREAREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $19.82 $59.00 MALE SPOUSE 1 050 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING AND /OR STANDING ACTIVITIES 9/13/2017 8/30/2017 9/12/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $1334 $54.00 MALE SPOUSE 1 ESE) MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION, LOS MORE REGIONS, EACH 15 MINUTES 9/18/2017 8/31/2017 9/15/2017 * * * ** * * 1 -1 * * * *' * * * ** $2,075.00 $2,075.00 MALE SPOUSE 1 050 9/19/2017 5/24/2017 9/18/2017 99222 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION M4806 SPINALSTENOSIS, PROFESSIONAL $166.73 $400.00 MALE SPOUSE 1050 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES LUMBAR REGION INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 9/19/2017 5/25/2017 9/18/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $86.65 $250.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD N ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 9/19/2017 5/26/2017 9/18/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $86.65 $250.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR C.7.f 3559 w 3559 N Q! 3559 i 3559 3559 W } fl 3559 CL CL Q 3559 n m= 3559 3559 3559 EAE mm 9/19/2017 5/27/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SP I SAL STENOSIS, PROFESSIONAL $47.79 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 5/28/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $4739 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LUMBAR REGION INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 5/29/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $47.79 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT 15 STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 5/30/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $47.79 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 5/31/2017 9/1S/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $4739 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LUMBAR REGION INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT 15 STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 6/1/2017 9/18/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N14806 SPINAL STENOSIS, PROFESSIONAL $86.65 $250.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 9/19/2017 6/2/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $4739 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LUMBAR REGION INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 6/3/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SP I SAL STENOSIS, PROFESSIONAL $47.79 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 6/4/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $4739 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LUMBAR REGION INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 6/5/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $47.79 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT 15 STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 6/6/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $47.79 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 6/7/2017 9/1S/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $4739 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LUMBAR REGION INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT 15 STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 6/8/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N14806 SPINAL STENOSIS, PROFESSIONAL $47.79 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT 15 STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 6/9/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL $4739 $200.00 MALE SPOUSE 1050 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH LUMBAR REGION INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 6/10/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SP I SAL STENOSIS, PROFESSIONAL $0.00 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH SPOUSE LUMBAR REGION INPATIENT /HOSPITAL $0.00 REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A SPOUSE 1050 3559 $0.00 PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM SPOUSE 1050 3559 $0.00 FOCUSED EXAMINATION; MEDICAL DECISION MAKING SPOUSE 1050 3559 $159.20 THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. SPOUSE 1050 3559 $6814 COUNSELING AND/ SPOUSE 1050 3559 9/19/2017 6/11/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 6/12/2017 9/18/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT 15 STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 9/19/2017 6/13/2017 9/18/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE M4806 SPINAL STENOSIS, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH LUMBAR REGION INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 9/22/2017 8/31/2017 9/21/2017 72131 COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT M47816 SPONDYLOSIS WITHOUT PROFESSIONAL CONTRAST MATERIAL MYELOPATHY OR OUTPATIENT /HOSPITAL RADICULOPATHY, LUMBAR REGION 9/25/2017 7/13/2017 9/22/2017 1126F INTERMEDIATE "DELAY" OF ANY FLAP, PRIMARY "DELAY" Z981 ARTHRODESIS STATUS PROFESSIONAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OUTPATIENT /HOSPITAL DIRECT FLAP, AT EYELIDS NOSE, 9/25/2017 7/13/2017 9/22/20171159F MEDICATION LIST DDCUMENTED IN MEDICAL RECORD Z981 ARTHRODESIS STATUS PROFESSIONAL (COA) OUTPATIENT /HOSPITAL 9/25/2017 7/13/2017 9/22/2017 99024 POSTOPERATIVE FOLLOW -UP VISIT, NORMALLY INCLUDED Z981 ARTHRODESIS STATUS PROFESSIONAL IN THE SURGICAL PACKAGE, TD INDICATE THAT AN OUTPATIENT /HOSPITAL EVALUATION AND MANAGEMENT SERVICE WAS PERFORMED DURING A POSTOPERATIVE PERIOD FOR A REASON(S) RELATED TO THE ORIGINAL PROCEDURE 9/25/2017 8/31/2017 9/22/2017 9/28/2017 5/17/2017 6/15/2017 95864 NEEDLE ELECTROMYOGRAPHY, FOUR EXTREMITIES WITH M4727 OTHER SPONDYLOSIS PROFESSIONAL OR WITHOUT RELATED PARASPINAL AREAS WITH RADICULOPATHY, INPATIENT /HDSPITAL LUMBOSACRAL REGION 9/28/2017 5/17/2017 6/15/2017 95938 SHORT -LATENCYSOMATOSENSORY EVOKED POTENTIAL M4727 OTHER SPONDYLOSIS PROFESSIONAL STUDY, STIMULATION OF ANY /ALL PERIPHERAL NERVES WITH RADICULOPATHY, INPATIENT /HOSPITAL ORSKIN SITES, RECORDING FROM THE CENTRAL NERVOUS LUMBOSACRAL REGION SYSTEM; IN UPPER AND LOWER LIMBS $47.79 $200.00 MALE SPOUSE 1050 $4739 $200.00 MALE SPOUSE 1050 $47.79 $200.00 MALE SPOUSE 1050 $86.65 $250.00 MALE SPOUSE 1050 C.7.f 3559 Im WE mm $93.63 $189.00 MALE SPOUSE 1050 3559 $0.00 $0.01 MALE SPOUSE 1050 3559 $0.00 $0.01 MALE SPOUSE 1050 3559 $0.00 $0.01 MALE SPOUSE 1050 3559 $0.00 $0.02 MALE SPOUSE 1050 3559 $159.20 $405.00 MALE SPOUSE 1050 3559 $6814 $170.00 MALE SPOUSE 1050 3559 9/28/2017 5/17/2017 6/15/2017 95939 CENTRAL MOTOR EVOKED POTENTIAL STUDY M4727 OTHER SPONDYLOSIS PROFESSIONAL W (TRANSCRANIALMDTORSTIMULATION(; IN UPPER AND SPOUSE WITH RADICULOPATHY, INPATIENT /HOSPITAL $32.91 LOWER LIMBS SPOUSE LUMBOSACRAL REGION 3559 9/28/2017 5/17/2017 6/15/2017 95941 CONTINUOUS INTRAOPERATIVE NEUROPHYSIOLOGY M4727 OTHER SPONDYLOSIS PROFESSIONAL SPOUSE MONITORING, FROM OUTSIDE THE OPERATING ROOM 3559 WITH RADICULOPATHY, INPATIENT /HOSPITAL (REMOTE DR NEARBY) OR FOR MONITORING OF MORE LUMBOSACRAL REGION THAN ONE CASE WHILE IN THE OPERATING ROOM, PER HOUR (LIST SEPARATELY 9/28/2017 5/17 /2017 6/15/2017 95864 NEEDLE ELECTROMYOGRAPHY, FOUR EXTREMITIES WITH M4727 OTHER SPONDYLOSIS PROFESSIONAL OR WITHOUT RELATED PARASPINAL AREAS i' WITH RADICULOPATHY, INPATIENT /HOSPITAL LUMBOSACRAL REGION 9128/2017 5/17/2017 6/15/2017 95938 SHORT LATENCY SOMATOSENSORY EVOKED POTENTIAL M4727 OTHER SPONDYLOSIS PROFESSIONAL ($159201 STUDY, STIMULATION OF ANY /ALL PERIPHERAL NERVES SPOUSE WITH RADICULOPATHY, INPATIENT /HOSPITAL ate+ ORSKIN SITES, RECORDING FROM THE CENTRAL NERVOUS LUMBOSACRAL REGION 5'(STEM; IN UPPER AND LOW ER LIMBS 9/28/2017 5/17/2017 6/15/2017 95939 CENTRAL MOTOR EVOKED POTENTIAL STUDY M4727 OTHER SPONDYLOSIS PROFESSIONAL (TRANSCRANIAL MOTOR STIMULATION(; IN UPPER AND WITH RADICULOPATHY, INPATIENT/HOSPITAL LOWER LIMBS LUMBOSACRAL REGION CL 9/28/2017 5/17/2017 6/15/2017 95941 CONTINUOUS INTRAOPERATIVE NEUROPHYSIOLOGY M4727 OTHER SPONDYLOSIS PROFESSIONAL Q, MONITORING, FROM OUTSIDE THE OPERATING ROOM WITH RADICULOPATHY, INPATIENT / HDSPITAL (REMOTE OR NEARBY) OR FOR MONITORING OF MORE LUMBOSACRAL REGION THAN ONE CASE WHILE IN THE OPERATING ROOM, PER HOUR (LIST SEPARATELY $0.00 10/12/2017 8/2/2017 10/11/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 182409 ACUTE EMBOLISM AND OTHER MEDICAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED THROMBOSIS OF F PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY UNSPECIFIED DEEPVEINS COMPONENTS: A DETAILED HISTORY; A DETAILED OF UNSPECIFIED LOWER EXAMINATION; MEDICAL DECISION MAKING OF E EXTREMITY MODERATE COMPLEXITY. COUNSELING AND /OR D I$I,99fi.68J {$S,iU.OUJ MALE COORDINATION OF CARE WITH OTHER 1 OSO 3559 10/24/2017 8/31/2017 10/412017- - N14726 OTHER SPONDYLOSIS HOSPITAL OUTPATIENT WITH RADICULOPATHY, LUMBAR REGION 11/1/2017 1013/2017 10/31/2017 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING 182501 CHRONIC EMBOLISM AND OTHER MEDICAL RESPONSESTO COMPRESSION AND OTHER MANEUVERS; THROMBOSIS OF COMPLETE BILATERAL STUDY UNSPECIFIED DEEP VEINS d $160.49 $337.00 MALE SPOUSE OF RIGHT LOWER 3559 LU EXTREMITY 11/2/2017 10/27/2017 11/1/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 1S M545 LOW BACK PAIN OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/2/2017 10/27/2017 11/1/2017 97116 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 11/2/2017 10/27/2017 11/1/2017 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES C.7.f $180.10 $455.00 MALE SPOUSE 1050 3559 $45.53 $303.50 MALE SPOUSE 1050 3559 W $120.00 MALE SPOUSE 1050 3559 $32.91 N SPOUSE 1050 3559 $1138 $52.00 MALE SPOUSE $1,996.68 $5,520.00 MALE SPOUSE 1050 3559 1050 3559 i' ($159201 (.$405.001 MALE SPOUSE 1 050 3559 ate+ W } fl R. CL $0.00 (5170.001 MALE SPOUSE 1 OSO 3559 Q, Q $0.00 ($455,00) MALE SPOUSE 1 050 3559 F W E D I$I,99fi.68J {$S,iU.OUJ MALE SPOUSE 1 OSO 3559 O d $160.49 $337.00 MALE SPOUSE 1050 3559 LU $45.53 $303.50 MALE SPOUSE 1050 3559 $34.97 $120.00 MALE SPOUSE 1050 3559 $32.91 $114.00 MALE SPOUSE 1050 3559 $1138 $52.00 MALE SPOUSE 1050 3559 $1334 $54.00 MALE SPOUSE 1050 3559 11/2/2017 10/30/2017 11/1/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $52.00 MALE MINUTES; THERAPEUTIC EXERCISES TO DEVELOP 1050 $13.34 $54.00 MALE SPOUSE STRENGTH AND ENDURANCE, RANGE OF MOTION AND $4,328.83 $7,140.00 MALE SPOUSE 1050 FLEXIBILITY $205.00 MALE SPOUSE 1050 11/2/2017 10/30/2017 11/1/2017 97116 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 11/2/2017 10/30/2017 11/1/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 11/3/2017 5/17 /2017 11/2/2017 630 ANESTHESIA FOR PROCEDURES IN LUMBAR REGION; NOT M4727 OTHER SPONDYLO515 PROFESSIONAL OTHERWISE SPECIFIED WITH RADICULOPATHY, INPATIENT /HOSPITAL LUMBOSACRAL REGION 11/3/2017 5/17/2017 11/2/2017 36620 ARTERIAL CATHETERIZATION OR CANNULATION FOR M4727 OTHER SPONDYLOSIS PROFESSIONAL SAMPLING, MONITORING OR TRANSFUSION (SEPARATE WITH RADICULOPATHY, INPATIENT /HOSPITAL PROCEDURE); PERCUTANEOUS LUMBOSACRAL REGION 11/3/2017 8/21/2017 10/31/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 182409 ACUTE EMBOLISM AND PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED THROMBOSIS OF PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY UNSPECIFIED DEEP VEINS COMPONENTS: A DETAILED HISTORY; A DETAILED OF UNSPECIFIED LOWER EXAMINATION; MEDICAL DECISION MAKING OF EXTREMITY MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 11/3/2017 10/2/2017 10131/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 182501 CHRONIC EMBOLISM AND PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED THROMBOSISOF PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY UNSPECIFIED DEEP VEINS COMPONENTS: AN EXPANDED PROBLEM FOCUSED OF RIGHT LOWER HISTORY; AN EXPANDED PROBLEM FOCUSED EXTREMITY EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 11/3/2017 10/3/2017 10/31/2017 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING 182501 CHRONIC EMBOLISM AND PROFESSIONAL OFFICE RESPONSESTO COMPRESSION AND OTHER MANEUVERS; THROMBOSISOF COMPLETE BILATERAL STUDY UNSPECIFIED DEEP VEINS OF RIGHT LOWER EXTREMITY 11/6/2017 8/21/2017 10/31/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 182409 ACUTE EMBOLISM AND PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED THROMBOSIS OF PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY UNSPECIFIED DEEP VEINS COMPONENTS: A DETAILED HISTORY; A DETAILED OF UNSPECIFIED LOWER EXAMINATION; MEDICAL DECISION MAKING OF EXTREMITY MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 11/7/2017 11/1/2017 11/6/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/7/2017 11/1/2017 11/6/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 111712017 11/1/2017 11/6/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT M545 LOW BACK PAIN OTHER MEDICAL CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES $32.91 $114.00 MALE SPOUSE 1050 $11.58 $52.00 MALE SPOUSE 1050 $13.34 $54.00 MALE SPOUSE 1050 $4,328.83 $7,140.00 MALE SPOUSE 1050 $81.80 $205.00 MALE SPOUSE 1050 $188.81 $337.00 MALE SPOUSE 1050 $129.02 $228.00 MALE SPOUSE 1050 $274.53 $837.00 MALE SPOUSE 1050 $0.00 $337.00 MALE SPOUSE 1050 $28.21 $114.00 MALE SPOUSE 1050 3559 $1134 $54.00 MALE SPOUSE 1050 3559 $19.82 $59.00 MALE SPOUSE 1050 3559 C.7.f 11/10/201] ]/24/201] 111812017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $14.10 $57.00 MALE SPOUSE 1 050 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY N 11/10/2017 7/24/2017 11/8/2017 97112 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $14.87 $59.00 MALE SPOUSE 1 OSO 3559 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /DR PROPRIOCEPTIDN FOR SITTING AND /OR STANDING ACTIVITIES 11/10/2017 7/24/2017 11/8/2017 97140 MANUALTHERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $54.00 MALE SPOUSE IOSO 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), l OR MORE REGIONS, EACH 15 MINUTES > 11/10/2017 7/24/2017 111812017 97161 Physical therapy evaluation: low complexity, requiring M545 LOW BACK PAIN OTHER MEDICAL $46.05 $153.00 MALE SPOUSE 1050 3559 fl these components: A history with no personal factors A. CL and /....morbidities that impact the plan of Q, Q 11/10/2017 7/24/2017 11/8/2017 68978 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL M545 LOW BACK PAIN OTHER MEDICAL $0.00 $0.00 MALE SPOUSE 1OSO 3559 v LIMITATION, CURRENT STATUS, ATTHERAPY EPISODE OUTSET AN D AT REPORTING INTERVALS .� 11/10/201] ]1241201] 11/8/2017689]9 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL M545 LOW BACK PAIN OTHER MEDICAL $0.00 $0.00 MALE SPOUSE 1050 3559 LIMITATION, PROJECTED GOAL STATUS, AT THERAPY Uj EPISODE OUTSET, AT REPORTING INTERVALS, AND AT D DISCHARGE OR TO END REPORTING 11/10/2017 7/26/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $14.10 $57.00 MALE SPOUSE 1 OSO 3559 MINUTES; THERAPEUTIC EXERCISESTO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 7/26/2017 11/8/2017 97112 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $19.82 $59.00 MALE SPOUSE 1 OSO 3559 Q MINUTES; NEURDMUSCULAR REEDUCATION OF {j MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING U`J AND /OR STANDING ACTIVITIES Q 11/10/2017 7/26/2017 111812017 97116 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $11.58 $52.00 MALE SPOUSE 1 050 3559 J MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) V 11/10/2017 7/26/2017 11/8/2017 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $54.00 MALE SPOUSE 1 0S 3559 �p MANIPULATION, MANUAL LYMPHATIC DRAINAGE, J MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES v 11/10/201] 8/2/2017 111812017 97110 THERAPEUTIC PROCEDURE, 1 OR MOREAREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $14.10 $57.00 MALE SPOUSE 1 OSO 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND IELJ FLEXIBILITY 11/10/2017 8/2/2017 11/8/2017 97116 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $11.58 $52.00 MALE SPOUSE 1 OSO 3559 MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) (' Q 11/10/201] 8/2/2017 11/8/2017 97140 MANUAL THERAPY TECH NIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $1334 $54.00 MALE SPOUSE 1050 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, „p MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES CNJ 11/10/2017 8/2/2017 11/8/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE- ON- ONE) PATIENT M54S LOW BACK PAIN OTHER MEDICAL $19.82 $59.00 MALE SPOUSE 1 0S 3559 Cy CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES = TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 y MINUTES 11/10/201] 8/9/2017 111812017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $14.10 $57.00 MALE SPOUSE 1 050 3559 ._ MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 8/9/2017 111812017 97112 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN SPOUSE MINUTES; NEURDMUSCULAR REEDUCATION OF 3559 OTHER MEDICAL MOVEMENT, BALANCE, COORDINATION, KINESTHETIC $114.00 MALE SPOUSE SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING 3559 OTHER MEDICAL AND /OR STANDING ACTIVITIES $59.00 MALE 11/10/2017 8/9/2017 111812017 97140 MANUAL THERAPY TECHNIQUES (EG ,MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, $54.00 MALE SPOUSE MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 3559 OTHER MEDICAL MINUTES $0.00 MALE 11/10/2017 8/14/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, I OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP $0.00 MALE SPOUSE STRENGTH AND ENDURANCE, RANGE OF MOTION AND 3559 OTHER MEDICAL FLEXIBILITY $54.00 MALE 11/10/2017 8/14/2017 111812017 97112 THERAPEUTIC PROCEDURE, I OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL MINUTES; NEUROMUSCULAR REEDUCATION OF $57.00 MALE SPOUSE MOVEMENT, BALANCE, COORDINATION, KINESTHETIC 3559 OTHER MEDICAL SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING $59.00 MALE SPOUSE AND /OR STANDING ACTIVITIES 3559 11/10/2017 8/14/2017 11/8/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN SPOUSE MANIPULATION, MANUAL LYMPHATIC DRAINAGE, 3559 OTHER MEDICAL MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 $59.00 MALE SPOUSE MINUTES 3559 11/10/2017 8/14/2017 11/8/2017 G8978 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL M545 LOW BACK PAIN SPOUSE LIMITATION, CURRENT STATUS, ATTHERAPY EPISODE 3559 OTHER MEDICAL OUTSETAND AT REPORTING INTERVALS $54.00 MALE 11/10/2017 8/14/2017 11/8/2017138979 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL M545 LOW BACK PAIN LIMITATION, PROJECTED GOAL STATUS, AT THERAPY EPISODE OUTSET, AT REPORTING INTERVALS, AND AT DISCHARGE OR TO END REPORTING 11/10/2017 8/16/2017 11/8/2017 97140 MANUAL THERAPY TECHNIQUES UP, MOBILIZATION/ M545 LOW BACK PAIN MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 11/10/2017 8/29/2017 111812017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 8/29/2017 11/8/2017 97112 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING AND /OR STANDING ACTIVITIES 11/10/2017 8/29/2017 11/8/2017 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILI2ATION/ M545 LOW BACK PAIN MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 11/10/2017 8/29/2017 11/8/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE - ON- ONE)PATIENT M545 LOW BACK PAIN CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 11/10/2017 9/1/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, I OR MORE AREAS, EACH 1S M545 LOW BACK PAIN MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 9/1/2017 11/8 /2017 97140 MANUAL THERAPY TECHNIQUES (EG ,MOBILIZATION/ M545 LOW BACK PAIN MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES OTHER MEDICAL $34.69 $118.00 MALE SPOUSE 1050 C.7.f 3559 OTHER MEDICAL $13.34 $54.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $28.21 $114.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $19.82 $59.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $13.34 $54.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $0.00 $0.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $0.00 $0.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $17.78 $54.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $14.10 $57.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $14.87 $59.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $13.34 $54.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $19.82 $59.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $47.01 $171.00 MALE SPOUSE 1050 3559 OTHER MEDICAL $13.34 $54.00 MALE SPOUSE 1050 3559 C.7.f 11/10/2017 9/5/2017 111812017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $14.10 $57.00 MALE SPOUSE 1 050 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY N 11/10/2017 9/5/2017 11/8/2017 97112 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $19.82 $59.00 MALE SPOUSE 1 050 3559 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /DR PROPRIOCEPTIDN FOR SITTING AND /OR STANDING ACTIVITIES 11/10/2017 9/5/2017 11/8/2017 97116 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $11.58 $52.00 MALE SPOUSE 1 OSO 3559 MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 11/10/2017 9/5/2017 11/8/2017 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ MS4S LOW BACK PAIN OTHER MEDICAL $1334 $54.00 MALE SPOUSE 1050 3SS9 } MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 iL CL MINUTES Q, 11110/2017 10/3/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $28.21 $114.00 MALE SPOUSE 1 DEC 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY rf 11/10/2017 10/3/2017 111812017 97112 THERAPEUTIC PROCEDURE, LOB MOREAREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $19.82 $59.00 MALE SPOUSE 1 EGO 3559 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC Lij SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING ~ AND /OR STANDING ACTIVITIES D Z 11/10/2017 10/3/2017 11/8/2017 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $54.00 MALE SPOUSE 1050 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 10R MORE REGIONS, EACH 15 MINUTES 11/10/2017 10/3/2017 11/8/201768978 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL M545 LOW BACK PAIN OTHER MEDICAL $0.00 $0.00 MALE SPOUSE 1050 3559 Q LIMITATION, CURRENT STATUS, ATTHERAPY EPISODE {i OUTSET AN D AT REPORTING INTERVALS 11/10/2017 10/3/2017 11/8/2017 66979 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL M545 LOW BACK PAIN OTHER MEDICAL $0.00 $0.00 MALE SPOUSE 1050 3559 LIMITATION, PROJECTED GOAL STATUS, AT THERAPY EPISODE OUTSET, AT REPORTING INTERVALS, AND AT DISCHARGE OR TO END REPORTING LLJ V 11/10/2017 10/4/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $47.01 $171.00 MALE SPOUSE 1 050 3559 �p MINUTES; THERAPEUTIC EXERCISES TO DEVELOP J STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY v 11/10/2017 10/4/2017 111812017 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $13.34 $54.00 MALE SPOUSE 1OSO 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 LLJ MINUTES 11/10/2017 10/6/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $32.91 $114.00 MALE SPOUSE 1 050 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP 0 STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 10/6/2017 11/8/2017 97116 THERAPEUTIC PROCEDURE, LOB MOREAREAS, EACH 1S M545 LOW BACK PAIN OTHER MEDICAL $11.58 $52.00 MALE SPOUSE 1 OSO 3559 MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 04 11/10/2017 10/6/2017 11/8/2017 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M54S LOW BACK PAIN OTHER MEDICAL $1134 $54.00 MALE SPOUSE 1050 3559 Cy MANIPULATION, MANUAL LYMPHATIC DRAINAGE, _ MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 y MINUTES 11/10/2017 10/9/2017 111812017 97110 THERAPEUTIC PROCEDURE, 1 OR MOREAREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $32.91 $114.00 MALE SPOUSE 1 050 3559 ._ MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 10/9/2017 111812017 11/10/2017 10/9/2017 11/8/2017 11/10/2017 10/11/2017 11/8/2017 11/10/2017 10/11/2017 11/8/2017 11/10/2017 10/13/2017 11/8/2017 11/10/2017 10/13/2017 11/8/2017 11/10/2017 10/13/2017 11/8/2017 11/10/2017 10/16/2017 11/8/2017 11/10/2017 10/16/2017 11/8/2017 11/10/2017 10/16/2017 11/8/2017 11110/2017 10/18/2017 11/8/2017 11/10/2017 10/18/2017 111812017 11/10/2017 10/20/2017 11/8/2017 11/10/2017 10/20/2017 111812017 11/10/2017 10/20/2017 11/8/2017 11/10/2017 10/23/2017 111812017 97116 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) $13.34 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN MANIPULATION, MANUAL LYMPHATIC DRAINAGE, $171.00 MALE MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 $13.34 MINUTES SPOUSE 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN MINUTES; THERAPEUTIC EXERCISES TO DEVELOP $11.58 STRENGTH AND ENDURANCE, RANGE OF MOTION AND SPOUSE FLEXIBILITY $54.00 MALE 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN MANIPULATION, MANUAL LYMPHATIC DRAINAGE, SPOUSE MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 $52.00 MALE MINUTES $1334 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN MINUTES; THERAPEUTIC EXERCISES TO DEVELOP $171.00 MALE STRENGTH AND ENDURANCE, RANGE OF MOTION AND $13.34 FLEXIBILITY SPOUSE 97116 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) $11.58 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN MANIPULATION, MANUAL LYMPHATIC DRAINAGE, $54.00 MALE MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 $47.01 MINUTES SPOUSE 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 97116 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 97110 THERAPEUTIC PROCEDURE, 10R MORE AREAS, EACH 15 M545 LOW BACK PAIN MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 97116 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 E1545 LOW BACK PAIN MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), l OR MORE REGIONS, EACH 15 MINUTES 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL OTHER MEDICAL $11.58 $52.00 MALE SPOUSE $13.34 $54.00 MALE SPOUSE $47.01 $171.00 MALE SPOUSE $13.34 $54.00 MALE SPOUSE $32.91 $114.00 MALE SPOUSE $11.58 $52.00 MALE SPOUSE $13.34 $54.00 MALE SPOUSE $32.91 $114.00 MALE SPOUSE $11.58 $52.00 MALE SPOUSE $1334 $54.00 MALE SPOUSE $47.01 $171.00 MALE SPOUSE $13.34 $54.00 MALE SPOUSE $32.91 $114.00 MALE SPOUSE $11.58 $52.00 MALE SPOUSE $13.34 $54.00 MALE SPOUSE $47.01 $171.00 MALE SPOUSE 1 050 1 BAD 1 EGO 1 EGO 1 O5O 1 EGO 1 EGO 1 OSO 1 EGO 1 EGO 1 050 1 EGO 1 EGO 1 OSO 1 O5O 1 EGO C.7.f 3559 w �1 3559 N 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 rl 11/10/2017 10/23/2017 111812017 97140 MANUAL THERAPY TECH N I QUES)EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL SPOUSE $11.58 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, SPOUSE $13.34 $54.00 MALE SPOUSE MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 $0.00 MALE SPOUSE $0.00 $0.00 MALE MINUTES $0.00 $0.01 MALE 11/10/2017 10/25/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $0.01 MALE SPOUSE MINUTES; THERAPEUTIC EXERCISES TO DEVELOP $0.01 MALE SPOUSE $0.00 $0.01 MALE STRENGTH AND ENDURANCE, RANGE OF MOTION AND $0.00 $0.01 MALE SPOUSE $0.00 FLEXIBILITY SPOUSE $0.00 11/10/2017 10/25/2017 1118 12017 97116 THERAPEUTIC PROCEDURE, l OR MOREAREAS, EACH 1S M545 LOW BACK PAIN OTHER MEDICAL MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 11/10/2017 10/25/2017 11/8/2017 97140 MANUAL THERAPY TECHNIQUES )EG ,MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 11/10/2017 10/25/2017 11/8/2017 68978 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL M545 LOW BACK PAIN OTHER MEDICAL LIMITATION, CURRENT STATUS, ATTHERAPY EPISODE OUTSETAND AT REPORTING INTERVALS 11/10/2017 10/25/2017 11/8/2017 G8979 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL N1545 LOW BACK PAIN OTHER MEDICAL LIMITATION, PROJECTED GOAL STATUS, AT THERAPY EPISODE OUTSET, AT REPORTING INTERVALS, AND AT DISCHARGE OR TO END REPORTING 11/10/2017 11/2/2017 11/9/20170518F Repair, intermediate, wounds of neck, hands, feet a nd /or Z981 ARTHRODESIS STATUS PROFESSIONAL external genitalia; 7.6 cm to 12.5 cm OUTPATIENT /HOSPITAL 11/10/2017 11/2/2017 11/9/2017 1036F CURRENTTOBACCO NON- USER(CAD, CAP,COPQ PV) Z981 ARTHRODESIS STATUS PROFESSIONAL )DM) (IBD) OUTPATIENT /HOSPITAL 11/10/2017 11/2/2017 11/9/20171100F PATIENTSCREENED FOR FUTURE FALLRISK; Z981 ARTHRODESIS STATUS PROFESSIONAL DOCUMENTATION OF 2 OR MORE FALLS IN THE PAST YEAR OUTPATIENT /HOSPITAL OR ANY FALL WITH INJURY IN THE PAST YEAR (GER) 11/10/2017 11/2/2017 11/9/2017 1123F ADVANCE CARE PLANNING DISCUSSED AND Z981 ARTHRODESIS STATUS PROFESSIONAL DOCUMENTED ADVANCE CARE PLAN OR SURROGATE OUTPATIENT /HOSPITAL DECISION MAKER DOCUMENTED IN THE MEDICAL RECORD )DEM)(GER, PALL CR) 11/10/2017 11/2/2017 11/9/2017 1125F INTERMEDIATE " DELAY" OFANY FLAP, PRIMARY "DELAY" Z981 ARTHRODESIS STATUS PROFESSIONAL OF SMALL FLAP, OR SECTIONING PEDICLE OF TUBED OR OUTPATIENT/HOSPITAL DIRECT FLAP, AT FOREHEAD, CHEF 11/10/2017 11/2/2017 11/9/20171159F MEDICATION LIST DOCUMENTED IN MEDICAL RECORD Z981 ARTHRODESIS STATUS PROFESSIONAL )COA) OUTPATIENT /HOSPITAL 11/10/2017 11/2/2017 11/9/20171220F PATIENTSCREENED FOR DEPRESSION (SUD) Z981 ARTHRODESIS STATUS PROFESSIONAL OUTPATIENT /HOSPITAL 11/10/2017 11/2/2017 11/9/20173288F DONOR HEPATECTOMY, WITH PREPARATION AND Z981 ARTHRODESIS STATUS PROFESSIONAL MAINTENANC E OF ALLOGRAFT, FROM LIVING DONOR; OUTPATIENT /HOSPITAL TOTAL LEFT LOBE CTOMY )SEGMENTS II, III AND 11/10/2017 11/2/2017 11/9/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z981 ARTHRODESIS STATUS PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY, COUNSELING AND COORD 11/10/2017 111212017 111912017 G8420 BMI IS DOCUMENTED WITHIN NORMAL PARAMETERS Z981 ARTHRODESIS STATUS PROFESSIONAL AND NO FOLLOW -UP PLAN IS REQUIRED OUTPATIENT /HOSPITAL $13.34 $54.00 MALE SPOUSE $32.91 $114.00 MALE SPOUSE $11.58 $52.00 MALE SPOUSE $13.34 $54.00 MALE SPOUSE $0.00 $0.00 MALE SPOUSE $0.00 $0.00 MALE SPOUSE $0.00 $0.01 MALE SPOUSE $0.00 $0.01 MALE SPOUSE $0.00 $0.01 MALE SPOUSE $0.00 $0.01 MALE SPOUSE $0.00 $0.01 MALE SPOUSE $0.00 $0.01 MALE SPOUSE $0.00 $0.01 MALE SPOUSE $0.00 $0.01 MALE SPOUSE $78.63 $193.00 MALE SPOUSE 1 050 1 OSO 1 050 1 OSO 1 050 1 OSO 1 050 1 050 1 OSO 1 EGO 1 OSO 1 OSO 1 OSO 1 OSO 1 050 $0.00 $0.01 MALE SPOUSE 1050 C.7.f 3559 4) 40 3559 Q! 3559 7 3559 W } fl 3559 CL CL Q 3559 3559 3559 3559 3559 3559 3559 3559 MIX M 11/10/2017 11 /2/2017 11/9/2017 G3427 11/10/2017 11/2/2017 11/9/2017 G8484 11/10/2017 11/2/2017 11/9/2017 G8732 11/15/2017 6/13/2017 11/14/2017 K0001 11/20/2017 11/13/2017 11/17/2017 1112012017 11/13/2017 11/17/2017 11/21/2017 11/16/2017 11/20/2017 11/21/2017 11/16/2017 11/20/2017 11/27/2017 11/2/2017 11/21/2017 1112712017 11/17/2017 1112212017 11/27/2017 11/17/2017 11/22/2017 1112712017 11/20/2017 1112212017 11/27/2017 11/20/2017 11/22/2017 11/28/2017 11/22/2017 11/27/2017 11/28/2017 11/22/2017 11/27/2017 ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN Z981 ARTHRODESIS STATUS PROFESSIONAL THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR OUTPATIENT /HOSPITAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS SPOUSE INFLUENZA IMMUNIZATION WAS NOT ADMINISTERED, Z981 ARTHRODESIS STATUS PROFESSIONAL REASON NOT GIVEN OUTPATIENT /HOSPITAL NO DOCUMENTATION OF PAIN ASSESSMENT Z981 ARTHRODESIS STATUS PROFESSIONAL $47.01 OUTPATIENT /HOSPITAL STANDARD WHEELCHAIR 534139A UNSPECIFIED INIURYTO OTHER MEDICAL $54.00 MALE SACRAL SPINAL CORD, $13.34 INITIAL ENCOUNTER 97110 THERAPEUTIC PROCEDURE, 1 OR MOREAREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP SPOUSE STRENGTH AND ENDURANCE, RANGE OF MOTION AND $189.00 MALE FLEXIBILITY $47.01 97140 MANUAL THERAPY TECH NIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, $54.00 MALE MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 $47.01 MINUTES SPOUSE 97140 MANUAL THERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, $1334 MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 SPOUSE MINUTES $177.00 MALE 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE - ON- ONE)PATIENT M545 LOW BACK PAIN OTHER MEDICAL CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 72131 COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT M48061 SPINAL STENOSIS, PROFESSIONAL CONTRAST MATERIAL LUMBAR REGION OUTPATIENT /HOSPITAL WITHOUT NEUROGENIC CLAUDICATION 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 97140 MANUALTHERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 97110 THERAPEUTIC PROCEDURE, 1 OR MOREAREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 97140 MANUALTHERAPY TECHNIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION(, 1 O MORE REGIONS, EACH 15 MINUTES 97140 MANUAL THERAPY TECH NIQUES(EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE- ON- ONE) PATIENT M54S LOW BACK PAIN OTHER MEDICAL CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES $0.00 $0.01 MALE SPOUSE $0.00 $0.01 MALE SPOUSE $0.00 $0.01 MALE SPOUSE $350.28 $350.28 MALE SPOUSE $47.01 $171.00 MALE SPOUSE $13.34 $54.00 MALE SPOUSE $13.34 $54.00 MALE SPOUSE $49.56 $177.00 MALE SPOUSE $68.55 $189.00 MALE SPOUSE $47.01 $171.00 MALE SPOUSE $13.34 $54.00 MALE SPOUSE $47.01 $171.00 MALE SPOUSE $13.34 $54.00 MALE SPOUSE $1334 $54.00 MALE SPOUSE $4936 $177.00 MALE SPOUSE 1 050 1 050 1 OSO 1 OSO 1 EGO 1 O5O 1 OSO 1 OSO 1 OSO 1 050 1 O5O 1 050 1 OSO 1 050 1 OSO C.7.f 3559 w 41 N 3559 Q! 3559 3559 BIB O {9 } 3559 D. CL CL Q 3559 v 4 3559 W D 3559 3559 fY 3559 3559 3559 3559 3559 3559 C.7.f 1112812017 11/22/2017 11/27/2017 G8979 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL M545 LOW BACK PAIN OTHER MEDICAL $0.00 $0.00 MALE SPOUSE 1050 3559 LIMITATION, PROJECTED GOAL STATUS, AT THERAPY I EPISODE OUTSET, AT REPORTING INTERVALS, AND AT {U DISCHARGE OR TO END REPORTING N 1112812017 11/22/2017 11/27/2017 G8980 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL M545 LOW BACK PAIN OTHER MEDICAL $0.00 $0.00 MALE SPOUSE 1050 3559 LIMITATION, DISCHARGE STATUS, AT DISCHARGE FROM THERAPY OR TO END REPORTING 11/29/2017 10/23/2017 11122/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 182522 CHRONIC EMBOLISM AND PROFESSIONAL OFFICE $188.81 $337.00 MALE SPOUSE 1050 3559 7 EVALUATION AND MANAGEMENTOFAN ESTABLISHED THROMBOSIS OF "a PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY UNSPECIFIED DEEPVEINS COMPONENTS: A DETAILED HISTORY; A DETAILED OF LEFT DISTAL LOWER EXAMINATION; MEDICAL DECISION MAKING OF EXTREMITY MODERATE COMPLEXITY. COUNSELING AND /OR } COORDINATION OF CARE WITH OTHER S. 12/6/2017 11/30/2017 12/5/2017 " "" * * "* " "' * " ** * * "* $307.69 $419.00 MALE SPOUSE 1 050 3559 Q, 12/7/2017 1215/2017 12/5/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $60.17 $180.00 MALE SPOUSE 1 OSO 3559 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY rf 12/7/2017 12/5/2017 12/5/2017 97162 Physical therapy evaluation: moderate complexity, M545 LOW BACK PAIN OTHER MEDICAL $49.12 $185.00 MALE SPOUSE 1 OSO 3559 �+ requiring these components: A history of present problem F with 1 -2 personal factors and /or comorbldities h 12/7/2017 12/5/2017 12/5/2017 G8978 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL M545 LOW BACK PAIN OTHER MEDICAL $0.00 $0.01 MALE SPOUSE 1 0S 3559 LIMITATION, CURRENT STATUS, ATTHERAPY EPISODE OUTSETAND AT REPDRTING INTERVALS _ 12/7/2017 12/5/2017 12/5/201768979 MOBILITY: WALKING AND MOVING AROUND FUNCTIONAL M545 LOW BACK PAIN OTHER MEDICAL $0.00 $0.01 MALE SPOUSE 1050 3559 LIMITATION, PROJECTED GOAL STATUS, AT THERAPY EPISODE OUTSET, AT REPORTING INTERVALS, AND AT a DISCHARGE OR TO END REPORTING uj 12/11/2017 12/6/2017 12/7/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 1S M545 LOW BACK PAIN OTHER MEDICAL $65.18 $180.00 MALE SPOUSE 1 OSO 3559 U`J MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND 0 FLEXIBILITY 12/14/2017 12/8/2017 1211212017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $50.14 $135.00 MALE SPOUSE 1 050 3559 ILLJ MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND � FLEXIBILITY w, J 12/14/2017 121812017 1211212017 97140 MANUAL THERAPY TECH NIQUES MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $14.23 $45.00 MALE SPOUSE 1050 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, v MANUAL TRACTION), FOR MORE REGIONS, EACH 15 MINUTES 12/18/2017 12/15/2017 12/15/2017 64550 APPLICATION OF SURFACE(TRANSCUTANEOUS) M545 LOW BACK PAIN OTHER MEDICAL $10.26 $32.00 MALE SPOUSE 1 OSO 3559 IFLJ NEUROSTIMULATOR 1211812017 1211512017 12/15/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $35.10 $90.00 MALE SPOUSE 1 OSO 3559 MINUTES; THERAPEUTIC EXERCISESTO DEVELOP U STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 12/18/2017 12/15/2017 12115/2017 97140 MANUALTHERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $28.46 $90.00 MALE SPOUSE 1050 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, N MANUAL TRACTION), l OR MORE REGIONS, EACH 15 MINUTES N 12/19/2017 12/11/2017 1211812017 64550 APPLICATION OF SURFACE(TRANSCUTANEOUS) M545 LOW BACK PAIN OTHER MEDICAL $10.26 $32.00 MALE SPOUSE 1 OSO 3559 = NEUROSTIMULATOR Bu 12/19/2017 12/11/2017 12/18/2017 97140 MANUAL THERAPY TECHNIQUES (EG , MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $4742 $135.00 MALE SPOUSE 1050 3559 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, ._ MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 12/19/2017 12/13/2017 12/1812017 64550 APPLICATION OF SURFACE(TRANSCUTANEOUS) M545 LOW BACK PAIN OTHER MEDICAL $10.26 $32.00 MALE SPOUSE 1 050 NEUROSTIMULATOR 12/19/2017 12/13/2017 12118/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $35.10 $90.00 MALE SPOUSE 1 0SO MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 12/19/2017 12/13/2017 12/18/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $28.46 $90.00 MALE SPOUSE 1 0SO MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 12/19/2017 12/18/2017 12/18/2017 64550 APPLICATION OF SURFACE(TRANSCUTANEOUS) M545 LOW BACK PAIN OTHER MEDICAL $10.26 $32.00 MALE SPOUSE 1 OSO NEUROSTIMUTATOR 12/19/2017 12/18/2017 12/18/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MS4S LOW BACK PAIN OTHER MEDICAL $35.10 $90.00 MALE SPOUSE 1 0SO MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 12/19/2017 12/18/2017 1211812017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $28.46 $90.00 MALE SPOUSE 1 OSO MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES 12/20/2017 11/2/2017 12/19/2017- - 7981 ARTHRODESIS STATUS HOSPITAL OUTPATIENT $2,075.00 $2,075.00 MALE SPOUSE 1050 1212112017 12/19/2017 1211912017 64550 APPLICATION OF SURFACE(TRANSCUTANEOUS) N1545 LOW BACK PAIN OTHER MEDICAL $10.26 $32.00 MALE SPOUSE 1 0SO NEUROSTIMULATOR 12/21/2017 12/19/2017 12/19/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MOREAREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $35.10 $90.00 MALE SPOUSE 1 050 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 12/21/2017 12/19/2017 12/19/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $28.46 $90.00 MALE SPOUSE 1 050 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 10R MORE REGIONS, EACH 15 MINUTES 12/27/2017 12/21/2017 12/26/2017 64550 APPLICATION OF SURFACE(TRANSCUTANEOUS) M545 LOW BACK PAIN OTHER MEDICAL $1016 $32.00 MALE SPOUSE 1 OSD NEUROSTIMUTATOR 12/27/2017 12/21/2017 12/26/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 M545 LOW BACK PAIN OTHER MEDICAL $20.06 $45.00 MALE SPOUSE 1 0SO MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 1212712017 1212112017 12/26/2017 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ M545 LOW BACK PAIN OTHER MEDICAL $14.23 $45.00 MALE SPOUSE 1 050 MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES Sub Total $137,794.64 $561,762.59 5.375E +10 1/3/2017 12/2/2016 12/30/2016 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE $103.91 $150.00 MALE SUBSCRIBER 1BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED HYPERTENSION PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 1/3/2017 12/23/2016 12/30/2016 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE $103.91 $150.00 MALE SUBSCRIBER 1BUG EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 1/30/2017 1/9/2017 111012017 20610 ARTHROCENTESIS, ASPIRATION AND /OR INJECTION, N11712 UNILATERAL PRIMARY PROFESSIONAL OFFICE $0.00 $262.00 MALE SUBSCRIBER 1 BCC MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE, OSTEOARTHRITIS, LEFT SUBACROMIAL BURSA); WITHOUT ULTRASOUND KNEE GUIDANCE 1/30/2017 1/9/2017 111012017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M1712 UNILATERAL PRIMARY PROFESSIONAL OFFICE $78.91 EVALUATION AND MANAGEMENT OF AN ESTABLISHED SUBSCRIBER OSTEOARTHRITIS, LEFT 3559 $0.00 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SUBSCRIBER KNEE 3559 $0.00 COMPONENTS: A PROBLEM FOCUSED HISTORY; A SUBSCRIBER 1 BCC 3559 $0.00 PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD SUBSCRIBER 1 BCC 3559 $100.94 MEDICAL DECISION MAKING. COUNSELING AND /OR SUBSCRIBER 1 BCC 3559 $78.89 COORDINATION OF CARE WIT SUBSCRIBER 1 BCC 3559 1/30/2017 1/9/2017 1/10/201710702 INJECTION, BETAMETHASONE ACETATE 3MG AND M1712 UNILATERAL PRIMARY PROFESSIONAL OFFICE $461.95 BETAMETHASONE SODIUM PHOSPHATE 3MG SUBSCRIBER OSTEOARTHRITIS, LEFT 3559 KNEE 3/17/2017 2/27/2017 3/9/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 3/17/2017 3/4/2017 3/14/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT R42 DIZZINESS AND GIDDINESS PROFE55IONAL CONTRAST MATERIAL OUTPATIENT /HOSPITAL 3/17/2017 3/4/2017 3/14/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R42 DIZZINESS AND GIDDINESS PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 3/21/2017 3/4/2017 3/20/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R0602 SHORTNESS OF BREATH PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 3/21/2017 3/7/2017 3120/2017 78452 Myocardial perfusion imaging, tomograph, (SPECT) 1209 ANGINA PECTORIS, PROFESSIONAL (including attenuation correction, qualitative or UNSPECIFIED INPATIENT /HOSPITAL quantitative all motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and /or 3/21/2017 3/9/2017 3/20/2017 70544 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT R42 DIZZINESS AND GIDDINESS PROFESSIONAL CONTRAST MATERIALS) INPATIENT /HOSPITAL 3121/2017 3/9/2017 3/20/2017 70551 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN R42 DIZZINESS AND GIDDINESS PROFESSIONAL (INCLUDING BRAIN STEM); WITHOUT CONTRAST INPATIENT /HOSPITAL MATERIAL 3/22/2017 31 312112017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 1350 NONRHEUMATIC AORTIC PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES (VALVE) STENOSIS OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 3/22/2017 3/10/2017 3/21/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1350 NONRHEUMATIC AORTIC OTHERMEDICAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH (VALVE) STENOSIS REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 3/23/2017 3/9/2017 3/21/20173100F CAROTID IMAGING STUDY REPORT (INCLUDES DIRECT OR R42 DIZZINESSAND GIDDINESS PROFESSIONAL INDIRECT REFERENCE TO MEASUREMENTS OF DISTAL INPATIENT /HOSPITAL INTERNAL CAROTID DIAMETER AS THE DENOMINATOR FOR STENO515 MEASUREMENT) (STR, BAD) $26.84 $140.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 $0.00 $25.00 MALE SUBSCRIBER 1 BCC 3559 $78.91 $150.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $322.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $58.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $41.00 MALE SUBSCRIBER 1 BCC 3559 $100.94 $384.00 MALE SUBSCRIBER 1 BCC 3559 $78.89 $243.00 MALE SUBSCRIBER 1 BCC 3559 $97.12 $302.00 MALE SUBSCRIBER 1 BCC 3559 $461.95 $1,450.00 MALE SUBSCRIBER 1 BCC 3559 $94.42 $449.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $0.01 MALE SUBSCRIBER 1 BCC 3559 3/23/2017 3/9/2017 3/21/2017 70549 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT R42 DIZZINESS AND GIDDINESS PROFESSIONAL $24.24 $172.00 MALE CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST 1 BCC 3559 OR INPATIENT /HOSPITAL CL $0.00 MATERIAL(S) AND FURTHER SEQUENCES SUBSCRIBER 1 BCC 3559 3/27/2017 3/6/2017 3/23/2017 93880 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE 16523 OCCLUSION AND PROFESSIONAL BILATERAL STUDY $767.00 MALE STENOSIS OF BILATERAL OUTPATIENT /HOSPITAL 3559 $302.20 $850.00 MALE SUBSCRIBER CAROTID ARTERIES 3559 y 3/29/2017 3/4/2017 3/28/2017 A0425 GROUND MILEAGE, PER STATUTE MILE R0789 OTHER CHEST PAIN OTHER MEDICAL 3/29/2017 3/4/2017 3128/2017 A0427 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, R0789 OTHER CHEST PAIN OTHER MEDICAL SUBSCRIBER 1 BCC EMERGENCY TRANSPORT, LEVEL 1 )AtSI- EMERGENCY) 3/29/2017 3/9/2017 3/20/2017 36224 SELECTIVE CATHETER PLACEMENT, INTERNAL CAROTID 16522 OCCLUSION AND PROFESSIONAL } fl ARTERY, UNILATERAL, WITH ANGIDGRAPHY OF THE STENOSIS OF LEFT INPATIENT /HOSPITAL $75.69 IPSILATERAL INTRACRANIAL CAROTID CIRCULATION AND SUBSCRIBER CAROTID ARTERY 3559 ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND $11.74 INTERPRETATION, SUBSCRIBER 1 BCC 3559 3/29/2017 319/2017 3/20/2017 37215 TRANSCATHETER PLACEMENT OF INTRAVASCULAR 16522 OCCLUSION AND PROFESSIONAL O STENT(SE CERVICAL CAROTID ARTERY, OPEN OR STENOSIS OF LEFT INPATIENT /HOSPITAL d $51.16 PERCUTANEOUS, INCLUDING ANGIOPLASTY, WHEN SUBSCRIBER CAROTID ARTERY 3559 PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION; WITH DISTAL EMBOLIC PROTECTION 3/29/2017 3/9/2017 3/20/2017 G9500 Radiation exposure.. dices, exposure ti meornumbe, of 16522 OCCLUSION AND PROFESSIONAL fluorographlc Images in final report for procedures using STENOSIS OF LEFT INPATIENT /HOSPITAL O flu orascopV, documented CAROTID ARTERY 3/29/2017 3/20/2017 3/28/2017 71250 COMPUTED TOMOGRAPHY, THORAX; WITHOUT R0789 OTHER CHEST PAIN PROFESSIONAL IELJ $78.91 CONTRAST MATERIAL SUBSCRIBER 1 BCC OUTPATIENT /HOSPITAL 3/29/2017 3/22/2017 3/28/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 3/31/2017 3/6/2017 3/29/2017 93306 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL -TIME WITH 1359 NONRHEUMATIC AORTIC PROFESSIONAL IMAGE DOCUMENTATION )2D), INCLUDES M -MODE VALVE DISORDER, INPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH UNSPECIFIED SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 3/31/2017 3/23/2017 3/29/2017 .... ..... ..x ++ ... *. ..... 3/31/2017 3/27/2017 3/30/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/3/2017 3/9/2017 4/1/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1658 OCCLUSION AND PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH STENOSIS OF OTHER INPATIENT /HOSPITAL REQU I R ES AT LEAST 20 F TH ESE 3 KEY COM PO N E NTS:AN P RECE RE B RAL ARTE R I ES EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 4/5/2017 3/6/2017 4/3/20173100F CAROTID IMAGING STUDY REPDRT( INCLUDES DIRECTOR 16522 OCCLUSIONAND PROFESSIONAL INDIRECT REFERENCE TO MEASUREMENTS OF DISTAL STENOSIS OF LEFT OUTPATIENT /HOSPITAL INTERNAL CAROTID DIAMETER AS THE DENOMINATOR CAROTID ARTERY FOR STENOSIS MEASUREMENT) )STR, RAD) 4/7/2017 3/4/2017 3/30/2017 .... " "* .... ..... " "' C.7.f $117.61 $365.00 MALE SUBSCRIBER 1 BCC 3559 $119.19 $228.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $0.01 MALE SUBSCRIBER 1 BCC 41 $24.24 $172.00 MALE SUBSCRIBER 1 BCC 3559 OR CL $0.00 $4,371.00 MALE SUBSCRIBER 1 BCC 3559 Q! $442.50 $767.00 MALE SUBSCRIBER 1 BCC 3559 $302.20 $850.00 MALE SUBSCRIBER 1 BCC 3559 y F $0.00 $0.01 MALE SUBSCRIBER $6510 $1,466.00 MALE SUBSCRIBER 1 BCC 3559 fl } fl $119.19 $228.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $0.01 MALE SUBSCRIBER 1 BCC 3559 CL $107,082.00 MALE SUBSCRIBER 1 BCC 3559 CL $0.00 $4,371.00 MALE SUBSCRIBER 1 BCC 3559 Q F $0.00 $0.01 MALE SUBSCRIBER 1 BCC 3559 h D $75.69 $362.00 MALE SUBSCRIBER 1 BCC 3559 $11.74 $58.00 MALE SUBSCRIBER 1 BCC 3559 O d $51.16 $1,100.00 MALE SUBSCRIBER 1 BCC 3559 f� O J $3,385.80 $8,024.00 MALE SUBSCRIBER 1 BCC 3559 IELJ $78.91 $150.00 MALE SUBSCRIBER 1 BCC 3559 $119.19 $228.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $0.01 MALE SUBSCRIBER 1 BCC 3559 3/4/2017 # #### # ## $65,124.82 $107,082.00 MALE SUBSCRIBER 1 BCC 3559 41712017 3/9/2017 4/5/2017 99291 CRITICAL CARE, EVALUATION AND MANAGE ME NT OF THE D126 BENIGN NEOPLASM OF PROFESSIONAL SUBSCRIBER 1 BCC 3559 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- $118.00 MALE COLON, UNSPECIFIED INPATIENT /HOSPITAL 3559 $103.91 $150.00 MALE 74 MINUTES 1 BCC 3559 $7,573.50 4/7/2017 3/9/2017 4/5/2017 99223 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION 16522 OCCLU510N AND PROFESSIONAL 1 BCC 3559 $590.00 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES SUBSCRIBER STENOSIS OF LEFT INPATIENT /HOSPITAL $380.00 $850.00 MALE SUBSCRIBER THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; 3559 CAROTID ARTERY $12,301.00 MALE SUBSCRIBER 1 BCC 3559 ACOMPREHENSIVE EXAMINATION; AND MEDICAL $6,507.00 MALE SUBSCRIBER 1 BCC 3559 DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS DR AGEN 4/7/2017 3/10/2017 4/5/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE D126 BENIGN NEOPLASM OF PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH COLON, UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 4/11/2017 3/18/2017 4/10/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1350 NONRHEUMATIC AORTIC PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES (VALVE) STENOSIS INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 4/12/2017 4/4/2017 4/10/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT R51 HEADACHE PROFESSIONAL CONTRAST MATERIAL OUTPATIENT /HOSPITAL 4/12/2017 4/4/2017 4/10/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, BEE HEADACHE PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 4/12/2017 4/4/2017 4/10/2017 93880 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE RSl HEADACHE PROFESSIONAL BILATERAL STUDY OUTPATIENT /HOSPITAL 4113/2017 4/10/2017 4/12/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/14/2017 3/4/2017 4/12/2017- - 1214 NON ST ELEVATION HOSPITAL OUTPATIENT (NSTEMI) MYOCARDIAL INFARCTION 4/14/2017 3/20/2017 4/12/2017- - 529012A STRAIN OF MUSCLE AND HOSPITAL OUTPATIENT TENDON OF BACK WALL OF THORAX, INITIAL ENCOUNTER 4/14/2017 3/22/2017 4112/2017 A0425 GROUND MILEAGE, PER STATUTE MILE R072 PRECORDIAL PAIN OTHER MEDICAL 4/14/2017 3/22/2017 4/12/2017 A0426 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NOW R072 PRECORDIAL PAIN OTHER MEDICAL EMERGENCY TRANSPORT, LEVEL 1(ALS 1) 4/14/2017 4/4/2017 4/12/2017 - - 644011 EPISODICCLUSTER HOSPITAL OUTPATIENT HEADACHE, INTRACTABLE 4/17/2017 3122/2017 4/13/2017 - - R072 PRECORDIAL PAIN HOSPITAL OUTPATIENT $261.20 $800.00 MALE SUBSCRIBER $202.75 $340.00 MALE SUBSCRIBER C.7.f 1 BCC 3559 w Z 1 BCC 3559 N $81.89 $190.00 MALE SUBSCRIBER 1 BCC $245.63 $893.00 MALE SUBSCRIBER 1 BCC i] $73.20 $322.00 MALE SUBSCRIBER 1 BCC 3559 $15.65 $58.00 MALE SUBSCRIBER 1 BCC 3559 $52.92 $118.00 MALE SUBSCRIBER 1 BCC 3559 $103.91 $150.00 MALE SUBSCRIBER 1 BCC 3559 $7,573.50 $101 MALE SUBSCRIBER 1 BCC 3559 $5,016.75 $6,689.00 MALE SUBSCRIBER 1 BCC 3559 $590.00 $767.00 MALE SUBSCRIBER 1 BCC 3559 $380.00 $850.00 MALE SUBSCRIBER 1 BCC 3559 $9,225.75 $12,301.00 MALE SUBSCRIBER 1 BCC 3559 $4,880.25 $6,507.00 MALE SUBSCRIBER 1 BCC 3559 rl 4/18/2017 4/4/2017 4/17/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION G459 TRANS I ENT CEREBRAL PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES I SCHEM I C ATTACK, OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS UNSPECIFIED IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 4/20/2017 4/11/2017 4 /1S /2017 72050 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; M542 CERVICALGIA PROFESSIONAL MINIMUM OF FOUR VIEWS OUTPATIENT /HOSPITAL 4/24/2017 4/11/2017 4/20/2017 - - M542 CERVICALGIA HOSPITAL OUTPATIENT 4/27/2017 3/6/2017 4/22/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1350 NONRHEUMATIC AORTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH (VALVE) STENOSIS INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVI 4/27/2017 31712017 412212017 93016 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR 1350 NONRHEUMATIC AORTIC PROFESSIONAL SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, (VALVE) STENOSIS INPATIENT /HOSPITAL CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND /OR PHARMACOLOGICAL STRESS; PHYSICIAN SUPERVISION ONLY, WITHOUT INTERPRETATION AND REPORT 4/27/2017 3/7/2017 4/22/2017 93018 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR 1350 NONRHEUMATIC AORTIC PROFESSIONAL SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, (VALVE) STENOSIS INPATIENT /HOSPITAL CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND /OR PHARMACOLOGICAL STRESS; INTERPRETATION AND REPORT ONLY 4/27/2017 3/8/2017 4122/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1350 NONRHEUMATIC AORTIC PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH (VALVE) STENOSIS INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 4/27/2017 3/23/2017 4/26/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 4/27/2017 4/4/2017 4/26/2017 A0425 GROUND MILEAGE, PER STATUTE MILE R202 PARESTHESIA OF SKIN OTHER MEDICAL 4/27/2017 4/4/2017 4/26/2017 A0429 AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY R202 PARESTHESIA OF SKIN OTHER MEDICAL TRANSPORT BLS- EMERGENCY) 4/27/2017 4/5/2017 4/26/2017 70496 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH G459 TRANSIENT CEREBRAL PROFESSIONAL CONTRAST MATERIAL(SE INCLUDING NONCONTRAST ISCHEMIC ATTACK, OUTPATIENT /HOSPITAL IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING UNSPECIFIED 4/27/2017 4/5/2017 4/26/2017 70498 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH 6459 TRANSIENT CEREBRAL PROFESSIONAL CONTRAST MATERIAL(S), INCLUDING NONCONTRAST ISCHEMIC ATTACK, OUTPATIENT /HOSPITAL IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING UNSPECIFIED $615.93 $1,450.00 MALE SUBSCRIBER 1 BCC $2732 $92.00 MALE SUBSCRIBER 1 BCC $808.50 $1,078.00 MALE SUBSCRIBER 1 BCC $113.66 $286.00 MALE SUBSCRIBER 1 BCC $19.94 $400.00 MALE SUBSCRIBER 1 BCC $13.42 $400.00 MALE SUBSCRIBER 1 BCC $78.97 $197.00 MALE SUBSCRIBER 1 BCC $615.93 $1,450.00 MALE SUBSCRIBER 1 BCC $590.00 $767.00 MALE SUBSCRIBER $339.32 $750.00 MALE SUBSCRIBER $153.80 $355.00 MALE SUBSCRIBER $15180 $355.00 MALE SUBSCRIBER C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 4/27/2017 4/5/2017 4/26/2017 72125 COMPUTED TOMOG RAP HY, CERVICAL SPINE; WITHOUT M47812 SPONDYLOSIS WITHOUT PROFESSIONAL SUBSCRIBER 1 BCC 3559 CONTRAST MATERIAL $58.00 MALE MYELOPATHY OR OUTPATIENT /HOSPITAL 3559 $9.23 $105.50 MALE SUBSCRIBER 1 BCC RADICULOPATHY, $27.69 $316.50 MALE SUBSCRIBER 1 BCC 3559 $6,144.75 CERVICAL REGION SUBSCRIBER 4/27/2017 4/19/2017 4/25/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT ROL HEADACHE PROFESSIONAL $74.34 $311.00 MALE SUBSCRIBER CONTRAST MATERIAL 3559 $74.34 OUTPATIENT /HOSPITAL 4/27/2017 4/19/2017 4125/2017 71010 RADIOLDGIC EXAMINATION, CHEST; SINGLE VIEW, R51 HEADACHE PROFESSIONAL 3559 $4,143.00 $5,859.00 MALE FRONTAL 1 BCC 3559 OUTPATIENT /HOSPITAL 4/27/2017 4/24/2017 4/25/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL 1 BCC 3559 FRONTAL OUTPATIENT /HOSPITAL 5/1/2017 3/4/2017 4/27/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 1214 NON ST ELEVATION PROFE55IONAL LEADS; INTERPRETATION AND REPORT ONLY (NSTEMI) MYOCARDIAL OUTPATIENT /HOSPITAL INFARCTION 5/1/2017 3/23/2017 4/27/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R0789 OTHER CHEST PAIN PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 5/1/2017 4/19/2017 4/28/2017 - - M25512 PAIN IN LEFT SHOULDER HOSPITAL OUTPATIENT 5/1/2017 4/19/2017 412812017 - - M25512 PAIN IN LEFT SHOULDER HOSPITAL OUTPATIENT 5/3/2017 4/6/2017 5/2/2017 99225 SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE R202 PARESTHESIA OF SKIN OTHER MEDICAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED 5/3/2017 4/7/2017 5/2/2017 99225 SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE R202 PARESTHESIA OF SKIN OTHER MEDICAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED 5/3/2017 4/8/2017 5/2/2017 99225 SUBSEQU ENT OBSERVATION CARE, PER DAY, FORTHE R202 PARESTHESIA OF SKIN OTHER MEDICAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PO ENTS: AN EXPANDED 5/3/2017 4124/2017 5/1/2017 - - R0789 OTHER CHEST PAIN HOSPITAL OUTPATIENT 5/4/2017 4/24/2017 5/2/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R0789 OTHER CHEST PAIN PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 5/4/2017 4/24/2017 5/2/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R0789 OTHER CHEST PAIN PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT/HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 5/5/2017 4/19/2017 5/3/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 G44219 EPISODIC TENSION -TYPE PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY HEADACHE,NOT OUTPATIENT /HOSPITAL INTRACTABLE 5/5/2017 4/19/2017 5/3/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION G44219 EPISODIC TENSION -TYPE PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES HEADACHE,NOT OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A INTRACTABLE DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PR $102.18 $229.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 $73.20 $322.00 MALE SUBSCRIBER 1 BCC 3559 $15.65 $58.00 MALE SUBSCRIBER 1 BCC 3559 $15.65 $58.00 MALE SUBSCRIBER 1 BCC 3559 $9.23 $105.50 MALE SUBSCRIBER 1 BCC 3559 $27.69 $316.50 MALE SUBSCRIBER 1 BCC 3559 $6,144.75 $8,528.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $8,528.00 MALE SUBSCRIBER 1 BCC 3559 $74.34 $311.00 MALE SUBSCRIBER 1 BCC 3559 $74.34 $311.00 MALE SUBSCRIBER 1 BCC 3559 $74.34 $311.00 MALE SUBSCRIBER 1 BCC 3559 $4,143.00 $5,859.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 $268.82 $665.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $443.00 MALE SUBSCRIBER 1 BCC 3559 C.7.f 5/8/2017 4/5/2017 5/5/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FORTH EVALUATION H540 BLINDNESS, BOTH EYES PROFESSIONAL $245.63 $893.00 MALE SUBSCRIBER 1 BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; Z A COMPREHENSIVE EXAMINATION; AND MEDICAL N DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 5/8/2017 5/4/2017 5/5/2017 20552 INJECTION; SINGLE OR MULTIPLE TRIGGER POINTS ), ONE M62838 OTHER MUSCLE SPASM OTHER MEDICAL $6713 $214.00 MALE SUBSCRIBER 1 BCC 3559 7 OR TWO MUSCLE(S) 5/8/2017 5/4/2017 S/5/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M62838 OTHER MUSCLE SPASM OTHER MEDICAL $198.48 $400.00 MALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE > } EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR G. 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COUNSELING AND /Oft COORDINATION OF CARE WITH OTHER 5/10/2017 5/1/2017 5/8/2017 - - R51 HEADACHE HOSPITAL OUTPATIENT $5,854.80 $9,758.00 MALE SUBSCRIBER 1 BCC 3559 511012017 5/1 /2017 51812017 - - RSl HEADACHE HOSPITAL OUTPATIENT $0.00 $9,758.00 MALE SUBSCRIBER 1 BCC 3559 IL 511012017 5/8/2017 5/9/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE $103.91 $150.00 MALE SUBSCRIBER 1BCC 3559 {i EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY UJ COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF 0 MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER W 0 5/11/2017 3/4/2017 5/9/2017 - - 1214 NON -ST ELEVATION HOSPITAL OUTPATIENT $0.00 $10,098.00 MALE SUBSCRIBER 1 BCC 3559 (NSTEMI) MYOCARDIAL J INFARCTION 5/16/2017 4/4/2017 5/15/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 G44019 EPISODICCLUSTER PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 V LEADS; INTERPRETATION AND REPORT ONLY HEADACHE,NOT OUTPATIENT /HOSPITAL INTRACTABLE 5/16/2017 4/4/2017 5/15/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION G44019 EPISODIC CLUSTER PROFESSIONAL $268.82 $665.00 MALE SUBSCRIBER 1 BCC 3559 LLJ AND MANAGEMENT OF A PATIENT, WHICH REQUIRES HEADACHE,NOT OUTPATIENT /HOSPITAL THESE3 KEY COMPONENTS WITHIN THE CONSTRAINTS INTRACTABLE IMPOSED BY THE URGENCY OF THE PATIENTS CLINICAL (' CONDITION AND /OR MENTALSTATUS: ACOMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS Q N 5/16/2017 4/27/2017 5/13/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M5481 OCCIPITAL NEURALGIA PROFESSIONAL OFFICE $250.55 $590,00 MALE SUBSCRIBER 1 BCC 3559 Cy EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A = COMPREHENSIVE HISTORY; A COMPREHENSIVE y EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY, COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE 2 5/17/2017 3/22/2017 5/15/2017 93010 ELECTROCARD I OG RAM, ROUTINE ECG WITH AT LEAST 12 R072 PRECORDIAL PAIN PROFESSIONAL 1 BCC LEADS; INTERPRETATION AND REPORT ONLY $16.29 OUTPATIENT /HOSPITAL 5/17/2017 3/22/2017 5/15/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 8072 PRECORDIAL PAIN PROFESSIONAL $199.00 MALE AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 1 BCC OUTPATIENT /HOSPITAL $9.23 THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS SUBSCRIBER 1 BCC 3559 IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL $67.36 MALE SUBSCRIBER 1 BCC CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 5/18/2017 5/11/2017 5/17/2017 11406 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS L720 EPIDERMAL CYST PROFESSIONAL OFFICE LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 4.0 CM 5/18/2017 5/11/2017 5/17/2017 13101 REPAIR, COMPLEX, TRUNK; 2.6 CM T07.5 CM L720 EPIDERMAL CYST PROFESSIONAL OFFICE 5118/2017 5/11/2017 5/17/2017 99202 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L720 EPIDERMAL CYST PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WITH O 5/19/2017 3/5/2017 5/17/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1214 NON ST ELEVATION PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES (NSTEMI) MYOCARDIAL INPATIENT /HOSPITAL THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; INFARCTION A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 5/23/2017 5/1/2017 5122/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT R51 HEADACHE PROFESSIONAL CONTRAST MATERIAL OUTPATIENT /HOSPITAL 5/23/2017 5/1/2017 5/22/2017 71010 R,ADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R0602 SHORTNESS OF BREATH PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 5/30/2017 3123/2017 5/24/2017 99225 SUBSEQUENT OBSERVATION CARE, PER DAY, FOR THE 80789 OTHER CHEST PAIN PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH OUTPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED 6/2/2017 5/1/2017 6/1/2017 93010 E LECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R42 DIZZINESS AND GIDDINESS PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 6/12/2017 5/11/2017 6/9/2017 88304 LEVELIII- SURGICAL PATHOLOGY, GROSS AND L720 EPIDERMAL CYST OTHER MEDICAL MICROSCOPIC EXAMINATION ABORTION, INDUCED, ABSCESS, ANEURYSM - ARTERIAL/VENTRICULAR, ANUS, TAG, APPENDIX, OTHER THAN INCIDENTAL, ARTERY, ATHEROMATOUS PLAQUE, BARTHOLIN'S GLAND CYST, BONE FRAGMENTS), OTHER THAN PATHOLOGIC FRACTURE, BURSA /SYNOVIAL 6/19/2017 6/9/2017 6/16/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER $0.00 $35.00 MALE SUBSCRIBER $0.00 $665.00 MALE SUBSCRIBER $123.13 $571.00 MALE SUBSCRIBER $320.25 $691.00 MALE SUBSCRIBER $57.18 $127.00 MALE SUBSCRIBER 1 BCC 1 BCC 1 BCC 1 BCC 1 BCC $151.11 $379.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 w Z 3559 N 3559 3559 3559 ®' $76.57 $203.00 MALE SUBSCRIBER 1 BCC 3559 $16.29 $41.00 MALE SUBSCRIBER 1 BCC 3559 $55.91 $199.00 MALE SUBSCRIBER 1 BCC 3559 $9.23 $105.50 MALE SUBSCRIBER 1 BCC 3559 $36.14 $67.36 MALE SUBSCRIBER 1 BCC 3559 $10191 $150.00 MALE SUBSCRIBER 1 BCC III rl 6/23/2017 3/9/2017 3/20/2017 36224 SELECTIVE CATHETER PLACE M ENT, INTERNAL CAROTID 16522 OCCLUSION AND PROFESSIONAL (.56,`,201 ARTERY, UN I LATERAL, WITH ANG I OG RAP HY OF THE SUBSCRIBER STENOSIS OF LEFT INPATIENT /HOSPITAL PSILATERAL INTRACRANIAL CAROTID CIRCULATION AND CAROTID ARTERY U1 ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND N INTERPRETATION, 6/23/2017 3/9/2017 3/20/2017 37215 TRANSCATHETER PLACEMENT OF INTRAVASCULAR 16522 OCCLUSION AND PROFESSIONAL $0.00 STENT(SE CERVICAL CAROTID ARTERY, OPEN OR SUBSCRIBER STENOSIS OF LEFT INPATIENT /HOSPITAL PERCUTANEOUS, INCLUDING ANGIOPLASTY, WHEN CAROTID ARTERY PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION; WITH DISTAL EMBOLIC PROTECTION 6/23/2017 3/9/2017 3/20/201769500 Radiation expos mmdices, exposure ti meornumber of 16522 OCCLUSION AND PROFESSIONAL fluorographlc Images in final reportfor procedures using STENOSIS OF LEFT INPATIENT /HOSPITAL fluoroscopy, documented CAROTID ARTERY 6/23/2017 3/9/2017 6/13/2017 36224 SELECTIVE CATHETER PLACEMENT, INTERNAL CAROTID 16522 OCCLUSION AND PROFESSIONAL ARTERY, UNILATERAL, WITH ANGIOGRAPHY OF THE STENOSIS OF LEFT INPATIENT /HOSPITAL IPSILATERAL INTRACRANIAL CAROTID CIRCULATION AND CAROTID ARTERY } ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND fl $0.00 INTERPRETATION, SUBSCRIBER 1 BCC 3559 ' CL 6/23/2017 31 6/13/2017 37215 TRANSCATHETER PLACEMENT OF INTRAVASCULAR 16522 OCCLUSION AND PROFESSIONAL STENT(SE CERVICAL CAROTID ARTERY, OPEN OR STENOSIS OF LEFT INPATIENT /HOSPITAL PERCUTANEOUS, INCLUDING ANGIOPLASTY, W HEN CAROTID ARTERY PERFORMED, AND RADIOLOGICAL SUPERVISION AND $1,925.92 INTERPRETATION; WITH DISTAL EMBOLIC PROTECTION SUBSCRIBER 1 BCC 3559 6/23/2017 3/9/2017 6/13/2017 G9500 Radiation exposure indices, exposure time or number of 16522 OCCLUSION AND PROFESSIONAL fluorographlc images in final report for procedures using STENOSIS OF LEFT INPATIENT /HOSPITAL fluoroscopy, documented CAROTID ARTERY E 7/14/2017 7/12/2017 7/13/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION $0.00 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SUBSCRIBER 1 BCC 3559 _ COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF $103.91 MODERATE COMPLEXITY. COUNSELING AND /OR SUBSCRIBER 1 BCC 3559 COORDINATION OF CARE WITH OTHER 7/19/2017 4/6/2017 7/17/2017 * *' "* 11 — *' " ** ..". ""' 7/24/2017 3/23/2017 7/20/2017 99236 OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE R072 PRECORDIAL PAIN OTHER MEDICAL EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELI 7/31/2017 1/9/2017 7/27/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K589 IRRITABLE BOWEL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED SYNDROME WITHOUT PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY DIARRHEA COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT 8/7/2017 7/18/2017 8/5/2017 - - K219 GASTRO- ESOPHAGEAL HOSPITAL OUTPATIENT REFLUX DISEASE WITHOUT ESOPHAGITIS $17,749.20 $29,634.00 MALE SUBSCRIBER 1 BCC 3559 $207.19 $597.00 MALE SUBSCRIBER 1 BCC 3559 $38.34 $141.00 MALE SUBSCRIBER 1 BCC 3559 $1,665.75 $2,221.00 MALE SUBSCRIBER 1 BCC 3559 C.7.f (.56,`,201 (51,466.00) MALE SUBSCRIBER 1 BCC 3559 W U1 N Q! $0.00 ($4,371.00j MALE SUBSCRIBER 1 BCC 3559 4 t6 $0.00 150.011 MALE SUBSCRIBER 1 BCC 3559 W } fl $0.00 $1,466.00 MALE SUBSCRIBER 1 BCC 3559 ' CL CL Q $1,925.92 $4,371.00 MALE SUBSCRIBER 1 BCC 3559 F W E D $0.00 $0.01 MALE SUBSCRIBER 1 BCC 3559 _ $103.91 $150.00 MALE SUBSCRIBER 1 BCC 3559 $17,749.20 $29,634.00 MALE SUBSCRIBER 1 BCC 3559 $207.19 $597.00 MALE SUBSCRIBER 1 BCC 3559 $38.34 $141.00 MALE SUBSCRIBER 1 BCC 3559 $1,665.75 $2,221.00 MALE SUBSCRIBER 1 BCC 3559 8/17/2017 7/24/2017 8/16/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K219 GASTRO- ESOPHAGEAL PROFESSIONAL OFFICE $58.00 MALE SUBSCRIBER EVALUATION AND MANAGEMENT OF AN ESTABLISHED 3559 REFLUX DISEASE $118.00 MALE SUBSCRIBER 1 BCC PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $103.91 WITHOUT ESOPHAGITIS SUBSCRIBER 1 BCC 3559 COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 8/17/2017 8/9/2017 8/16/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K219 GASTRO- ESOPHAGEAL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED REFLUX DISEASE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY WITHOUT ESOPHAGITIS COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 8/23/2017 8/6/2017 812212017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT R51 HEADACHE PROFESSIONAL CONTRAST MATERIAL OUTPATIENT /HOSPITAL 8/23/2017 8/6/2017 812212017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R51 HEADACHE PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 8/23/2017 8/6/2017 8/22/2017 93880 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE R51 HEADACHE PROFESSIONAL BILATERAL STUDY OUTPATIENT /HOSPITAL 812312017 8/18/2017 812212017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 10/4/2017 8/6/2017 10/2/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R0789 OTHER CHEST PAIN PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 11/3/2017 10/27/2017 11/2/20173074F MOST REC ENT SYSTOLIC BLOOD PRESSURE LESS THAN 130110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE MM HG HDM� UHTN, CKD,CAD) HYPERTENSION 11/3/2017 1012712017 1112120173078F MOST REC ENT DIASTOLIC BLOOD PRESSURE LESS THAN 80110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE MM HG ADM) UHTN, CKD, CAD) HYPERTENSION 11/3/2017 1012712017 111212017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 11/3/2017 11/1/2017 111212017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER $103.91 $150.00 MALE SUBSCRIBER 1 BCC $103.91 $150.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' $73.20 $322.00 MALE SUBSCRIBER 1 BCC 3559 $15.65 $58.00 MALE SUBSCRIBER 1 BCC 3559 $52.92 $118.00 MALE SUBSCRIBER 1 BCC 3559 $103.91 $150.00 MALE SUBSCRIBER 1 BCC 3559 $10.15 $100.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $001 MALE SUBSCRIBER 1 BCC 3559 $0.00 $0.01 MALE SUBSCRIBER 1 BCC 3559 $103.91 $150.00 MALE SUBSCRIBER 1 BCC 3559 $103.91 $150.00 MALE SUBSCRIBER 1 BCC Em 111812017 3/5/2017 11/6/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FORTH E EVALUATION R42 DIZZINESSAND GIDDINESS PROFESSIONAL $337.50 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES SUBSCRIBER 1 BCC INPATIENT /HOSPITAL $700.00 MALE THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; 1 BCC A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 11/8/2017 3/6/2017 11/6/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R42 DIZZINESSAND GIDDINESS PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HDSPITAL REQUI RES AT LEAST 2 OF TH ESE 3 KEY COMPON ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 111812017 31712017 11/6/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R42 DIZZINESS AND GIDDINESS PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 11/8/2017 3/8/2017 11/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 16522 OCCLUSION AND PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH STENOSIS OF LEFT INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A CAROTID ARTERY DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 11/8/2017 3/9/2017 11/6/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 16522 OCCLUSION AND PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH STENOSIS OF LEFT INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS:A CAROTID ARTERY DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 111812017 3/10/2017 11/6/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE 16522 OCCLUSION AND PROFESSIONAL THAN 30 MINUTES STENOSIS OF LEFT INPATIENT/HOSPITAL CAROTID ARTERY 11/13/2017 10/30/2017 11/9/2017- - R079 CHEST PAIN, UNSPECIFIED HOSPITAL OUTPATIENT 11/15/2017 4/6/2017 11/14/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H53123 TRANSIENTVISUAL LOSS, PROFESSIONAL EVALUATION AND MANAGEMENT OF A NEW PATIENT, BILATERAL OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 11/17/2017 11/15/2017 11/16/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 169252 HEMIPLEGIAAND PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HEMIPARESIS FOLLOWING PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY OTHER NONTRAUMATIC COMPONENTS: A DETAILED HISTORY; A DETAILED INTRACRANIAL EXAMINATION; MEDICAL DECISION MAKING OF HEMORRHAGE AFFECTING MODERATE COMPLEXITY. COUNSELING AND /OR LEFT DOMINANT SIDE COORDINATION OF CARE WITH OTHER $188.01 $558.00 MALE SUBSCRIBER 1 BCC $6632 $197.00 MALE SUBSCRIBER 1 BCC $66.72 $197.00 MALE SUBSCRIBER 1 BCC $96.12 $286.00 MALE SUBSCRIBER 1 BCC $96.12 $286.00 MALE SUBSCRIBER 1 BCC $96.01 $292.00 MALE SUBSCRIBER 1 BCC $337.50 $450.00 MALE SUBSCRIBER 1 BCC $0.00 $700.00 MALE SUBSCRIBER 1 BCC $103.91 $150.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 ®' WE mm ®' 3559 3559 3559 WbS] 11/29/2017 11/20/2017 1112812017 93880 DUPLEX SCAN OF EXTRACRANIALARTERIES; COMPLETE 1672 CEREBRAL PROFESSIONAL 12/11/2017 EXAMINATION; MEDICAL DECISION MAKING OF BILATERALSTUDY 12/11/2017 ATHEROSCLEROSIS OUTPATIENT /HOSPITAL 12/1/2017 11/20/2017 11/29/2017- - 16529 OCCLU510NAND HOSPITAL OUTPATIENT 12/20/2017 EVALUATION AND MANAGEMENT OF AN ESTABLISHED 12/19/2017 THYROID NODULE STENOSIS OF UNSPECIFIED OTHER MEDICAL 3559 COMPONENTS: A DETAILED HISTORY; A DETAILED THYROID NODULE SUBSCRIBER CAROTID ARTERY PROFESSIONAL OFFICE 12/1/2017 11/29/2017 11/30/2017 992140FFI C E O R OTH E R OUTPATI E NT VI S IT FOR TH E E041 NONTOXIC 51 NO LE PROFESSIONAL OFFICE 12/8/2017 11/30/2017 12/6/2017 76536 ULTRASOUND, SOFTTISSUES OF HEAD AND NECK(EG, EVALUATION AND MANAGEMENT OF AN ESTABLISHED OTHER MEDICAL THYROID NODULE 12/11/2017 11/30/2017 12/7/2017 12/11 /2017 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY 121812017 12/11/2017 COMPONENTS: A DETAILED HISTORY; A DETAILED 12/8/2017 12/11/2017 EXAMINATION; MEDICAL DECISION MAKING OF 12/8/2017 12/11/2017 MODERATE COMPLEXITY. COUNSELING AND /OR 12/8/2017 12/14/2017 COORDINATION OF CARE WITH OTHER 1211212017 12/4/2017 12/14/2016 11/30/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE D126 12/20/2017 EVALUATION AND MANAGEMENT OF AN ESTABLISHED 12/19/2017 THYROID NODULE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY OTHER MEDICAL 3559 COMPONENTS: A DETAILED HISTORY; A DETAILED THYROID NODULE SUBSCRIBER EXAMINATION; MEDICAL DECISION MAKING OF PROFESSIONAL OFFICE $0.00 MODERATE COMPLEXITY. COUNSELING AND /OR SUBSCRIBER 1 BCC COORDINATION OF CARE WITH OTHER THYROID NODULE 12/8/2017 11/30/2017 12/6/2017 76536 ULTRASOUND, SOFTTISSUES OF HEAD AND NECK(EG, E041 OTHER MEDICAL THYROID, PARATHYROID, PAROTID), REALTIME WITH NONTOXIC SINGLE IMAGE DOCUMENTATION $0.00 12/8/2017 12/4/2017 12/7/20173074F MOST RECENT SYSTOLIC BLOOD PRESSURE LESSTHAN 130 E041 3559 MM HG (DM) )HTN, CKD,CAD) HYPERTENSION 12/8/2017 12/4/2017 12/7/2017 3078F MOST RECENT DIASTOLIC BLOOD PRESSURE LESS THAN 80 E041 NONTOXIC MM HE )DM) )HTN, CKD, CAD) NONTOXIC SINGLE 12/8/2017 12/4/2017 12/7/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E041 SUBSCRIBER EVALUATION AND MANAGEMENT OF AN ESTABLISHED 3559 THYROID NODULE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY DISORDERS OF THYROID COMPONENTS: A DETAILED HISTORY; A DETAILED QUANTITATIVE MEASUREMENT(S) )INCLUDING EXAMINATION; MEDICAL DECISION MAKING OF STIMULATION, SUPPRESSION, OR DISCHARGE, WHEN MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/11/2017 11/30/2017 12/7/2017 12/11 /2017 12/4/2017 121812017 12/11/2017 121412017 12/8/2017 12/11/2017 12/4/2017 12/8/2017 12/11/2017 12/4/2017 12/8/2017 12/14/2017 4/4/2017 1211212017 12/15/2017 12/6/2017 12113/2017 12/20/2017 12/7/2017 12/19/2017 $52.92 $118.00 MALE SUBSCRIBER $1,989.00 $2,652.00 MALE SUBSCRIBER C.7.f 1 BCC 3559 w Z 1 DEC 3559 N $103.91 $150.00 MALE SUBSCRIBER 1 BCC mm BENIGN NEOPLASM OF PROFESSIONAL OFFICE $95.18 $346.00 MALE SUBSCRIBER 1 BCC 3559 COLON, UNSPECIFIED 1 BCC 3559 CAROTID ARTERY $130.49 MALE 84436 THYROXINE; TOTAL E041 NONTOXICSINGLE PROFESSIONAL $47.40 $178.00 MALE SUBSCRIBER 1 BCC 3559 THYROID NODULE OUTPATIENT /HOSPITAL OTHER MEDICAL 3559 $8.95 THYROID NODULE SUBSCRIBER NONTOXIC SINGLE PROFESSIONAL OFFICE $0.00 $0.01 MALE SUBSCRIBER 1 BCC 3559 THYROID NODULE 84480 TRIIODOTHYRONINE TEL TOTAL ITT 3) E041 NONTOXIC SINGLE OTHER MEDICAL NONTOXIC SINGLE PROFESSIONAL OFFICE $0.00 $0.01 MALE SUBSCRIBER 1 BCC 3559 THYROID NODULE HYPERTENSION OUTPATIENT /HOSPITAL - E042 NONTOXIC HOSPITAL OUTPATIENT NONTOXIC SINGLE PROFESSIONAL OFFICE $103.91 $150.00 MALE SUBSCRIBER 1 BCC 3559 THYROID NODULE PERFORMED); WITH SINGLE OR MULTIPLE UPTAKE(S) DISORDERS OF THYROID OUTPATIENT /HOSPITAL QUANTITATIVE MEASUREMENT(S) )INCLUDING - 16522 OCCLUSION AND HOSPITAL OUTPATIENT 3559 $0.00 STENO515 OF LEFT SUBSCRIBER 1 BCC 3559 CAROTID ARTERY $130.49 MALE 84436 THYROXINE; TOTAL E041 NONTOXIC SINGLE OTHER MEDICAL $50.62 MALE SUBSCRIBER THYROID NODULE 3559 84443 THYROID STIMULATING HORMONE )TSH) E041 NONTOXIC SINGLE OTHER MEDICAL 3559 $8.95 THYROID NODULE SUBSCRIBER 84479 THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID E041 NONTOXIC SINGLE OTHER MEDICAL HORMONE BINDING RATIO (THEIR) 1 BCC THYROID NODULE $0.00 84480 TRIIODOTHYRONINE TEL TOTAL ITT 3) E041 NONTOXIC SINGLE OTHER MEDICAL THYROID NODULE 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 110 ESSENTIAL (PRIMARY) PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY HYPERTENSION OUTPATIENT /HOSPITAL - E042 NONTOXIC HOSPITAL OUTPATIENT MULTINODULAR GOITER 78014 THYROID IMAGING (INCLUDING VASCULAR FLOW, WHEN E0789 OTHER SPECIFIED PROFESSIONAL PERFORMED); WITH SINGLE OR MULTIPLE UPTAKE(S) DISORDERS OF THYROID OUTPATIENT /HOSPITAL QUANTITATIVE MEASUREMENT(S) )INCLUDING STIMULATION, SUPPRESSION, OR DISCHARGE, WHEN PERFORMED) $600.00 $800.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $49.49 MALE SUBSCRIBER 1 BCC 3559 $0.00 $130.49 MALE SUBSCRIBER 1 BCC 3559 $0.00 $50.62 MALE SUBSCRIBER 1 BCC 3559 $0.00 $129.36 MALE SUBSCRIBER 1 BCC 3559 $8.95 $28.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $2,961.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $168.00 MALE SUBSCRIBER 1 BCC 3559 rl 12/27/2017 121812017 12/6/2017 80053 COMP RE HE NSIVE METABOLIC PANEL THIS PANEL MUST E041 NONTOXIC SINGLE PROFESSIONAL 1 BCC $0.00 $33.00 MALE INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, 1 BCC THYROID NODULE OUTPATIENT /HOSPITAL SUBSCRIBER 1 BCC $0.00 TOTAL (82247), CALCIUM, TOTAL (82310), CARBON SUBSCRIBER 1 BCC $0.00 $17.00 MALE SUBSCRIBER 1 BCC DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), $284,130.14 $10117 $360.00 FEMALE DEPENDENT CREATININE( 82565), GLUCOSE (82947), PH0SPHATASE, $88.62 $150.00 FEMALE DEPENDENT 1050 ALKALINE (84075), POTASSIUM (84132), PROTEIN, 12/27/2017 12/8/2017 12/6/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR E041 NONTOXIC SINGLE PROFESSIONAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, THYROID NODULE OUTPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY 12/27/2017 12/8/2017 12/6/2017 83690 LIPASE E041 NONTOXIC SINGLE PROFESSIONAL THYROID NODULE OUTPATIENT /HOSPITAL 12/27/2017 12/8/2017 12/6/2017 84702 GONADOTROPIN, CHORIONIC(HCG); QUANTITATIVE E041 NONTOXIC SINGLE PROFESSIONAL THYROID NODULE OUTPATIENT /HOSPITAL 12/27/2017 121812017 12/6/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E041 NONTOXIC SINGLE PROFESSIONAL HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED THYROID NODULE OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 12/27/2017 12/8/2017 12/6/2017 86900 BLOOD TYPING, SERDLOGIC; ABO E041 NONTOXIC SINGLE PROFESSIONAL THYROID NODULE OUTPATIENT /HOSPITAL 12/27/2017 12/8/2017 12/6/2017 86901 BLOOD TYPING, SEROLOGIC; RH(D) E041 NONTOXIC SINGLE PROFESSIONAL THYROID NODULE OUTPATIENT /HOSPITAL Sub Total 5.75E +10 1/6/2017 12/8/2016 1/5/2017 * *' *" " * * "* * * * ** * * * ** " * * *" 1/13/2017 11/10/2016 1/12/2017 99381 INITIAL COMPREHENSIVE PREVENTIVE MEDICINE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION, COUNSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, NEW PATIENT; INFANT(AGEYOUNGER THAN l YEAR) 1/13/2017 11/28/2016 111212017 99213 OFFICE 0R OTHER OUTPATIENT VISIT FOR THE L0390 CELLULITIS, UNSPECIFIED PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 1/25/2017 11/1/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 CASTRO- ESOPHAGEAL OTHER MEDICAL REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/2/2016 1/23/2017 64035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL REFLUX DISEASE WITHOUT ESOPHAGITIS 112512017 11/3/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 CASTRO- ESOPHAGEAL OTHER MEDICAL REFLUX DISEASE WITHOUT ESOPHAGITIS $0.00 $30.00 MALE SUBSCRIBER 1 BCC $0.00 $15.00 MALE SUBSCRIBER 1 BCC $0.00 $15.00 MALE SUBSCRIBER 1 BCC $0.00 $33.00 MALE SUBSCRIBER 1 BCC $0.00 $16.25 MALE SUBSCRIBER 1 BCC $0.00 $17.00 MALE SUBSCRIBER 1 BCC $0.00 $17.00 MALE SUBSCRIBER 1 BCC $148,601.94 $284,130.14 $10117 $360.00 FEMALE DEPENDENT 1050 $88.62 $150.00 FEMALE DEPENDENT 1050 $63.86 $125.00 FEMALE DEPENDENT 1050 $0.00 $161.20 FEMALE DEPENDENT 1050 $0.00 $5.20 FEMALE DEPENDENT 1050 $0.00 $5.20 FEMALE DEPENDENT 1 EGO C.7.f 3559 mm 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 1/25/2017 11/4/2016 1/23/2017 B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/5/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/6/2016 1/23/2017 B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 OSO REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/7/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 OSO REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/8/2016 112312017 B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/9/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 OSO REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/10/2016 1/23/2017 B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/11/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/12/2016 1/23/2017 B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 OSO REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11113/2016 1/23/2017 B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 O5O REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/14/2016 112312017 B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/15/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/16/2016 1/23/2017 B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 OSO REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/17/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 OSO REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/18/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO-ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 O5O REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/19/2016 1/23/2017 B4035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/20/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/21/2016 1/23/2017 B4035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 OSO REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/22/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/23/2016 112312017 B4035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/24/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/25/2016 1/23/2017 B4035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/26/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/27/2016 1/23/2017 B4035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 OSO REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11128/2016 1/23/2017 B4035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/29/2016 112312017 B4035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/25/2017 11/30/2016 1/23/2017 84035 ENTERAL FEEDING SUPPLY KIT, PUMP FED PER DAY K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $5.20 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/30/2017 1/8/2017 1/1012017 E0618 APNEA MONITOR, WITHOUT RECORDING FEATURE K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $179.79 FEMALE DEPENDENT 1 OSO REFLUX DISEASE WITHOUT ESOPHAGITIS 1/30/2017 1/8/2017 1/10/201789002 ENTERAL NUTRITION INFUSION PUMP- WITHALARM K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $0.00 $76.44 FEMALE DEPENDENT 1050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/30/2017 1/8/2017 111012017 E0776 IV POLE K219 GASTRO-ESOPHAGEAL OTHER MEDICAL $0.00 $12.97 FEMALE DEPENDENT 1 050 REFLUX DISEASE WITHOUT ESOPHAGITIS 1/30/2017 1/8/2017 111012017 E0600 RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $200.00 FEMALE DEPENDENT 1050 1050 OR STATIONARY, ELECTRIC $467.00 REFLUX DISEASE DEPENDENT 1050 $76.07 $569.00 FEMALE DEPENDENT WITHOUT ESOPHAGITIS $227.81 1/30/2017 1/11/2017 1/18/2017 - - K9423 GASTROSTOMY HOSPITAL OUTPATIENT MALFUNCTION 1/30/2017 1/11/2017 1/26/2017 99202 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Q750 CRANIOSYNOSTOSIS PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WITH 0 1/30/2017 1/18/2017 1/20/2017 93000 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 Q211 ATRIAL SEPTAL DEFECT PR0FE55IONAL OFFICE LEADS; WITH INTERPRETATION AND REPORT 1130/2017 1/18/2017 1/20/2017 93303 TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE CARDIAC ANOMALIES; COMPLETE 1/30/2017 1/18/2017 1/20/2017 93320 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND /OR Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); COMPLETE 1/30/2017 1/18/2017 1/20/2017 93325 DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE MAPPING (UST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHY) 1/30/2017 1/18/2017 1/20/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 1/30/2017 1/18/2017 1/21/2017 43760 CHANGE OF GASTROSTOMY TUBE, PERCUTANEOUS, K9423 GASTROSTOMY PROFESSIONAL WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE MALFUNCTION OUTPATIENT /HOSPITAL 1130/2017 1/18/2017 1/25/2017 - - Z431 ENCOUNTER FOR HOSPITAL OUTPATIENT ATTENTION TO GASTROSTOMY 2/3/2017 12/21/2016 21212017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE P9163 SEVERE HYPDXIC PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED ISCHEMIC PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY ENCEPHALOPATHY[HIE] COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 21712017 12/8/2016 2/6/2017 - - Q02 MICROCEPHALY HOSPITAL OUTPATIENT 2/13/2017 2/8/2017 2/9/2017 B9002 ENTERAL NUTRITION INFUSION PUMP- WITHALARM K219 GASTRO- ESOPHAGEAL OTHER MEDICAL REFLUX DISEASE WITHOUT ESOPHAGITIS 2/13/2017 2/8/2017 2/9/2017 E0776 IV POLE K219 GASTRO- ESOPHAGEAL OTHER MEDICAL REFLUX DISEASE WITHOUT ESOPHAGITIS 2/13/2017 21812017 2/9/2017 E0618 APNEA MONITOR, WITHOUT RECORDING FEATURE K219 GASTRO- ESOPHAGEAL OTHER MEDICAL REFLUX DISEASE WITHOUT ESOPHAGITIS $0.00 $34.55 FEMALE DEPENDENT 1050 $28.02 $594.00 FEMALE DEPENDENT 1050 $56.34 $200.00 FEMALE DEPENDENT 1050 $33.32 $122.00 FEMALE DEPENDENT 1050 $385.27 $1,487.00 FEMALE DEPENDENT 1050 $127.31 $467.00 FEMALE DEPENDENT 1050 $76.07 $569.00 FEMALE DEPENDENT 1050 $227.81 $544.00 FEMALE DEPENDENT 1050 $81.08 $1,505.00 FEMALE DEPENDENT 1050 $477.99 $1,284.00 FEMALE DEPENDENT 1050 $211.72 $345.00 FEMALE DEPENDENT 1050 $1,255.60 $1,720.00 FEMALE DEPENDENT 1050 $57.33 $76.44 FEMALE DEPENDENT 1050 $933 $12.97 FEMALE DEPENDENT 1050 $134.84 $179.79 FEMALE DEPENDENT 1050 C.7.f 3559 w U1 N 3559 tU 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 WE E 2/17/2017 2/8/2017 2/9/2017 EO6O0 RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE K219 GASTRO- ESOPHAGEAL OTHER MEDICAL $933 OR STATIONARY, ELECTRIC FEMALE REFLUX DISEASE 1050 $23.82 $35.00 FEMALE WITHOUT ESOPHAGITIS 1050 2/24/2017 12/7/2016 2/23/2017 49465 CONTRAST INJECLIDN(S) FOR RADIOLOGICAL EVALUATION K9423 GASTROSTOMY PROFESSIONAL OF EXISTING GASTROSTOMY, DUODENOSTOMY, MALFUNCTION OUTPATIENT /HOSPITAL JEJUNOSTOMY, GASTRO- JEJUNDSTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, FROM A PERCUTANEDUS APPROACH INCLUDING IMAGE DOCUMENTATION AND REPORT 3/13/2017 2/9/2017 2/16/2017 - - Z931 GASTROSTOMY STATUS HOSPITAL OUTPATIENT 3/13/2017 3/8/2017 3/9/2017 EO776 IV POLE K219 CASTRO- ESOPHAGEAL OTHER MEDICAL REFLUX DISEASE WITHOUT ESOPHAGITIS 3117/2017 1/4/2017 3/15/2017 90460 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS ZOO129 ENCOUNTER FOR PROFESSIONAL OFFICE OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH EXAMINATION WITHOUT CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF ABNORMAL FINDINGS EACH VACCINE OR TOXOID ADMINISTERED 3/17/2017 1/4/2017 3/15/2017 9O461 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS ZOO129 ENCOUNTER FOR PROFESSIONAL OFFICE OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH EXAMINATION WITHOUT CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR ABNORMAL FINDINGS TOXCID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 3/17/2017 1/4/2017 3/15/2017 9O472 IMMUNIZATION ADMINISTRATION (INCLUDES ZOO129 ENCOUNTER FOR PROFESSIONAL OFFICE PERCUTANEDUS, INTRADERMAL, SUBCUTANEOUS, OR ROUTINE CHILD HEALTH INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL EXAMINATION WITHOUT VACCINE (SINGLE OR COMBINATION VACCINE /TOXOID) ABNORMAL FINDINGS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 3/17/2017 1/4/2017 3/15/2017 90670 PNEUCOCOCCAL CONJUGATE VACCINE, 13 VALENT, FOR ZOO129 ENCOUNTER FOR PROFESSIONAL OFFICE INTRAMUSCULAR USE ROUTINE CHILD HEALTH EXAMINATION WITHOUT ABNORMAL FINDINGS 3/17/2017 1/4/2017 3/15/2017 90698 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS ZOO129 ENCOUNTER FOR PROFESSIONAL OFFICE VACCINE, HAEMOPHILUS INFLUENZA TYPE B, AND ROUTINE CHILD HEALTH POLIOVIRUSVACCINE, INACTIVATED (DTAP- HIB -IPV), EXAMINATION WITHOUT FOR INTRAMUSCULAR USE ABNORMAL FINDINGS 3/17/2017 1/4/2017 3/15/2017 90744 HEPATITIS B VACCINE, PEDIATRIC /ADOLESCENT DOSAGE ZOO129 ENCOUNTER FOR PROFESSIONAL OFFICE (3 DOSE SCHEDULE), FOR INTRAMUSCULAR USE ROUTINE CHILD HEALTH EXAMINATION WITHOUT ABNORMAL FINDINGS 3/17/2017 1/4/2017 3115/2017 99391 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE ZOO129 ENCOUNTER FOR PROFESSIONAL OFFICE REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION, CCU NSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; INFANT (AGE (OUNGERTHAN 1YEAR) $25.90 $34.55 FEMALE DEPENDENT 1050 $303.61 $520.00 FEMALE DEPENDENT 1050 $223.95 $820.00 FEMALE DEPENDENT 1050 $933 $12.97 FEMALE DEPENDENT 1050 $23.82 $35.00 FEMALE DEPENDENT 1050 $12.07 $35.00 FEMALE DEPENDENT 1050 $10.73 $35.00 FEMALE DEPENDENT 1050 $175.00 $195.95 FEMALE DEPENDENT 1050 $94.00 $115.95 FEMALE DEPENDENT 1050 $20.00 $75.35 FEMALE DEPENDENT 1050 $74.48 $150.00 FEMALE DEPENDENT 1050 C.7.f 3559 w O1 N 3559 3559 3559 3559 "M 3559 3559 3559 3559 3559 R 3/17/2017 3/2/2017 3/14/2017 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT G9389 OTHER SPECIFIED PROFESSIONAL $76.44 FEMALE DEPENDENT 1050 $134.84 CONTRAST MATERIAL 1050 DISORDERS OF BRAIN OUTPATIENT /HOSPITAL 3/17/2017 3/8/2017 3/9/2017 E0600 RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE K219 CASTRO- ESOPHAGEAL OTHER MEDICAL $24.01 $360.00 FEMALE DEPENDENT 1050 OR STATIONARY, ELECTRIC $200.00 FEMALE DEPENDENT REFLUX DISEASE WITHOUT ESOPHAGITIS 3/17/2017 3/8/2017 3/9/201789002 ENTERAL NUTRITION INFUSION PUMP- WITHALARM K219 GASTRO- ESOPHAGEAL OTHER MEDICAL REFLUX DISEASE WITHOUT ESOPHAGITIS 3/17/2017 3/8/2017 3/9/2017 E0618 APNEA MONITOR, WITHOUT RECORDING FEATURE K219 CASTRO- ESOPHAGEAL OTHER MEDICAL REFLUX DISEASE WITHOUT ESOPHAGITIS 3/17/2017 3/13/2017 3/14/2017 92012 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H4903 THIRD[OCULOMOTORI PROFESSIONAL OFFICE AND EVALUATION, WITH INITIATION OR CONTINUATION NERVE PALSY, BILATERAL OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT 3/17/2017 3/13/2017 3/16/2017 k}b 3/20/2017 3/2/2017 3/10/2017 - - Q02 MICROCEPHALY HOSPITAL OUTPATIENT 3/29/2017 3/2/2017 3/28/2017 95930 VISUAL EVOKED POTENTIALLVEP) TESTING CENTRAL Q750 CRANIOSYNOSTOSIS PROFESSIONAL NERVOUS SYSTEM, CHECKERBOARD OR FLASH OUTPATIENT/HOSPITAL 41712017 4/3/2017 4/5/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K210 GASTRO- ESOPHAGEAL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED REFLUX DISEASE WITH PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY ESOPHAGITIS COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/10/2017 3/27/2017 4/8/2017 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Q750 CRANIOSYNOSTOSIS PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING, COUNSELING AND /OR COORDINATION OF CARE WIT 4/10/2017 4/3/2017 4/8/2017 k}b * * * ** * " * ** * * * ** * * * ** 4/12/2017 4/8/2017 4/11/2017 E0600 RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE K219 GASTRO- ESOPHAGEAL OTHER MEDICAL OR STATIONARY, ELECTRIC REFLUX DISEASE WITHOUT ESOPHAGITIS 4/17/2017 4/4/2017 4/13/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E232 DIABETES INSIPIDUS PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 4/20/2017 4/14/2017 4/19/2017 99282 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R0981 NASAL CONGESTION OTHER MEDICAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER $61.53 $371.00 FEMALE DEPENDENT 1050 $25.90 $34.55 FEMALE DEPENDENT 1050 $57.33 $76.44 FEMALE DEPENDENT 1050 $134.84 $179.79 FEMALE DEPENDENT 1050 $118.46 $250.00 FEMALE DEPENDENT 1050 $162.62 $360.00 FEMALE DEPENDENT 1 OSD $715.35 $1,306.58 FEMALE DEPENDENT 1050 $24.01 $360.00 FEMALE DEPENDENT 1050 $148.73 $200.00 FEMALE DEPENDENT 1050 $22.13 $117.00 FEMALE DEPENDENT 1050 $162.62 $360.00 FEMALE DEPENDENT 1050 $25.90 $34.55 FEMALE DEPENDENT 1050 $186.72 $348.00 FEMALE DEPENDENT 1050 $61.18 $140.00 FEMALE DEPENDENT 1050 C.7.f 3559 w Z 3559 N 3559 3559 3559 I III I@ KibSl III rl C.7.f 4/24/2017 4/14/2017 412112017- - R0981 NASAL CONGESTION HOSPITAL OUTPATIENT $562.50 $1,050.00 FEMALE DEPENDENT 1050 3559 4/25/2017 3/13/2017 4/24/2017 90460 IMMUNIZATION ADMINISTRATION THROUGH 18YEARS Z00129 ENCOUNTERFOR PROFESSIONAL OFFICE $23.82 $35.00 FEMALE DEPENDENT IOSO w 3559 C! OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH N COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH EXAMINATION WITHOUT CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF ABNORMAL FINDINGS EACH VACCINE DR TOXOID ADMINISTERED 4/25/2017 3/13/2017 4/24/2017 90461 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $12.07 $35.00 FEMALE DEPENDENT 1050 3559 7 OFAGEVIAANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH EXAMINATION WITHOUT CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR ABNORMAL FINDINGS TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) } fl C. CL 4/25/2017 3/13/2017 4/24/2017 90472 IMMUNIZATION ADMINISTRATION (INCLUDES 200129 ENCOUNTER FOR PROFESSIONAL OFFICE $10.73 $35.00 FEMALE DEPENDENT 1050 3559 Q, PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR ROUTINE CHILD HEALTH INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL EXAMINATION WITHOUT VACCINE (SINGLE OR COMBINATION VACCINE / TOXOID) ABNORMAL FINDINGS )LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 4/25/2017 3/13/2017 4/24/2017 90670 PNEUCOCOCCAL CONJUGATE VACCINE, 13 VALENT, FOR Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $186.00 $195.95 FEMALE DEPENDENT 1 OSO 3559 INTRAMUSCULAR USE ROUTINE CHILD HEALTH uj EXAMINATION WITHOUT ABNORMAL FINDINGS 4/25/2017 3/13/2017 4/24/2017 90698 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $97.00 $115.95 FEMALE DEPENDENT 1050 3559 VACCINE, HAEMOPHILUS INFLUENZATYPE B, AND ROUTINE CHILD HEALTH POLIOVIRUS VACCINE, INACTIVATED )DTAP- HIB -IPV), EXAMINATION WITHOUT FOR INTRAMUSCULAR USE ABNORMAL FINDINGS IL 4/25/2017 3/13/2017 4124/2017 99391 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $74.48 $150.00 FEMALE DEPENDENT 1050 3559 {i REEVALUATION AND MANAGEMENTOF AN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGEAND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT U`J EXAMINATION, CCU NSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, 0 ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; INFANT (AGE rW YOUNGERTHAN 1YEAR) 5/10/2017 518/2017 5/9/2017 E0600 RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE K219 CASTRO- ESOPHAGEAL OTHER MEDICAL $25.90 $34.55 FEMALE DEPENDENT 1 OSO 3559 OR STATIONARY, ELECTRIC REFLUX DISEASE WITHOUT ESOPHAGITIS v 5/11/2017 5/2/2017 5/10/2017 74230 SWALLOWING FUNCTION, WITH T17800A UNSPECIFIED FOREIGN OTHER MEDICAL $0.00 $405.00 FEMALE DEPENDENT IOSO 3559 CINERADIOGRAPHY /VIDEORADIOGRAPHY BODY IN OTHER PARTS OF LLJ RESPIRATORY TRACT CAUSING ASPHYXIATION, INITIAL ENCOUNTER (' 5/18/2017 5/2/2017 5/16/2017 * * * ** * * * ** *• * ** * * * ** * * * ** $354.00 $1,075.00 FEMALE DEPENDENT 1 050 3559 5/22/2017 5/8/2017 5119/2017 99254 INPATIENT CONSULTATION FOR ANEW OR ESTABLISHED G9349 OTHER ENCEPHALOPATHY PROFESSIONAL $219.70 $710.00 FEMALE DEPENDENT 1050 3559 < PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF Cy MODERATE COMPLEXITY. COUNSELING AND /OR = COORDINATION OF CARE WITH OTHER PROVIDERS OR y AGENCIES ARE PROVIDED C 5/22/2017 5/9/2017 5/19/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE G9349 OTHER ENCEPHALOPATHY PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 5/22/2017 5/11/2017 5/19/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE G9349 OTHER ENCEPHALOPATHY PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT / HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 5/30/2017 5/1/2017 5/29/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE RO5 COUGH PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 5/30/2017 5/5/2017 5/26/2017 70360 RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE 1352 HYPERTROPHY OF PROFESSIONAL ADENOIDS OUTPATIENT /HOSPITAL 5/30/2017 5/5/2017 5/26/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 1069 ACUTE UPPER PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES RESPIRATORY INFECTION, INPATIENT /HOSPITAL THESE KEY COMPONENTS A COMPREHENSIVE HISTORY; UNSPECIFIED A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 5/30/2017 5/5/2017 5/26/2017 31575 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC RO683 SNORING PROFESSIONAL INPATIENT /HOSPITAL 5/30/2017 5/5/2017 5/26/2017 99253 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED 80683 SNORING PROFESSIONAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT /HOSPITAL DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH 5/30/2017 5/5/2017 5/26/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, Z452 ENCOUNTER FOR PROFESSIONAL FRONTAL AND LATERAL; ADJUSTMENT AND OUTPATIENT /HOSPITAL MANAGEMENT OF VASCULAR ACCESS DEVICE 5/30/2017 5/6/2017 5/26/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, RO5 COUGH OTHER MEDICAL FRONTAL 5/30/2017 5/8/2017 5/26/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E87O HYPEROSMOLALITY AND PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HYPERNATREMIA INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $95.71 $265.00 FEMALE DEPENDENT 1050 $9531 $265.00 FEMALE DEPENDENT 1050 $63.86 $125.00 FEMALE DEPENDENT 1050 $12.11 $90.00 FEMALE DEPENDENT 1050 $117.69 $455.00 FEMALE DEPENDENT 1050 $123.87 $376.00 FEMALE DEPENDENT 1050 $189.89 $400.00 FEMALE DEPENDENT 1050 $15.44 $90.00 FEMALE DEPENDENT 1050 $1107 $74.00 FEMALE DEPENDENT 1050 $16035 $343.00 FEMALE DEPENDENT 1050 C.7.f 3559 ®' WE 3559 3559 I M ®' 5/30/2017 5/8/2017 5/26/2017 71010 RADIOLOGIC EXAM I NATION, CHEST; SINGLE VIEW, Z4682 ENCOUNTER FOR FITTING PROFESSIONAL $13.07 $74.00 FEMALE DEPENDENT 1050 FRONTAL ANDADIUSTMENTOF INPATIENT /HOSPITAL NON - VASCULAR CATHETER 5/30/2017 5/8/2017 5/26/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITHATLEAST12 R001 BRADYCARDIA, OTHER MEDICAL $0.00 $28.00 FEMALE DEPENDENT 1050 LEADS; INTERPRETATION AND REPORT ONLY UNSPECIFIED 5/30/2017 5/9/2017 5/26/2017 76770 ULTRASOUND, RETROPERITONEAL(EG, RENAL, AORTA, N390 URINARY TRACT PROFESSIONAL $52.73 $363.00 FEMALE DEPENDENT 1 OSO NODES), REALTIME WITH IMAGE DOCUMENTATION; INFECTION, SITE NOT INPATIENT /HDSPITAL COMPLETE SPECIFIED 5/30/2017 5/9/2017 5/26/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E970 HYPEROSMOLALITY AND PROFESSIONAL $62.32 $130.00 FEMALE DEPENDENT 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HYPERNATREMIA INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 5/30/2017 5/9/2017 5/26/2017 74000 RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE Z4682 ENCOUNTER FOR FITTING PROFESSIONAL $13.07 $77.00 FEMALE DEPENDENT 1050 ANTEROPOSTERIOR VIEW ANDADIUSTMENTOF INPATIENT /HOSPITAL NON - VASCUTAR CATHETER 5/30/2017 5/10/2017 5/26/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E870 HYPEROSMOLALITYAND PROFESSIONAL $62.32 $130.00 FEMALE DEPENDENT 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH HYPERNATREMIA INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 5/30/2017 5/10/2017 5/26/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E232 DIABETES INSIPIDUS PROFESSIONAL $111.31 $236.00 FEMALE DEPENDENT 1050 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 5/30/2017 5/13/2017 5/26/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E232 DIABETES INSIPIDUS PROFESSIONAL $111.31 $236.00 FEMALE DEPENDENT 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 5/30/2017 5/16/2017 5/26/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, Z4682 ENCOUNTER FOR FITTING PROFESSIONAL $13.07 $74.00 FEMALE DEPENDENT 1050 FRONTAL ANDADIUSTMENTOF INPATIENT /HDSPITAL NON - VASCULAR CATHETER 5/30/2017 5/18/2017 5/26/2017 74000 RADIOLOGIC EXAM I NATION, A PROVEN, SINGLE Z4682 ENCOUNTER FOR FITTING PROFESSIONAL $39.21 $231.00 FEMALE DEPENDENT 1050 ANTEROPOSTERIOR VIEW ANDADIUSTMENTOF INPATIENT /HOSPITAL NON - VASCULAR CATHETER 5/30/2017 5/21/2017 5/26/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 8341 ENTEROVIRUS INFECTION, PROFESSIONAL $61.16 $236,00 FEMALE DEPENDENT 1050 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR C.7.f 5/30/2017 5/22/2017 5/26/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE 1069 ACUTE UPPER PROFESSIONAL $90.70 $351.00 FEMALE DEPENDENT 1050 3559 THAN 3D MINUTES RESPIRATORY INFECTION, INPATIENT /HDSPITAL UNSPECIFIED N 6/1/2017 5/5/2017 5/26/2017 - - E232 DIABETES INSIPIDUS HOSPITAL INPATIENT 5/5/2017 # #H # # # ## $177,299.49 $247,664.57 FEMALE DEPENDENT 1 050 3559 6/1/2017 5/6/2017 5/31/2017 99471 INITIAL INPATIENT PEDIATRIC CRITICAL CARE, PER DAY, 19601 ACUTE RESPIRATORY PROFESSIONAL $1,203.41 $2,200.00 FEMALE DEPENDENT 1050 3559 FORTHE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT /HOSPITAL CRITICALLY ILL INFANT DR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE } 6/1/2017 5/7/2017 5131/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $570.57 $1,100.00 FEMALE DEPENDENT 1050 3559 DAY, FOR THE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE W } 6/1/2017 5/8/2017 5/31/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $570.57 $1,100.00 FEMALE DEPENDENT 1050 3559 DAY, FOR THE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT /HOSPITAL B. CL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS Q, THROUGH 24 MONTHS OF AGE 6/1/2017 5/9/2017 5/31/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $570.57 $1,100.00 FEMALE DEPENDENT 1050 3559 DAY, FOR THE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT/HOSPITAL rf CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE F LL! 6/1/2017 5/10/2017 5/31/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $570.57 $1,100.00 FEMALE DEPENDENT 1050 3559 F DAY, FORTHE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE _ F 6/1/2017 5/11/2017 5/31/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $57037 $1,100.00 FEMALE DEPENDENT 1050 3559 DAY, FORTHE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS Q THROUGH 24 MONTHS OF AGE uj 6/1/2017 5/12/2017 5/31/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $570.57 $1,100.00 FEMALE DEPENDENT 1050 3559 UJ DAY, FOR THE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE LLJ 6/1/2017 5/13/2017 5/31/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $570.57 $1,100.00 FEMALE DEPENDENT 1050 3559 DAY, FOR THE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT /HOSPITAL �q CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS J THROUGH 24 MONTHS OF AGE v 6/1/2017 5/14/2017 5/31/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $570.57 $1,100.00 FEMALE DEPENDENT 1050 3559 F DAY, FOR THE EVALUATION AND MANAGEMENT OF A FAILUREWITH HYPDXIA INPATIENT/HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS LLJ THROUGH 24 MONTHS OF AGE 6/1/2017 5/15/2017 5/31/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $57037 $1,100.00 FEMALE DEPENDENT 1050 3559 (' DAY, FOR THE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE N 6/1/2017 5/16/2017 5/31/2017 99472 SU BS EQU E NT I N FALL ENT P E D IATRIC CR ITT CAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $57037 $1,100.00 FEMALE DEPENDENT 1050 3559 N DAY, FORTHE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS = THROUGH 24 MONTHS OF AGE C.7.f 6/1/2017 5/17/2017 5/31/2017 99472 SUBS EQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $570.57 $1,100.00 FEMALE DEPENDENT 1050 3559 DAY, FOR THE EVALUATION AND MANAGEMENT OF A FAILUREWITH HYPDXIA INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS {U THROUGH 24 MONTHS OF AGE U) 6/1/2017 5/18/2017 5/31/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $570.57 $1,100.00 FEMALE DEPENDENT 1050 3559 DAY, FORTHE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE r 6/1/2017 5/19/2017 5/31/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER 19601 ACUTE RESPIRATORY PROFESSIONAL $57037 $1,100.00 FEMALE DEPENDENT 1050 3559 DAY, FORTHE EVALUATION AND MANAGEMENT OF A FAILURE WITH HYPDXIA INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE } fl 6/1/2017 5120/2017 5/31/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 19601 ACUTE RESPIRATORY PROFESSIONAL $143.36 $300.00 FEMALE DEPENDENT 1050 3559 CL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH FAILURE WITH HYPDXIA INPATIENT /HOSPITAL Q, REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PC ENTS: A v DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI F 6/12/2017 5/5/2017 6/8/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $48.00 FEMALE DEPENDENT 1050 3559 LIJ MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL INPATIENT /HOSPITAL ~ (823101 CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) _ 6/12/2017 5/5/2017 6/8/2017 82330 CALCIUM; IONIZED E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $22.00 FEMALE DEPENDENT 1 ESE) 3559 INPATIENT /HOSPITAL 6/12/2017 5/5/2017 6/8/2017 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, P02, E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $48.00 FEMALE DEPENDENT 1 050 3559 Q C0E, HCO3 (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL ui WITH 02 SATURATION, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIMETRY UJ 6/12/2017 5/5/2017 6/8/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1050 3559 STRIP) INPATIENT /HOSPITAL 0 6112/2017 5/5/2017 6/8/2017 84132 POTASSIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL W 6/12/2017 5/5/2017 6/8/2017 84295 SODIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $22.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL Q . 6/12/2017 515/2017 6/8/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1050 3559 J EXAMINATION WITH MANUAL DIFFERENTIAL W BC COUNT INPATIENT /HOSPITAL v 6/12/2017 5/5/2017 6/5/2017 85014 BLOOD COUNT; HEMATOCRIT (HCT) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $38.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 5/5/2017 6/8/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E232 DIABETES INSIPIDUS PROFE55IONAL $0.00 $11.00 FEMALE DEPENDENT 1050 3559 LLJ HCT, DEC, W BC AND PLATELET COUNT) INPATIENT /HOSPITAL 6/12/2017 5/5/2017 6/8/2017 87486 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $20.00 FEMALE DEPENDENT 1050 3559 RNA); CHLAMYDIA PNEUMONIAE, AMPLIFIED PROBE INPATIENT /HOSPITAL 0 TECHNIQUE 6/12/2017 5/5/2017 6/8/2017 87502 INFECT IOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1050 3559 RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB- INPATIENT /HOSPITAL Q TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, FIRST2 TYPES OR SUB -TYPES cq Cy C.7.f 6/12/2017 5/5/2017 6/8/2017 87503 INFECTIOUS AGENT DETECTION BY NUCLEIC AC I D(DNA OR E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $75.00 FEMALE DEPENDENT 1050 3559 RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB- INPATIENT /HOSPITAL TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION AND MULTIPLEX AMPLIFIED PROBE TECHNIQUE, EACH ADDITIONAL INFLUENZA VIRUS TYPE OR SUB -TYPE BEYOND 2 )LIST S 6/12/2017 5/5/2017 6/8/2017 87581 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA Oft E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1050 3559 RNA I; MYCOPLASMA PNEUMONIAE, AMPLIFIED PROBE INPATIENT /HDSPITAL TECHNIQUE 6/12/2017 5/5/2017 6/8/2017 87798 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $325.00 FEMALE DEPENDENT 1050 3559 RNA), NOT OTHERWISE SPECIFIED; AMPLIFIED PROBE INPATIENT /HOSPITAL TECHNIQUE, EACH ORGANISM 6/12/2017 5/6/2017 6/8/2017 82533 CORTISOL; TOTAL E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $28.00 FEMALE DEPENDENT 1 050 3559 INPATIENT /HOSPITAL 6/12/2017 516/2017 6/8/2017 84295 SODIUM; SERUM, PIASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $22.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 516/2017 6/8/2017 84300 SODIUM; URINE E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1 OSO 3559 INPATIENT /HOSPITAL 6/12/2017 5/6/2017 6/8/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HGB, E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1050 3559 HCT, BBC, W BC AND PLATELET COUNT) INPATIENT /HOSPITAL 6/12/2017 5/6/2017 6/8/2017 86140 C- REACTIVE PROTEIN; E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $24.00 FEMALE DEPENDENT 1 050 3559 INPATIENT /HOSPITAL 6/12/2017 5/6/2017 6/8/2017 87186 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $32.00 FEMALE DEPENDENT 1050 3559 MICRODILUTION OR AGAR DILUTION (MINIMUM INPATIENT /HOSPITAL INHIBITORY CONCENTRATION AMICA" OR BREAKPOINT), EACH MULTI - ANTIMICROBIAL, PER PLATE 6/12/2017 5/6/2017 6/8/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $57.00 FEMALE DEPENDENT 1050 3559 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 6/12/2017 5/6/2017 6/8/2017 82330 CALCIUM; IONIZED E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $110.00 FEMALE DEPENDENT 1 050 3559 INPATIENT /HOSPITAL 6/12/2017 5/6/2017 6/8/2017 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, P02, E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $288.00 FEMALE DEPENDENT 1 050 3559 C0P, HCO3 (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL WITH 02 SATURATION, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIMET D 6/12/2017 5/6/2017 6/8/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $55.00 FEMALE DEPENDENT 1050 3559 STRIP) INPATIENT/HOSPITAL 6/12/2017 5/6/2017 6/8/2017 83605 LACTATE)LACTICACID) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $22.00 FEMALE DEPENDENT 1050 3559 INPATIENT/HOSPITAL 6/12/2017 5/6/2017 6/8/2017 8393005MOLALITY; BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 5/6/2017 6/8/2017 839350SMOLALITY; URINE E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 5/6/2017 6/8/2017 84132 POTASSIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $55.00 FEMALE DEPENDENT 1050 3559 INPATIENT/HOSPITAL 6/12/2017 5/6/2017 6/8/2017 84295 SODIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $55.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HDSPITAL 6/12/2017 5/6/2017 6/8/2017 84439 THYROXINE; FREE E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1 050 3559 INPATIENT /HOSPITAL 6/12/2017 5/6/2017 6/8/2017 84443 THYROID STIMULATING HORMONE)TSH) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $35.00 FEMALE DEPENDENT 1 OSO 3559 INPATIENT /HOSPITAL 6/12/2017 5/6/2017 6/8/2017 95007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC E232 DIABETES INSIPIDUS PROFESSIONAL $0DD $11.00 FEMALE DEPENDENT 1050 3559 EXAMINATION WITH MANUAL DIFFERENTIAL W BC COUNT INPATIENT /HOSPITAL 6/12/2017 5/6/2017 6/8/2017 85014 BL00D COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $190.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL C.7.f 6/12/2017 5/6/2017 6/8/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $31.00 FEMALE DEPENDENT 1050 3559 AND PRESUMPTIVE IDENTIFICATION OF ISOLATES INPATIENT /HOSPITAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) Z N 6/12/2017 5/6/2017 6/8/2017 87077 CULTURE, BACTERIAL; AEROBIC ISDIATE, ADDITIONAL E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $13.00 FEMALE DEPENDENT 1050 3559 METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, INPATIENT /HOSPITAL EACH ISOLATE 6/12/2017 5/6/2017 6/8/2017 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $19.00 FEMALE DEPENDENT 1050 3559 URINE INPATIENT /HDSPITAL } 6/12/2017 5/7/2017 6/8/2017 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $240.00 FEMALE DEPENDENT 1 050 3559 "a COE, HCO3 (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL WITH 02 SATURATION, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIMETRY 6/12/2017 5/7/2017 6/8/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $55.00 FEMALE DEPENDENT 1050 3559 } STRIP) INPATIENT /HOSPITAL 6/12/2017 5/7/2017 6/8/2017 84132 POTASSIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $55.00 FEMALE DEPENDENT 1050 3559 N. CL INPATIENT /HOSPITAL CL 6112/2017 5/7/2017 6/8/2017 84295 SODIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $55.00 FEMALE DEPENDENT 1050 3559 Q INPATIENT /HOSPITAL v 6/12/2017 5/7 /2017 6/8/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $95.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 5/]/201] 6/8/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $38.00 FEMALE DEPENDENT 1050 3559 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, uj UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; 6/12/2017 5/7 /2017 6/8/2017 AUTOMATED, WITH MICROSCOPY 82330 CALCIUM; IONIZED E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $110.00 FEMALE DEPENDENT 1 OSO 3559 INPATIENT /HOSPITAL 6/12/2017 51712017 6/8/2017 84295 SODIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $22.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 5/7/2017 6/8/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $95.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HDSPITAL IL 6/12/2017 5/8/2017 6/8/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $19.00 FEMALE DEPENDENT 1050 3559 {i BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, Uy UROBILINDGEN, ANY NUMBER OF THESE CONSTITUENTS; cn AUTOMATED, WITH MICROSCOPY 6112/2017 5/8/2017 6/8/2017 82330 CALCIUM; IONIZED E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $154.00 FEMALE DEPENDENT 1 050 3559 Q INPATIENT /HOSPITAL W 6/12/2017 5/8/2017 6/8/2017 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, POE, E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $336.00 FEMALE DEPENDENT 1 OSO 3559 COE, HCO3 (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL Q . WITH 02 SATURATION, BY DIRECT MEASUREMENT, J EXCEPT PULSE OXIMETRY 6/12/2017 5/8/2017 6/8/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $77.00 FEMALE DEPENDENT 1050 3559 v STRIP) INPATIENT /HOSPITAL 6/12/2017 5/8/2017 6/8/2017 84132 POTASSIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $77.00 FEMALE DEPENDENT 1050 3559 INPATIENT/HOSPITAL LLJ 6/12/2017 5/8/2017 6/8/2017 84295 SODIUM; SERUM, PLASMA OR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $99.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 5/8/2017 6/8/2017 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1050 3559 EXAMINATION WITH MANUAL DIFFERENTIAL W BC COUNT INPATIENT /HOSPITAL 6/12/2017 5/8/2017 6/8/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $266.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 5/8/2017 6/8/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E232 DIABETES INSIPIDUS PROFE55IONAL $0.00 $11.00 FEMALE DEPENDENT 1050 3559 {V HCT, RBC, W BC AND PLATELET COUNT) INPATIENT /HOSPITAL N 6/12/2017 5/8/2017 6/8/2017 86140 C- REACTIVE PROTEIN; E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $24.00 FEMALE DEPENDENT 1 OSO 3559 INPATIENT /HOSPITAL L 6/12/2017 5/9/2017 6/8/2017 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $192.00 FEMALE DEPENDENT 1 050 3559 COE, HCD3 (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL ._ WITH 02 SATURATION, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIM ETRY t ^ C.7.f 6/12/2017 5/9/2017 6/8/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $44.00 FEMALE DEPENDENT 1050 3559 STRIP) INPATIENT /HOSPITAL 6/12/2017 5/9/2017 6/8/2017 84132 POTASSIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $44.00 FEMALE DEPENDENT 1050 3559 C! INPATIENT /HOSPITAL N 6/12/2017 5/9/2017 6/8/2017 84295 SODIUM; SERUM, PLASMA OR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $44.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 5/9/2017 6/8/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $38.00 FEMALE DEPENDENT 1050 3559 A BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INPATIENT /HOSPITAL t LEUIOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, } UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; "a AUTOMATED, WITH MICROSCOPY m 6/12/2017 5/9/2017 6/8/2017 82330 CALCIUM; IONIZED E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $88.00 FEMALE DEPENDENT 1 OSO 3559 INPATIENT /HOSPITAL 6/12/2017 S/9/2017 6/8/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $152.00 FEMALE DEPENDENT 1 OSO 3SS9 fl } INPATIENT /HOSPITAL 6/12/2017 5/10/2017 6/8/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $19.00 FEMALE DEPENDENT 1050 3559 B. CL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INPATIENT /HOSPITAL Q, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 6/12/2017 5/10/2017 6/8/2017 82330 CALCIUM; IONIZED E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $88.00 FEMALE DEPENDENT 1 OSO 3559 ® y INPATIENT /HOSPITAL 6/12/2017 5/10/2017 6/8/2017 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, POE, E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $192.00 FEMALE DEPENDENT 1 OSO 3559 CO2, HCO3 (INCLUDING CALCULATED D2 SATURATION); INPATIENT /HDSPITAL W WITH 02 SATURATION, BY DIRECT MEASUREMENT, 6/12/2017 5/10/2017 6/8/2017 EXCEPT PULSE OXIMETRV 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $33.00 FEMALE DEPENDENT 1050 3559 STRIP) INPATIENT /HOSPITAL 6/12/2017 5/10/2017 6/8/2017 84132 POTASSIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $44.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 5/10/2017 6/8/2017 84295 SODIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $44.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HDSPITAL IL 6/12/2017 S/10/2017 6/8/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $152.00 FEMALE DEPENDENT 1050 3559 {i INPATIENT /HOSPITAL 6/12/2017 5/11/2017 6/8/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR E232 DIABETES INSIPIDUS PROFESSIONAL $ODD $38.00 FEMALE DEPENDENT 1050 3559 (fJ BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, 0 UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY LLJ 6/12/2017 5/11/2017 6/8/2017 82330 CALCIUM; IONIZED E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $110.00 FEMALE DEPENDENT 1 050 3559 INPATIENT /HOSPITAL Q . 6/12/2017 5/11/2017 6/8/2017 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, POE, E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $240.00 FEMALE DEPENDENT 1 OSO 3559 J CO2, HCO3 (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL WITH 02 SATURATION, BY DIRECT MEASUREMENT, v EXCEPT PULSE OXIMETRY 6/12/2017 5/11/2017 6/8/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $55.00 FEMALE DEPENDENT 1050 3559 STRIP) INPATIENT/HOSPITAL W 6/12/2017 5/11/2017 6/8/2017 84132 POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $55.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 5/11/2017 6/8/2017 84295 SODIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $55.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HOSPITAL 6/12/2017 5/11/2017 6/8/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $190.00 FEMALE DEPENDENT 1050 3559 INPATIENT /HDSPITAL „p 6/12/2017 S/12/2017 6/8/2017 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $192.00 FEMALE DEPENDENT 1 050 3559 CO2, HCO3 (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL N WITH 02 SATURATION, BY DIRECT MEASUREMENT, fV EXCEPT PULSE OXIMETRY = 6/12/2017 5/12/2017 6/8/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $44.00 FEMALE DEPENDENT 1050 3559 93 STRIP) INPATIENT /HOSPITAL 6/12/2017 5/12/2017 6/8/2017 84132 POTASSIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $44.00 FEMALE DEPENDENT 1050 3559 ._ INPATIENT /HOSPITAL 6/12/2017 5/12/2017 6/8/2017 84295 SODIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $44.00 FEMALE DEPENDENT 1050 3559 INPATIENT/HOSPITAL V t',{ 6/12/2017 5/12/2017 6/8/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL FEMALE DEPENDENT 1050 $0.00 $88.00 FEMALE INPATIENT /HOSPITAL 6/12/2017 5/12/2017 6/8/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR E232 DIABETES INSIPIDUS PROFESSIONAL $38.00 FEMALE DEPENDENT BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, $0.00 $66.00 INPATIENT /HOSPITAL DEPENDENT 1050 $0.00 LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, FEMALE DEPENDENT 1050 $0.00 $33.00 FEMALE UROBILINOGEN, ANY NUMBER DF THESE CONSTITUENTS; 1050 $0.00 $33.00 FEMALE DEPENDENT 1050 AUTOMATED, WITH MICROSCOPY $33.00 FEMALE DEPENDENT 6/12/2017 5/12/2017 6/8/2017 82330 CALCIUM; IONIZED E232 DIABETES INSIPIDUS PROFESSIONAL $38.00 FEMALE DEPENDENT 1050 $0.00 $88.00 INPATIENT /HDSPITAL 6/12/2017 5/12/2017 6/8/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $44.00 FEMALE DEPENDENT 1050 $0.00 INPATIENT /HOSPITAL 6/12/2017 5/13/2017 6/8/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR E232 DIABETES INSIPIDUS PROFESSIONAL 1050 $0.00 $152.00 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, DEPENDENT 1050 INPATIENT /HOSPITAL $22.00 FEMALE DEPENDENT LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, $0.00 $22.00 FEMALE DEPENDENT 1050 $0.00 UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; FEMALE DEPENDENT 1050 $0.00 $44.00 FEMALE AUTOMATED, WITH MICRO5COPY 1050 $0.00 $22.00 6112/2017 5/13/2017 6/8/2017 82330 CALCIUM; IONIZED E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 6/12/2017 5/13/2017 6/8/2017 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, P02, E232 DIABETES INSIPIDUS PROFESSIONAL CO2, HCO3 (INCLUDING CALCULATED 02 SATURATION; INPATIENT /HOSPITAL WITH 02 SATURATION, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIMETRY 6/12/2017 5/13/2017 6/8/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 DIABETES INSIPIDUS PROFESSIONAL STRIP) INPATIENT /HOSPITAL 6/12/2017 5/13/2017 6/8/2017 84132 POTASSIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 6/12/2017 5/13/2017 6/8/2017 84295 SODIUM; SERUM, PLASMA OR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 6/12/2017 5/13/2017 6/8/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 6/12/2017 5/14/2017 6/8/2017 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR E232 DIABETES INSIPIDUS PROFESSIONAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INPATIENT /HDSPITAL LEUIOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 6/12/2017 5/14/2017 6/8/2017 82330 CALCIUM; IONIZED E232 DIABETES INSIPIDUS PROFE55IONAL INPATIENT /HOSPITAL 6112/2017 5/14/2017 6/8/2017 82374 CARBON DIOXIDE (BICARBONATE) E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 6/12/2017 5/14/2017 6/8/2017 84132 POTASSIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 6/12/2017 5/14/2017 6/8/2017 84295 SODIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 6/12/2017 5/14/2017 6/8/2017 84439 THYROXINE; FREE E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 6/12/2017 5/14/2017 6/8/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 6/12/2017 5/14/2017 6/8/2017 82435 CHLORIDE; BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 6/12/2017 5/14/2017 6/8/2017 82565 CREATININE; BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 6/12/2017 5/14/2017 6/8/2017 82805 GASES, BLOOD, .ANY COMBINATION OF PH, PCO2, P02, E232 DIABETES INSIPIDUS PROFESSIONAL CO2, HCO3 (INCLUDING CALCULATED D2 SATURATION); INPATIENT /HDSPITAL WITH 02 SATURATION, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIMETRY 6/12/2017 5/14/2017 6/8/2017 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 DIABETES INSIPIDUS PROFESSIONAL STRIP) INPATIENT /HOSPITAL 6/12/2017 5/14/2017 6/8/2017 84520 UREA NITROGEN; QUANTITATIVE E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL $0.00 $76.00 FEMALE DEPENDENT 1050 $0.00 $38.00 FEMALE DEPENDENT 1050 $0.00 $88.00 FEMALE DEPENDENT 1050 $0.00 $76.00 FEMALE DEPENDENT 1050 $0.00 $38.00 FEMALE DEPENDENT 1050 $0.00 $66.00 FEMALE DEPENDENT 1050 $0.00 $144.00 FEMALE DEPENDENT 1050 $0.00 $33.00 FEMALE DEPENDENT 1050 $0.00 $33.00 FEMALE DEPENDENT 1050 $0.00 $33.00 FEMALE DEPENDENT 1050 $0.00 $114.00 FEMALE DEPENDENT 1050 $0.00 $38.00 FEMALE DEPENDENT 1050 $0.00 $88.00 FEMALE DEPENDENT 1050 $0.00 $22.00 FEMALE DEPENDENT 1050 $0.00 $44.00 FEMALE DEPENDENT 1050 $0.00 $44.00 FEMALE DEPENDENT 1050 $0.00 $11.00 FEMALE DEPENDENT 1050 $0.00 $152.00 FEMALE DEPENDENT 1050 $0.00 $22.00 FEMALE DEPENDENT 1050 $0.00 $22.00 FEMALE DEPENDENT 1050 $0.00 $96.00 FEMALE DEPENDENT 1050 $0.00 $44.00 FEMALE DEPENDENT 1050 $0.00 $22.00 FEMALE DEPENDENT 1050 C.7.f 3559 w 3559 f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 6/12/2017 5/15/2017 6/8/2017 6/12/2017 5 /15 /2017 6/8/2017 6/12/2017 5/15/2017 6/8/2017 6/12/2017 5/15/2017 6/8/2017 6/12/2017 5/15/2017 6/8/2017 6/12/2017 5/15/2017 6/8/2017 6112/2017 5/15/2017 6/8/2017 6/12/2017 5/16/2017 6/8/2017 6/12/2017 5/16/2017 6/8/2017 6/12/2017 5/16/2017 6/8/2017 6/12/2017 5/16/2017 6/8/2017 6/12/2017 5/16/2017 6/8/2017 6/12/2017 5/16/2017 6/8/2017 6/12/2017 5/16/2017 6/8/2017 6/12/2017 5/16/2017 6/8/2017 6/12/2017 5/16/2017 6/8/2017 6/12/2017 5/17/2017 6/8/2017 6/12/2017 5/17/2017 6/8/2017 6/12/2017 5/17/2017 6/8/2017 6/12/2017 5/17/2017 6/8/2017 6/12/2017 5/17/2017 6/8/2017 6/12/2017 5/17/2017 6/8/2017 6/12/2017 5/17/2017 6/8/2017 6/12/2017 5/17/2017 6/8/2017 81001 URINALYSIS, BY D I P STICK OR TABLET REAGENT FOR E232 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, PROFESSIONAL UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; INPATIENT /HDSPITAL AUTOMATED, WITH MICROSCOPY PROFESSIONAL 82330 CALCIUM; IONIZED E232 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, E232 COD, HELP (INCLUDING CALCULATED 02 SATURATION); INPATIENT /HOSPITAL WITH 02 SATURATION, BY DIRECT MEASUREMENT, PROFESSIONAL EXCEPT PULSE OXIMETRY INPATIENT /HOSPITAL 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 STRIP) INPATIENT /HOSPITAL 84132 POTASSIUM; SERUM, PLASMAOR WHOLE BLOOD E232 84295 SODIUM; SERUM, PLASMAOR WHOLE BLOOD E232 85014 BLOOD COUNT; HEMATOCRIT (HCT) E232 80051 ELECTROLYTE PANEL E232 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR E232 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, $22.00 FEMALE DEPENDENT UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; 3559 AUTOMATED, WITH MICROSCOPY $11.00 FEMALE DEPENDENT 82330 CALCIUM; IONIZED E232 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 STRIP) 3559 83605 LACTATE (LACTIC ACID) E232 84132 POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD E232 84295 SODIUM; SERUM, PLASMA OR WHOLE BLOOD E232 85014 BLOOD COUNT; HEMATOCRIT (HCT) E232 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, POP, E232 COD, HCO3 (INCLUDING CALCULATED 02 SATURATION); 3559 WITH 02 SATURATION, BY DIRECT MEASUREMENT, $58.00 FEMALE DEPENDENT EXCEPT PULSE OXIMETRY 3559 80051 ELECTROLYTE PANEL E232 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR E232 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, $22.00 FEMALE DEPENDENT LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, 3559 UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; $48.00 FEMALE DEPENDENT AUTOMATED, WITH MICROSCOPY 3559 82330 CALCIUM; IONIZED E232 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, E232 COE, HCO3 (INCLUDING CALCULATED 02 SATURATION); $11.00 FEMALE DEPENDENT WITH 02 SATURATION, BY DIRECT MEASUREMENT, 3559 EXCEPT PULSE OXIMETRY $11.00 FEMALE DEPENDENT 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 STRIP) $38.00 FEMALE DEPENDENT 84132 POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD E232 84295 SODIUM; SERUM, PLASMA OR WHOLE BLOOD E232 85014 BLOOD COUNT; HEMATOCRIT (HCT) E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HDSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1 EGO INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HDSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1 EGO INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HDSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1 EGO INPATIENT /HOSPITAL DIABETES INSIPIDUS PROFESSIONAL 1050 INPATIENT /HOSPITAL $0.00 $38.00 FEMALE DEPENDENT 1050 C.7.f 3559 $0.00 $110.00 FEMALE DEPENDENT 1050 3559 $0.00 $240.00 FEMALE DEPENDENT 1050 3559 $0.00 $55.00 FEMALE DEPENDENT 1050 3559 $0DD $55.00 FEMALE DEPENDENT 1050 3559 $0.00 $55.00 FEMALE DEPENDENT 1 EGO 3559 $0.00 $190.00 FEMALE DEPENDENT 1050 3559 $0.00 $58.00 FEMALE DEPENDENT 1050 3559 $0.00 $38.00 FEMALE DEPENDENT 1050 3559 $0.00 $44.00 FEMALE DEPENDENT 1050 3559 $0.00 $22.00 FEMALE DEPENDENT 1 ESE) 3559 $0.00 $11.00 FEMALE DEPENDENT 1050 3559 $0.00 $22.00 FEMALE DEPENDENT l ESE) 3559 $ODD $22.00 FEMALE DEPENDENT 1 DISC 3559 $0.00 $76.00 FEMALE DEPENDENT 1050 3559 $0.00 $144.00 FEMALE DEPENDENT 1050 3559 $0.00 $58.00 FEMALE DEPENDENT 1050 3559 $0.00 $19.00 FEMALE DEPENDENT 1 ESE) 3559 $0.00 $22.00 FEMALE DEPENDENT 1050 3559 $0.00 $48.00 FEMALE DEPENDENT 1050 3559 $0.00 $11.00 FEMALE DEPENDENT 1050 3559 $0.00 $11.00 FEMALE DEPENDENT 1050 3559 $0.00 $11.00 FEMALE DEPENDENT 1050 3559 $0.00 $38.00 FEMALE DEPENDENT 1050 3559 6/12/2017 5/18/2017 6/8/2017 6/12/2017 5/19/2017 6/8/2017 6/12/2017 5/19/2017 6/8/2017 6/12/2017 5/19/2017 6/8/2017 6/12/2017 5/19/2017 6/8/2017 6/12/2017 5/19/2017 6/8/2017 6/12/2017 5/19/2017 6/8/2017 6/12/2017 5/19/2017 6/8/2017 6/12/2017 5/19/2017 6/8/2017 6/12/2017 5/19/2017 6/8/2017 6/12/2017 5/19/2017 6/8/2017 6/12/2017 5/20/2017 6/8/2017 6/12/2017 5/20/2017 6/8/2017 6/12/2017 5121/2017 6/8/2017 6/12/2017 5/21/2017 6/8/2017 6/12/2017 5/21/2017 6/8/2017 6/12/2017 5/21/2017 6/8/2017 6/12/2017 5/22/2017 6/8/2017 6/12/2017 6/8/2017 6/9/2017 E0600 80051 ELECTROLYTE PANEL E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $66.00 FEMALE DEPENDENT INPATIENT /HOSPITAL 82330 CALCIUM; IONIZED E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $22.00 FEMALE DEPENDENT INPATIENT /HOSPITAL 82374 CARBON DIOXIDE (BICARBONATE) E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $48.00 FEMALE DEPENDENT INPATIENT /HOSPITAL 82435 CHLORIDE; BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $33.00 FEMALE DEPENDENT INPATIENT /HOSPITAL 82565 CREATININE; BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $22.00 FEMALE DEPENDENT INPATIENT /HDSPITAL 82805 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, P02, E232 DIABETES INSIPIDUS PROFESSIONAL CO2, HCO3 (INCLUDING CALCULATED 02 SATURATION); $18.00 FEMALE DEPENDENT INPATIENT /HOSPITAL WITH 02 SATURATION, BY DIRECT MEASUREMENT, $48.00 FEMALE DEPENDENT 1 oso EXCEPT PULSE OXIMETRY $48.00 FEMALE DEPENDENT 1050 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E232 DIABETES INSIPIDUS PROFESSIONAL STRIP) $11.00 FEMALE DEPENDENT INPATIENT /HOSPITAL 84132 POTASSIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL $0.00 $48.00 FEMALE DEPENDENT INPATIENT/HOSPITAL 84295 SODIUM; SERUM, PLASMAOR WHOLE BLOOD E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 84520 UREA NITROGEN; QUANTITATIVE E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 85014 BLOOD COUNT; HEMATOCRIT(HCT) E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 80047 BASIC METABOLIC PANEL (CALCIUM, IONIZED) THIS PANEL E232 DIABETES INSIPIDUS PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, IONIZED INPATIENT /HDSPITAL (82330) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E232 DIABETES INSIPIDUS PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (92374) CHLORIDE (92435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E232 DIABETES INSIPIDUS PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL INPATIENT /HOSPITAL (823101 CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (92565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 82340 CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 84133 POTASSIUM; URINE E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 84300 SODIUM; URINE E232 DIABETES INSIPIDUS PROFESSIONAL INPATIENT /HOSPITAL 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E232 DIABETES INSIPIDUS PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL INPATIENT /HDSPITAL (823101 CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE K219 GASTRO- ESOPHAGEAL OTHER MEDICAL OR STATIONARY, ELECTRIC REFLUX DISEASE WITHOUT ESOPHAGITIS $0.00 $174.00 FEMALE DEPENDENT 1050 $0.00 $66.00 FEMALE DEPENDENT 1050 $0.00 $22.00 FEMALE DEPENDENT 1050 $0.00 $22.00 FEMALE DEPENDENT 1 OSO $0.00 $22.00 FEMALE DEPENDENT 1050 $0.00 $48.00 FEMALE DEPENDENT 1050 $0.00 $33.00 FEMALE DEPENDENT 1050 $0.00 $33.00 FEMALE DEPENDENT 1050 $0.00 $33.00 FEMALE DEPENDENT 1050 $0.00 $22.00 FEMALE DEPENDENT 1050 $0.00 $114.00 FEMALE DEPENDENT 1 oso $0.00 $18.00 FEMALE DEPENDENT 1050 $0.00 $48.00 FEMALE DEPENDENT 1 oso $0.00 $48.00 FEMALE DEPENDENT 1050 $0.00 $22.00 FEMALE DEPENDENT 1050 $0.00 $11.00 FEMALE DEPENDENT 1050 $0.00 $11.00 FEMALE DEPENDENT 1 oso $0.00 $48.00 FEMALE DEPENDENT 1050 $34.54 $34.55 FEMALE DEPENDENT 1050 C.7.f 3559 w 3559 C! N 3559 Q! 3559 a 3559 7 3559 OR co } 3559 N. CL 3559 Q, Q 3559 v 3559 3559 W 3559 h Km III. 3559 3559 3559 3559 ®' 6/20/2017 6/10/2017 6/19/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FORTH E EVALUATION N390 URINARY TRACT PROFESSIONAL $23,300.26 FEMALE DEPENDENT AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 3559 INFECTION, SITE NOT INPATIENT /HOSPITAL 1050 THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; $211.72 SPECIFIED 2 050 3559 A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH Q! OTHER PROVIDERS OR A 4 6/20/2017 6/11/2017 6/19/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N390 URINARY TRACT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH $81.55 INFECTION, SITE NOT INPATIENT / HDSPITAL DEPENDENT REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS: AN 3559 SPECIFIED EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 6/20/2017 6/12/2017 6/19/2017 74455 URETHROCYSTOGRAPHY, VOIDING, RADIOLOGICAL N390 URINARY TRACT PROFESSIONAL SUPERVISION AND INTERPRETATION INFECTION, SITE NOT INPATIENT /HOSPITAL SPECIFIED 6/21/2017 5/8/2017 6/20/2017 95951 MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE 8259 UNSPECIFIED ABNORMAL PROFESSIONAL fl N. FOCUS BY CABLE OR RADIO, 160R MORE CHANNEL INVOLUNTARY INPATIENT /HOSPITAL TELEMETRY, COMBINED ELECTROENCEPHALOGRAPHIC CL MOVEMENTS $34.00 FEMALE (EEG) AND VIDEO RECORDING AND INTERPRETATION (EG, Z 050 3559 CL FOR PRESURGICAL LOCALIZATION), EACH 24 HOURS 6/21/2017 5/21/2017 6/20/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE B341 ENTEROVIRUS INFECTION, PROFESSIONAL FEMALE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH 1050 UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM ED EN ES: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. F COUNSELING AND /OR 6/22/2017 6/12/2017 6121/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N390 URINARY TRACT PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INFECTION, SITE NOT INPATIENT /HOSPITAL $0.00 REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS AN FEMALE SPECIFIED 1050 3559 EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 6/22/2017 6/13/2017 6/21/2017 99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES N390 URINARY TRACT PROFESSIONAL OR LESS INFECTION, SITE NOT INPATIENT /HOSPITAL SPECIFIED 6/23/2017 6/9/2017 6/19/2017 * + + ** * * * ** * + * ** • * *wr *ww ». 6/26/2017 5/14/2017 6/23/2017 95782 POLYSOMNOGRAPHY; YOUNGER THAN 6 YEARS, SLEEP G4730 SLEEP APNEA, OTHER MEDICAL STAGING WITH 40R MORE ADDITIONAL PARAMETERS OF UNSPECIFIED SLEEP, ATTENDED BY A TECHNOLOGIST 6/27/2017 6/19/2017 6/26/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E232 DIABETES INSIPIDUS PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 7/5/2017 619/2017 7/1/2017 - - N390 URINARY TRACT HOSPITAL OUTPATIENT INFECTION, SITE NOT SPECIFIED C.7.f $156.92 $288.00 FEMALE DEPENDENT 2 050 3559 $13705 $149.00 FEMALE DEPENDENT 2 OSO 3559 $137.77 $149.00 FEMALE DEPENDENT 2 OSO 3559 6/9/2017 # # # # # # ## $23,300.26 $23,300.26 FEMALE DEPENDENT 41 3559 $220.95 $420.00 FEMALE DEPENDENT 1050 3559 $211.72 N 2 050 3559 Q! A 4 $81.55 $149.00 FEMALE DEPENDENT 2 050 3559 7 fl } fl N. CL $31.67 $34.00 FEMALE DEPENDENT Z 050 3559 CL Q $564.60 $3,000.00 FEMALE DEPENDENT 1050 3559 Q F W h $0.00 $236.00 FEMALE DEPENDENT 1050 3559 $13705 $149.00 FEMALE DEPENDENT 2 OSO 3559 $137.77 $149.00 FEMALE DEPENDENT 2 OSO 3559 6/9/2017 # # # # # # ## $23,300.26 $23,300.26 FEMALE DEPENDENT 1 EGO 3559 $220.95 $420.00 FEMALE DEPENDENT 1050 3559 $211.72 $220.00 FEMALE DEPENDENT 2 050 3559 $456.17 $456.17 FEMALE DEPENDENT 1050 3559 7/10/2017 6/9/2017 7/6/2017 7/10/2017 6/9/2017 7/6/2017 7/10/2017 6/9/2017 7/6/2017 7110/2017 6/9/2017 7/6/2017 711012017 6/9/2017 7/6/2017 7/10/2017 6/9/2017 7/6/2017 7/10/2017 6/9/2017 7/6/2017 7/10/2017 6/9/2017 7/6/2017 7/10/2017 6/9/2017 7/6/2017 7/10/2017 619/2017 7/6/2017 7/10/2017 6/9/2017 7/6/2017 7/10/2017 6/12/2017 7/6/2017 7/10/2017 6/12/2017 7/6/2017 7/12/2017 7/8/2017 7/11/2017 E0600 711412017 711112017 7/13/2017 711712017 711212017 7/15/2017 xxxxx 80047 BASIC METABOLIC PANEL (CALCIUM, IONIZED) THIS PANEL N390 URINARYTRACT PROFESSIONAL MUST INCLUDETHE FOLLOWING: CALCIUM, IONIZED 1050 INFECTION, SITE NOT INPATIENT /HOSPITAL (82330) CARBON DIOXIDE (82374) CHLORIDE (82435) DEPENDENT SPECIFIED $0.00 CREATININE(82565) GLUCOSE (82947) POTASSIUM FEMALE DEPENDENT 1050 (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) $11.00 FEMALE DEPENDENT 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL N390 URINARY TRACT PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL 1 oso INFECTION, SITE NOT INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (92374) CHLORIDE (92435) DEPENDENT SPECIFIED $0.00 CREATININE(82565) GLUCOSE (82947) POTASSIUM FEMALE DEPENDENT 1050 (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) $13.00 FEMALE DEPENDENT 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR N390 URINARY TRACT PROFESSIONAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, 1050 INFECTION, SITE NOT INPATIENT /HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, DEPENDENT SPECIFIED $0.00 UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; FEMALE DEPENDENT 1050 AUTOMATED, WITH MICROSCOPY $19.00 FEMALE DEPENDENT 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC N390 URINARY TRACT PROFESSIONAL EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT 1 oso INFECTION, SITE NOT INPATIENT /HOSPITAL FEMALE DEPENDENT SPECIFIED $14346 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, N390 URINARY TRACT PROFESSIONAL HUT, BBC, WBC AND PLATELET COUNT) $360.00 INFECTION, SITE NOT INPATIENT /HOSPITAL 2 OSO SPECIFIED 86140 C- REACTIVE PROTEIN; N390 URINARY TRACT PROFESSIONAL INFECTION, SITE NOT INPATIENT /HOSPITAL SPECIFIED 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION N390 URINARY TRACT PROFESSIONAL AND PRESUMPTIVE IDENTIFICATION OF ISOLATES INFECTION, SITE NOT INPATIENT /HDSPITAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) SPECIFIED 87077 CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL N390 URINARY TRACT PROFESSIONAL METHODS REQUIRED FOR DEFINITIVE IDENTIFICATION, INFECTION, SITE NOT INPATIENT /HOSPITAL EACH ISOIATE SPECIFIED 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, N390 URINARY TRACT PROFESSIONAL URINE INFECTION, SITE NOT INPATIENT /HOSPITAL SPECIFIED 87186 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; N390 URINARY TRACT PROFESSIONAL MICRODILUTION OR AGAR DILUTION (MINIMUM INFECTION, SITE NOT INPATIENT /HOSPITAL INHIBITORY CONCENTRATION AMICA ORBREAKPOINT), SPECIFIED EACH MULTI - ANTIMICROBIAL, PER PLATE 87807 INFECTIOUS AGENTANTIGEN DETECTION BY N390 URINARYTRACT PROFESSIONAL IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; INFECTION, SITE NOT INPATIENT /HOSPITAL RESPIRATORY SYNCYTIAL VIRUS SPECIFIED 81001 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR N390 URINARYTRACT PROFESSIONAL BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, INFECTION, SITE NOT INPATIENT/HOSPITAL LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, SPECIFIED UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, N390 URINARYTRACT PROFESSIONAL URINE INFECTION, SITE NOT INPATIENT /HOSPITAL SPECIFIED RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE K219 GASTRO- ESOPHAGEAL OTHER MEDICAL OR STATIONARY, ELECTRIC REFLUX DISEASE WITHOUT ESOPHAGITIS 92012 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H4903 THIRD[OCULOMOTOR) PROFESSIONAL OFFICE AND EVALUATION, WITH INITIATION OR CONTINUATION NERVE PALSY, BILATERAL OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT $0.00 $18.00 FEMALE DEPENDENT 1050 $0.00 $48.DO FEMALE DEPENDENT 1050 $0.00 $19.00 FEMALE DEPENDENT 1050 $0.00 $11.00 FEMALE DEPENDENT 1050 $0.00 $11.00 FEMALE DEPENDENT 1 oso $0.00 $24.00 FEMALE DEPENDENT 1050 $0.00 $31.00 FEMALE DEPENDENT 1050 $0.00 $13.00 FEMALE DEPENDENT 1050 $0.00 $19.00 FEMALE DEPENDENT 1050 $0.00 $32.00 FEMALE DEPENDENT 1050 $0.00 $48.00 FEMALE DEPENDENT 1050 $0.00 $19.00 FEMALE DEPENDENT 1 050 $0.00 $19.00 FEMALE DEPENDENT 1 oso $34.54 $34.55 FEMALE DEPENDENT 2 050 $14346 $250.00 FEMALE DEPENDENT 2 OSO $187.62 $360.00 FEMALE DEPENDENT 2 OSO C.7.f 3559 im im 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 .I C.7.f 712112017 71712017 7/20/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Q02 MICROCEPHALY PROFESSIONAL OFFICE $145.47 $348.00 FEMALE DEPENDENT 2050 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED N EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER t 712112017 7/11/2017 7/20/2017 82374 CARBON DIOXIDE (BICARBONATE) Q02 MICROCEPHALY OTHER MEDICAL $0.00 $19.67 FEMALE DEPENDENT 2 050 3559 7 7/21/2017 7/11/2017 7120/2017 84295 SODIUM; SERUM, PLASMA OR WHOLE BLOOD Q02 MICROCEPHALY OTHER MEDICAL $0.00 $19.38 FEMALE DEPENDENT 2 OSO 3559 "a 7/24/2017 7/19/2017 7/21/20171160F REVIEW OF ALL MEDICATIONS BY A PRESCRIBING Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE $0.00 $0.00 FEMALE DEPENDENT 2050 3559 � PRACTITIONER OR CLINICAL PHARMACIST (SUCH AS, ROUTINE CHILD HEALTH PRESCRIPTIONS, OTCS, HERBAL THERAPIES AND EXAMINATION WITH SUPPLEMENTS) DOCUMENTED IN THE MEDICAL RECORD ABNORMAL FINDINGS } (COA)2 O 7/24/2017 7119/2017 7/21/20172001F W EIGHT RECORDED (CITE, PAG) Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE $0.00 $0.00 FEMALE DEPENDENT 2050 3559 B. CL ROUTINE CHILD HEALTH Q, EXAMINATION WITH ABNORMAL FINDINGS 7/24/2017 7/19/2017 7/21/2017 99381 INITIAL COMPREHENSIVE PREVENTIVE MEDICINE Z00121 ENCOUNTER FOR PROFESSIONAL OFFICE $100.83 $175.00 FEMALE DEPENDENT 2 OSO 3559 EVALUATION AND MANAGEMENT OF AN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITH EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS F GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORV /DIAGNOSTIC PROCEDURES, NEW PATIENT; INFANT(AGEYOUNGER THAN 1 YEAR) _ 7/26/2017 7/24/2017 7/25/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Q02 MICROCEPHALY PROFESSIONAL OFFICE $14547 $348.00 FEMALE DEPENDENT 2050 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED 0 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY IL COMPONENTS: A DETAILED HISTORY; A DETAILED Lli EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY, COUNSELING AND /DR UJ COORDINATION OF CARE WITH OTHER 8/1/2017 6119/2017 7/31/2017 90460 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $23.82 $35.00 FEMALE DEPENDENT 2050 3559 OFAGEVIAANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH LLJ COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH EXAMINATION WITHOUT CARE PROFESSIONAL; FIRSTOR ONLY COMPONENTOF ABNORMAL FINDINGS �q EACH VACCINE OR TOXOID ADMINISTERED 8/1/2017 6/19/2017 7/31/2017 90744 HEPATITIS B VACCINE, PEDIATRIC /ADOLESCENT DOSAGE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $20.00 $52.50 FEMALE DEPENDENT 2050 3559 V (3 DOSE SCHEDULE), FOR INTRAMUSCULAR USE ROUTINE CHILD HEALTH EXAMINATION WITHOUT ABNORMAL FINDINGS LLJ 8/1/2017 6/19/2017 7/31/2017 99391 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $74.48 $150.00 FEMALE DEPENDENT 2OS0 3559 REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL ROUTINE CHILD HEALTH (' INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; INFANT (AGE N YOUNGERTHAN 1YEAR) 8/7/2017 813/2017 8/4/20171160F REVIEW OF ALL MEDICATIONS BY APRESCRIBING 1218 ACUTE BRONCHIOLITIS PROFESSIONAL OFFICE $0.00 $0.00 FEMALE DEPENDENT 2050 3559 iU PRACTITIONER OR CLINICAL PHARMACIST (SUCH AS, DUE TO OTHER SPECIFIED PRESCRIPTIONS, OTCS, HERBAL THERAPIES AND ORGANISMS .0 SUPPLEMENTS) DOCUMENTED IN THE MEDICAL RECORD (COA)2 �. 81712017 8/3/2017 814120172001F WEIGHT RECORDED (CITE, PAG) 1218 ACUTE BRONCHIOUTIS PROFESSIONAL OFFICE $1.98 $20.00 FEMALE DEPENDENT 2 OSO DUE TO OTHER SPECIFIED N 1050 3559 ORGANISMS m 8/7/2017 8/3/2017 8/4/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR 1218 ACUTE BRONCHIOLITIS PROFESSIONAL OFFICE BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, DUE TO OTHER SPECIFIED LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, ORGANISMS UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY i 8/7/2017 8/3/2017 8/4/2017 87804 INFECTIOUS AGENT ANTIGEN DETECTION BY 1218 ACUTE BRONCHIOLITIS PROFESSIONAL OFFICE IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; DUE TO OTHER SPECIFIED INFLUENZA ORGANISMS 8/7/2017 8/3/2017 8/4/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1218 ACUTE BRONCHICUTIS PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DUE TO OTHER SPECIFIED W PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY ORGANISMS } COMPONENTS: A DETAILED HISTORY; A DETAILED fl N. EXAMINATION; MEDICAL DECISION MAKING OF CL MODERATE COMPLEXITY. COUNSELING AND /OR CL COORDINATION OF CARE WITH OTHER Q 8/11/2017 8/9/2017 8110120171160F REVIEW OF ALL MEDICATIONS BYA PRESCRIBING 1069 ACUTE UPPER PROFESSIONAL OFFICE $0.00 $0.00 FEMALE PRACTITIONER OR CLINICAL PHARMACIST (SUCH AS, 2 OSO RESPIRATORY INFECTION, PRESCRIPTIONS, OTCS, HERBAL THERAPIES AND UNSPECIFIED SUPPLEMENTS) DOCUMENTED IN THE MEDICAL RECORD F (C0A2 W 811112017 8/9/2017 8110120172001F WEIGHT RECORDED(CHF, PAG) 1069 ACUTE UPPER PROFESSIONAL OFFICE RESPIRATORY INFECTION, $0.00 $0.00 FEMALE DEPENDENT 2 OSO UNSPECIFIED Z 8/11/2017 8/9/2017 8110/2017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 1069 ACUTE UPPER PROFESSIONAL OFFICE $72.67 $115.00 FEMALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 2 OSO RESPIRATORY INFECTION, PATIENT, WHICH REQUIRESAT LEAST20F THESE 3 KEY UNSPECIFIED COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND GOURD 8117/2017 8/8/2017 8/16/2017 E0600 RESPIRATORY SUCTION PUMP, HOME MODEL, PORTABLE K219 GASTRO- ESOPHAGEAL OTHER MEDICAL OR STATIONARY, ELECTRIC REFLUX DISEASE WITHOUT ESOPHA.GITIS 811812017 8/10/2017 8/16/2017- - 1469 CARDIAC ARREST, CAUSE HOSPITAL OUTPATIENT UNSPECIFIED 812112017 8/10/2017 8/19/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 1639 CEREBRAL INFARCTION, PROFESSIONAL FRONTAL UNSPECIFIED OUTPATIENT /HOSPITAL 8/22/2017 5/4/2017 8/21/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION K117 DISTURBANCES OF PROFE55IONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES SALIVARY SECRETION OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 8/22/2017 8/10/2017 8/21/2017 A0425 GROUND MILEAGE, PER STATUTE MILE R092 RESPIRATORY ARREST OTHER MEDICAL 8/22/2017 8/10/2017 8/21/2017 A0433 ADVANCED LIFESUPPORT, LEVEL2(ALS2( R092 RESPIRATORY ARREST OTHER MEDICAL 8/28/2017 8/10/2017 8/25/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) 1469 CARDIAC ARREST, CAUSE PROFESSIONAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE UNSPECIFIED OUTPATIENT /HOSPITAL 9/5/2017 811012017 91112017 315001NTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE 1469 CARDIACARREST, CAUSE PROFESSIONAL UNSPECIFIED OUTPATIENT /HOSPITAL C.7.f $0.00 $0.00 FEMALE DEPENDENT 2 050 3559 $34.54 $34.55 FEMALE DEPENDENT 2 050 3559 $5,595.00 $9,325.00 FEMALE DEPENDENT W $1.98 $20.00 FEMALE DEPENDENT 2 OSO 3559 N 1050 3559 m Q! i $21.12 $50.00 FEMALE DEPENDENT 2 OSO 3559 "a $10834 $170.00 FEMALE DEPENDENT 2 OSO 3559 W } fl N. CL CL Q $0.00 $0.00 FEMALE DEPENDENT 2 OSO 3559 F W h $0.00 $0.00 FEMALE DEPENDENT 2 OSO 3559 Z $72.67 $115.00 FEMALE DEPENDENT 2 OSO 3559 $34.54 $34.55 FEMALE DEPENDENT 2 050 3559 $5,595.00 $9,325.00 FEMALE DEPENDENT 2 OSO 3559 $16.29 $41.00 FEMALE DEPENDENT 1050 3559 $342.79 $588.00 FEMALE DEPENDENT 1050 3559 $20.00 $30.00 FEMALE DEPENDENT 1050 3559 $58310 $980.00 FEMALE DEPENDENT 1050 3559 $0.00 $18.00 FEMALE DEPENDENT 1050 3559 $216.58 $576.00 FEMALE DEPENDENT 1050 3559 9/5/2017 8/10/2017 9/1/2017 11/16/2017 6/9/2017 11/14/2017 11/16/2017 6/12/2017 11/14/2017 Sub Total $342,490.28 UNSPECIFIED OUTPATIENT /HOSPITAL 5E +10 5/22/2017 5/8/2017 5/18/2017 5/22/2017 5/9/2017 5118/2017 5/22/2017 5/10 /2017 5/18/2017 5/22/2017 S/11/2017 5/18/2017 5/22/2017 5/12/2017 5/18/2017 5/22/2017 5/13/2017 5/18/2017 5/22/2017 5/14/2017 5118/2017 5/26/2017 5/8/2017 5/25/2017 5/26/2017 5/9/2017 5/25/2017 5/26/2017 5/10/2017 5/25/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 1469 CARDIAC ARREST, CAUSE PROFESSIONAL AND MANAGEM ENT OF A PATIENT, WHICH REQUIRES $342,490.28 UNSPECIFIED OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS $4,409.00 FEMALE DEPENDENT 1 BCC IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL $4,409.00 FEMALE DEPENDENT 1 BCC CONDITION AND /DR MENTAL STATUS: A COMPREH ENSIVE $4,409.00 FEMALE DEPENDENT 1 BCC HISTORY; A COMPREHENSIVE EXAMINATION; AND $4,409.00 FEMALE DEPENDENT 1 BCC MEDICAL DECIS $4,409.00 FEMALE DEPENDENT 1 BCC 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N390 URINARY TRACT PROFESSIONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED $4,409.00 FEMALE DEPENDENT INFECTION, SITE NOT OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $4,409.00 FEMALE DEPENDENT SPECIFIED COMPONENTS: A COMPREHENSIVE HISTORY; A $4,409.00 FEMALE DEPENDENT 1 BCC COMPREHENSIVE EXAMINATION; MEDICAL DECISION $4,409.00 FEMALE DEPENDENT 1 BCC MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 74455 URETHROCYSTOGRAPHY , VOIDING, RADIOLOGICAL N390 URINARY TRACT PROFESSIONAL SUPERVISION AND INTERPRETATION INFECTION, SITE NOT INPATIENT /HOSPITAL SPECIFIED 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P280 PRIMARY ATELECTA515 OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS $254.65 $780.00 FEMALE DEPENDENT 1050 $0.00 $298.00 FEMALE DEPENDENT 1050 $0.00 $34.00 FEMALE DEPENDENT 2 050 $228,921.68 $342,490.28 $840.60 $4,409.00 FEMALE DEPENDENT 1 BCC $840.60 $4,409.00 FEMALE DEPENDENT 1 BCC $840.60 $4,409.00 FEMALE DEPENDENT 1 BCC $840.60 $4,409.00 FEMALE DEPENDENT 1 BCC $540.60 $4,409.00 FEMALE DEPENDENT 1 BCC $870.02 $4,409.00 FEMALE DEPENDENT 1 BCC $870.02 $4,409.00 FEMALE DEPENDENT 1 BCC $0.00 $4,409.00 FEMALE DEPENDENT 1 BCC $0.00 $4,409.00 FEMALE DEPENDENT 1 BCC $0.00 $4,409.00 FEMALE DEPENDENT 1 BCC C.7.f 3559 ®' 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 C.7.f 5/26/2017 5/11/2017 5/25/2017 99469 SUBS EQU ENT INPATIENT NEONATAL CRITICAL CARE, PER P280 PRIMARY ATE LECTAS IS OF PROFESSIONAL $0.00 $4,409.00 FEMALE DEPENDENT 1 BCC 3559 DAY, FORTHE EVALUATIONAND MANAGEMENTOFA NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS N 5/30/2017 4/14/2017 5/25/2017 99291 CRITICALC ARE, EVALUATION AND MANAGEMENT OF THE R7881 BACTEREMIA PROFESSIONAL $317.84 $1,300.00 FEMALE DEPENDENT 1 BCC 3559 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- INPATIENT /HOSPITAL 74 MIN UTES 5/30/2017 4/14/2017 5/25/2017 99292 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE R7881 BACTEREMIA PROFESSIONAL $143.47 $800.00 FEMALE DEPENDENT 1 BCC 3559 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH INPATIENT /HDSPITAL } ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION "a TO CODE FOR PRIMARY SERVICE) � S/30/2017 4/15/2017 S/2S/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE R7881 BACTEREMIA PROFESSIONAL $317.84 $1,300.00 FEMALE DEPENDENT 1 BCC 3SS9 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- INPATIENT /HOSPITAL } 74 MIN UTES 5/30/2017 4115/2017 5/25/2017 99292 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE R7881 BACTEREMIA PROFESSIONAL $143.47 $800.00 FEMALE DEPENDENT 1 BCC 3559 E. CL CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH INPATIENT /HOSPITAL Q, ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE) 5/30/2017 4/17/2017 5/25/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE R7881 BACTEREMIA PROFESSIONAL $317.84 $1,300.00 FEMALE DEPENDENT 1 BCC 3559 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- INPATIENT /HOSPITAL 74 MIN UTES 5/30/2017 4/18/2017 5/25/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE R7881 BACTEREMIA PROFESSIONAL $317.84 $1,300.00 FEMALE DEPENDENT 1 BCC 3559 uj CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- INPATIENT /HOSPITAL 74 MIN UTES 5/30/2017 4/19/2017 5/25/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE R7881 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- BACTEREMIA PROFESSIONAL INPATIENT /HOSPITAL $317.84 $1,300.00 FEMALE DEPENDENT 1 BCC 3559 _ 74 MIN UTES 5/30/2017 4/20/2017 5/25/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE R7881 BACTEREMIA PROFESSIONAL $317.84 $1,300.00 FEMALE DEPENDENT 1 BCC 3559 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- INPATIENT /HDSPITAL 74 MIN UTES IL 5/30/2017 4/21/2017 5/25/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE R7881 BACTEREMIA PROFESSIONAL $317.84 $1,300.00 FEMALE DEPENDENT 1 BCC 3559 uj CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- INPATIENT /HOSPITAL 74 MIN UTES UJ 5/30/2017 4/22/2017 5/25/2017 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE R7881 BACTEREMIA PROFESSIONAL $317.84 $1,300.00 FEMALE DEPENDENT 1 BCC 3559 CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30- INPATIENT /HOSPITAL 74 MIN UTES Q 5/30/2017 4/24/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 87881 BACTEREMIA PROFESSIONAL $120.17 $925.00 FEMALE DEPENDENT 1BCC 3559 W EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A �q DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; J MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH v OTHER PROVI 5/30/2017 4/25/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL $120.17 $925.00 FEMALE DEPENDENT 1BCC 3559 LLJ EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; U MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM Q CN! S/30/2017 4/26/2017 512512017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7981 BACTEREMIA PROFESSIONAL $120.17 $925.00 FEMALE DEPENDENT 1BCC 3559 N EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A = DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 2 5/30/2017 4/27/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL $120.17 $925.00 FEMALE DEPENDENT 1BCC EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 4/28/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL $120.17 $925.00 FEMALE DEPENDENT 1BCC EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 5/30/2017 4/29/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL $120.17 $925.00 FEMALE DEPENDENT 1BCC EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/1/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL $120.17 $925.00 FEMALE DEPENDENT 1BCC EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/2/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL $120.17 $925.00 FEMALE DEPENDENT 1BCC EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 5/30/2017 5/3/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL $120.17 $925.00 FEMALE DEPENDENT 1BCC EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/4/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL $120.17 $925.00 FEMALE DEPENDENT 1BCC EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/5/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/6/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 5/30/2017 5/8/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/9/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/10/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 5/30/2017 5/12/2017 5/25/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT/HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 5/30/2017 5/12/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PO ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/13/2017 5/25/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE $120.17 $925.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $0.00 $4,409.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $0.00 $4,409.00 FEMALE DEPENDENT 1 BCC C.7.f 3559 ®' WE mm ®' 3559 3559 Im 5/30/2017 5/13/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/14/2017 5/25/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P280 PRIMARY ATELECTASIS OF PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN INPATIENT / HDSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE S/30/2017 5/15/2017 5/2S/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 5/30/2017 5/15/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 87881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY DOM TON ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/16/2017 5/25/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT DR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 5/30/2017 5/16/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/17/2017 5/25/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 5/30/2017 5/17/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY DOM RD N ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 S/18/2017 5125/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE $120.17 $925.00 FEMALE DEPENDENT 1 BCC $0.00 $4,409.00 FEMALE DEPENDENT 1 BCC $870.02 $4,409.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $870.02 $4,409.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $870.02 $4,409.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $870.02 $4,409.00 FEMALE DEPENDENT 1 BCC C.7.f 3559 w Z N Q! A 4 3559 7 3SS9 > } fl i® CL CL Q 3559 v Im IM III ®' 5/30/2017 5/18/2017 5/25/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 5/30/2017 5/19/2017 5/25/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT / HDSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE S/30/2017 5/20/2017 5/2S/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 5/30/2017 5/21/2017 5/25/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 6/9/2017 4/24/2017 6/7/2017 93306 ECHOCARDIOGRAPHY, TRANSTHDRACIC, REAL -TIME WITH Q256 STENOSIS OF PULMONARY PROFESSIONAL IMAGE DOCUMENTATION (2D), INCLUDES M -MODE ARTERY INPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 6/9/2017 4/24/2017 6/7/2017 99253 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED Q256 STENOSIS OF PULMONARY PROFESSIONAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A ARTERY INPATIENT /HOSPITAL DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH 6/9/2017 5/19/2017 6/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/9/2017 5/20/2017 6/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM RD ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/9/2017 S/22/2017 6/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMI, PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PO ENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $120.17 $925.00 FEMALE DEPENDENT 1 BCC $870.02 $4,409.00 FEMALE DEPENDENT 1 BCC $870.02 $4,409.00 FEMALE DEPENDENT 1 BCC $870.02 $4,409.00 FEMALE DEPENDENT 1 BCC $79.30 $964.00 FEMALE DEPENDENT 1 BCC $144.55 $2,566.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC C.7.f 3559 w Z N Q! A 3559 7 3SS9 > } fl i® CL CL Q 3559 v Iim. mm gm. ma 6/9/2017 5/23/2017 6/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/9/2017 5/24/2017 6/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 6/9/2017 5/26/2017 6/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/9/2017 5/30/2017 6/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/9/2017 5/31/2017 6/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 6/12/2017 4/24/2017 6/9/2017 93306 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH Q256 STENOSIS OF PULMONARY PROFESSIONAL IMAGE DOCUMENTATION (2D), INCLUDES M -MODE ARTERY INPATIENT/HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 6/12/2017 4/24/2017 6/9/2017 99253 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED Q256 STENOSIS OF PULMONARY PROFESSIONAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS :A ARTERY INPATIENT /HOSPITAL DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH 6/14/2017 6/1/2017 6/12/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7981 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $120.17 $925.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $0.00 $964.00 FEMALE DEPENDENT 1 BCC $0.00 $2,566.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC C.7.f 3559 ®' WE mm ®' WE gm ®' 6/14/2017 6/3/2017 6/12/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/14/2017 6/5/2017 6/12/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 6/16/2017 5/22/2017 6/15/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICALCARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT/HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 6/16/2017 5/23/2017 6/15/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT DR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 6/16/2017 5/24/2017 6/15/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT DR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 6/16/2017 5/25/2017 6/15/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 6116/2017 5/26/2017 6/15/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 6/16/2017 5/27/2017 6/15/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT/HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 6/16/2017 5/28/2017 6/15/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATIDN AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HDSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 6/19/2017 5/29/2017 6/16/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT DR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 6/19/2017 5/30/2017 6/16/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A FROM FETAL BLOOD LO55 INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE $120.17 $925.00 FEMALE DEPENDENT 1 BCC $120.17 $925.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $870.02 $4,409.00 FEMALE DEPENDENT 1 BCC $910.90 $4,409.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC 6/19/2017 5/31/2017 6/16/2017 99472 SUBS EQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL DAY, FOR THE EVA LUATI ON AND MANAGE ME NT OF A FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE 6/19/2017 6/1/2017 6/16/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER Q221 CONGENITAL PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A PULMONARY VALVE INPATIENT /HOSPITAL CRITICALLY ILL INFANT DR YOUNG CHILD, 29 DAYS STENOSIS THROUGH 24 MONTHS OF AGE 6/19/2017 6/212017 6/16/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER Q221 CONGENITAL PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A PULMONARY VALVE INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS STENOSIS THROUGH 24 MONTHS OF AGE 6/19/2017 613/2017 6/16/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER Q221 CONGENITAL PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A PULMONARY VALVE INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS STENOSIS THROUGH 24 MONTHS OF AGE 6/19/2017 6/4/2017 6/16/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER Q221 CONGENITAL PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A PULMONARY VALVE INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS STENOSIS THROUGH 24 MONTHS OF AGE 6/21/2017 6/2/2017 6/19/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/21/2017 6/6/2017 6/19/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/21/2017 6/7/2017 6/19/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT/HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/21/2017 6/8/2017 6/19/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 DEC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $160.23 $925.00 FEMALE DEPENDENT 1 BCC $160.23 $925.00 FEMALE DEPENDENT 1 BCC $160.23 $925.00 FEMALE DEPENDENT 1 BCC $160.23 $925.00 FEMALE DEPENDENT 1 BCC C.7.f 6/23/2017 6/12/2017 6/22/2017 99381 INITIAL COMPREHENSIVE PREVENTIVE MEDICINE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $134.95 $185.00 FEMALE DEPENDENT 1 BCC 3559 EVALUATION AND MANAGEMENT OF AN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, NEW PATIENT; INFANT(AGEYOUNGER THAN 1 YEAR) 6/23/2017 6/20/2017 6122/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R0683 SNORING PROFESSIONAL OFFICE $279.67 $1,173.00 FEMALE DEPENDENT 1BCC 3559 EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING .AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 6126/2017 4/14/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL ARTERY INPATIENT /HOSPITAL (82310)CARBON DIOXIDE(82374) CHLORIDE(82435) CREATI NINE (82565) GLUCOSE(B2947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6/26/2017 4/14/2017 6/23/2017 80307 Drugtest(s), piesumpti -,any rumberofdrugdasses, any Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $27.00 FEMALE DEPENDENT 1BCC 3559 numberofdeyim-procedures, byinstrumentchemistry ARTERY INPATIENT /HOSPITAL analyzers (eg, utilizing immunoassay 6/26/2017 4/14/2017 6/23/2017 82247 BILIRUBIN; TOTAL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 82330 CALCIUM; IONIZED Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $18.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 82435 CHLORI DE; BLOOD Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6123/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $91.00 FEMALE DEPENDENT 1 BCC 3559 COE, HCO3 (INCLUDING CALCULATED O2 SATURATION); ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $63.00 FEMALE DEPENDENT 1 BCC 3559 STRIP) ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(5) Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $24.00 FEMALE DEPENDENT 1BCC 3559 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 84132 POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $6.00 FEMALE DEPENDENT 1BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 84295 SODIUM; SERUM, PLASMA OR WHOLE BLOOD Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $6.00 FEMALE DEPENDENT 1BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 HCT,BBC, WBC AND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT 6/26/2017 4/14/2017 6123/2017 86140 C- REACTIVE PROTEIN; Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 86850 ANTIBODY SCREEN, PEE, EACH SERUM TECHNIQUE Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT I BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 86900 BLOOD TYPING, SEROLOGIC; ABO Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $21.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/14/2017 6/23/2017 86901 BLOOD TYPING, SEROLOGIC; BIT (D) Q256 STENO5I5 OF PULMONARY PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1BCC 3559 ARTERY INPATIENT /HOSPITAL C.7.f 6/26/2017 4/14/2017 6/23/2017 87040 CULTURE, BACTERIAL; BLOOD, AEROB I C,WITH ISOLATION Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1BCC 3559 AND PRESUMPTIVE IDENTIFICATION OF ISOLATES ARTERY INPATIENT /HOSPITAL (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) 6/26/2017 4/15/2017 6/23/2017 82247 BILIRUBIN;TDTAL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/15/2017 6/23/2017 82330 CALCIUM; IONIZED Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $18.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/15/2017 6/23/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HDSPITAL 6/26/2017 4/15/2017 6123/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/15/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT I BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL ARTERY INPATIENT /HOSPITAL (82310)CARBON DIOXIDE(82374) CHLORIDE(82435) CREATI NINE (92565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6/26/2017 4/15/2017 6/23/2017 82247 BILIRUBIN; TOTAL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/15/2017 6/23/2017 82248 BILIRUBIN; DIRECT Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/15/2017 6/23/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, POE, Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $13.00 FEMALE DEPENDENT 1 BCC 3559 COE, HCO3 ( INCLUDING CALCULATED O2 SATURATION); ARTERY INPATIENT /HOSPITAL 6/26/2017 4/15/2017 6/23/2017 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 STRIP) ARTERY INPATIENT /HOSPITAL 6/26/2017 4/15/2017 6/23/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 6/26/2017 4/15/2017 6/23/2017 85045 BLOOD COUNT; RETICULOCYTE, AUTOMATED Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HDSPITAL 6/26/2017 4/15/2017 6123/2017 86140 C- REACTIVE PROTEIN; Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/16/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $ODD $50.00 FEMALE DEPENDENT 1 BCC 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL ARTERY INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (62374) CHLORIDE (82435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6/26/2017 4/16/2017 6/23/2017 80170 GENTAMICIN Q256 STEN05I5 OF PULMONARY PROFESSIONAL $0.00 $54.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/16/2017 6/23/2017 82247 BILIRUBIN; TOTAL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $19.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/16/2017 6/23/2017 82248 BILIRUBIN; DIRECT Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT/HOSPITAL 6/26/2017 4/16/2017 6/23/2017 82330 CALCIUM; IONIZED Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $18.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HDSPITAL 6/26/2017 4/16/2017 6/23/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCD2, PO2, Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $52.00 FEMALE DEPENDENT 1 BCC 3559 COE, HCO3 (INCLUDING CALCULATED O2 SATURATION); ARTERY INPATIENT /HOSPITAL 6/26/2017 4/16/2017 6/23/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $36.00 FEMALE DEPENDENT 1 BCC 3559 STRIP) ARTERY INPATIENT /HDSPITAL 6/26/2017 4/16/2017 6123/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/16/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/16/2017 6/23/2017 85025 BLOOD COUNT; COMPLETE(CBCL AUTOMATED(HGB, Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 HCT,BBC, WBC AND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT 6/26/2017 4/16/2017 6/23/2017 85045 BLOOD COUNT; RETICULOCYTE, AUTOMATED Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/16/2017 6/23/2017 86923 COMPATIBILITY TEST EACH UNIT; ELECTRONIC Q256 STENOSIS OF PULMONARY PROFESSIONAL 1 BCC 3559 $0.00 $9.00 FEMALE DEPENDENT 1 BCC ARTERY INPATIENT /HOSPITAL 6/26/2017 4/17/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL( THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL 1 BCC 3559 $0.00 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL 1 BCC ARTERY INPATIENT /HOSPITAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) $0.00 $50.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 CREATININE (82565) GLUCOSE (82947) POTASSIUM 1 BCC 3559 $0.00 $8.00 FEMALE DEPENDENT 1 BCC (84132) 5ODIUM (84295) UREA NITROGEN (BUN( (84520) $0.00 $18.00 FEMALE DEPENDENT 6/26/2017 4/17/2017 6/23/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $27.00 FEMALE DEPENDENT 1 BCC THE FOLLOW ING! ALBUMIN (9204D), BILIRUBIN, TOTAL $0.00 ARTERY INPATIENT /HDSPITAL 1 BCC 3559 $0.00 (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, 1 BCC 3559 $0.00 $25.00 FEMALE DEPENDENT 1 BCC ALKALINE (94075(, PROTEIN, TOTAL (84155), $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 TRANSFERASE, ALANINE AMINO (ALT) (SEPT) (84460(, 1 BCC 3559 TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 6/26/2017 4/17/2017 6/23/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, POE, Q256 STENOSIS OF PULMONARY PROFESSIONAL CO2,HCD3(INCLUDING CALCULATED O2 SATURATION); ARTERY INPATIENT /HOSPITAL 6/26/2017 4/17/2017 6/23/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT Q256 STENOSIS OF PULMONARY PROFESSIONAL STRIP) ARTERY INPATIENT /HOSPITAL 6/26/2017 4/17/2017 6/23/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 4/17/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 4/17/2017 6/23/2017 84478 TRIGLYCERIDES Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 4/17/2017 6/23/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, Q256 STENOSIS OF PULMONARY PROFESSIONAL HCT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 6/26/2017 4/17/2017 6123/2017 86140 C- REACTIVE PROTEIN; Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 4/18/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL ARTERY INPATIENT /HOSPITAL (823101 CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (S2947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6126/2017 4/18/2017 6/23/2017 82247 BILIRUBIN; TOTAL Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 4/18/2017 6/23/2017 82248 BILIRUBIN; DIRECT Q256 STENO5I5 OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 4/18/2017 6/23/2017 82330 CALCIUM; IONIZED Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 4/18/2017 6/23/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, Q256 STENOSIS OF PULMONARY PROFESSIONAL CO2, HCO3 ( INCLUDING CALCULATED O2 SATURATION); ARTERY INPATIENT /HOSPITAL 6/26/2017 4/18/2017 6/23/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT Q256 STENOSIS OF PULMONARY PROFE55IONAL STRIP) ARTERY INPATIENT /HOSPITAL 6/26/2017 4/18/2017 6/23/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 4/18/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HDSPITAL 6/26/2017 4/19/2017 6123/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL ARTERY INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6/26/2017 4/19/2017 6/23/2017 82248 BILIRUBIN; DIRECT Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 4/19/2017 6/23/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, Q256 STENOSIS OF PULMONARY PROFESSIONAL COE, HCO3 (INCLUDING CALCULATED 02 SATURATION); ARTERY INPATIENT /HOSPITAL $0.00 $27.00 FEMALE DEPENDENT 1 BCC $0.00 $25.00 FEMALE DEPENDENT 1 BCC C.7.f 3559 w 3559 $0.00 $29.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $39.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $27.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $11.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $50.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $19.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $18.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $39.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $27.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $78.00 FEMALE DEPENDENT 1 BCC 3559 C.7.f 6/26/2017 4/19/2017 6/23/2017 6/26/2017 4/19/2017 6/23/2017 6/26/2017 4/19/2017 6/23/2017 6/26/2017 4/19/2017 6/23/2017 6/26/2017 4/20/2017 6/23/2017 6/26/2017 4/20/2017 6/23/2017 6/26/2017 4/20/2017 6/23/2017 6/26/2017 4/20/2017 6/23/2017 6/26/2017 4/20/2017 6/23/2017 6/26/2017 4/20/2017 6/23/2017 6/26/2017 4/20/2017 6/23/2017 6/26/2017 4/21/2017 6/23/2017 6/26/2017 4/21/2017 6/23/2017 6/26/2017 4/21/2017 6/23/2017 6/26/2017 4/21/2017 6/23/2017 6/26/2017 4/21/2017 6/23/2017 6/26/2017 4/21/2017 6/23/2017 6/26/2017 4/21/2017 6/23/2017 6/26/2017 4/22/2017 6/23/2017 6/26/2017 4/22/2017 6/23/2017 6/26/2017 4/22/2017 6/23/2017 6/26/2017 4/22/2017 6123/2017 6/26/2017 4/22/2017 6/23/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT Q256 STRIP) 1 BCC 82247 BILIRUBIN; TOTAL Q256 83735 MAGNESIUM Q256 84100 PHOSPHORUS INORGANIC PHOSPHATE); Q256 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL 1 BCC (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) ARTERY INPATIENT /HOSPITAL CREATININE(82565) GLUCOSE (82947) POTASSIUM $12.00 FEMALE DEPENDENT (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 3559 82247 BILIRUBIN; TOTAL Q256 82248 BILIRUBIN; DIRECT Q256 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, Q256 COP, HCO3 (INCLUDING CALCULATED 02 SATURATION); 3559 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT Q256 STRIP) $0.00 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HOD, Q256 NET, RBC, W BC AND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT $26.00 FEMALE DEPENDENT 85045 BLOOD COUNT; RETICULOCVTE, AUTOMATED Q256 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL 1 BCC (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) ARTERY INPATIENT /HDSPITAL CREATININE(82565) GLUCOSE (82947) POTASSIUM 3559 (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) $7.00 FEMALE DEPENDENT 82247 BILIRUBIN; TOTAL Q256 82248 BILIRUBIN; DIRECT Q256 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, Q256 CO2, HCO3 (INCLUDING CALCULATED 02 SATURATION); $7.00 FEMALE DEPENDENT 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT Q256 STRIP) $18.00 FEMALE DEPENDENT 83735 MAGNESIUM Q256 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 83735 MAGNESIUM Q256 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT Q256 STRIP) 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, Q256 COE, HCO3 (INCLUDING CALCULATED 02 SATURATION); STENOSIS OF PULMONARY PROFESSIONAL $0.00 $54.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 1 BCC 3559 $0.00 $39.00 FEMALE DEPENDENT STENOSIS OF PULMONARY PROFESSIONAL $0.00 $19.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 1 BCC 3559 $0.00 $19.00 FEMALE DEPENDENT STENOSIS OF PULMONARY PROFESSIONAL $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL $0.00 $26.00 FEMALE DEPENDENT 1 BCC 3559 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HDSPITAL 1 BCC 3559 $0.00 $7.00 FEMALE DEPENDENT STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT/HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT/HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HDSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL $0.00 $19.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $39.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $27.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $11.00 FEMALE DEPENDENT 1 BCC 3559 $000 $25.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $19.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $26.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $18.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $18.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $26.00 FEMALE DEPENDENT 1 BCC 3559 C.7.f 6/26/2017 4/23/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL ARTERY INPATIENT /HOSPITAL (82310)CARBON DIOXIDE(82374) CHLDRIDE(82435) CREATI NINE (82565) GLUCOSE(82947) POTASSIUM N (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) m tU 6/26/2017 4/23/2017 6/23/2017 82247 BILIRUBIN; TOTAL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $19.00 FEMALE DEPENDENT 1 BCC 3559 A ARTERY INPATIENT /HOSPITAL t 6/26/2017 4/23/2017 6/23/2017 82248 BILIRUBIN; DIRECT Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 } ARTERY INPATIENT /HDSPITAL 6/26/2017 4/23/2017 6123/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PD2, Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $13.00 FEMALE DEPENDENT 1 BCC 3559 m COP, HCO3(INCLUDING CALCULATED O2 SATURATION); ARTERY INPATIENT /HOSPITAL 6/26/2017 4/23/2017 6/23/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT Q256 STENOSIS OF PULMONARY PROFESSIONAL $aDD $9.00 FEMALE DEPENDENT 1 BCC 3SS9 lu } STRIP) ARTERY INPATIENT /HOSPITAL 6/26/2017 4/23/2017 6/23/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $6.00 FEMALE DEPENDENT 1BCC 3559 iL CL ARTERY INPATIENT /HOSPITAL Q, 6126/2017 4/23/2017 6/23/2017 85018 BLOOD COUNT; HEMOGLOBIN(HGB) Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1BCC 3559 ARTERY INPATIENT /HOSPITAL v 6/26/2017 4/24/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL ARTERY INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATI NINE (92565) GLUCOSE (82947) POTASSIUM F (84132) SODIUM 184295) UREA NITROGEN (BUN) (84520) h 6/26/2017 4/24/2017 6/23/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN,TOTAL Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL $0.00 $29.00 FEMALE DEPENDENT 1 BCC 3559 z (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, _ ALKALINE (94075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 0 IL 6/26/2017 4/24/2017 6123/2017 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $13.00 FEMALE DEPENDENT 1 BCC 3559 {i DOE, HCO3 (INCLUDING CALCULATED O2 SATURATION); ARTERY INPATIENT /HOSPITAL 6/26/2017 4/24/2017 6/23/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 STRIP) ARTERY INPATIENT /HOSPITAL 0 6126/2017 4/24/2017 6/23/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL W 6/26/2017 4/24/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STEN0515 OF PULMONARY PROFESSIONAL $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL Q . 6/26/2017 4/24/2017 6/23/2017 85014 BLOOD COUNT; HEMATOCRIT(HCT) Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $6.00 FEMALE DEPENDENT 1BCC 3559 J ARTERY INPATIENT /HOSPITAL 6/26/2017 4/24/2017 6/23/2017 85018 BLOOD COUNT; HEMOGLOBIN(HGB) Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1BCC 3559 v ARTERY INPATIENT /HOSPITAL 6/26/2017 4/24/2017 6/23/2017 85045 BLOOD COUNT; RETICULOCYTE, AUTOMATED Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT/HOSPITAL LLJ 6/26/2017 4/25/2017 6/23/2017 82247 BILIRUBIN; TOTAL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/25/2017 6/23/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/25/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HDSPITAL „p 6/26/2017 4/25/2017 6123/2017 86140 C- REACTIVE PROTEIN; Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $24.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL N 6/26/2017 4/25/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC N 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL ARTERY INPATIENT /HOSPITAL = (823101 CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE(92565) GLUCOSE (82947) POTASSIUM E (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6/26/2017 4/25/2017 6/23/2017 82247 BILIRUBIN; TOTAL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL C.7.f 6/26/2017 4/25/2017 6/23/2017 82248 BILIRUBIN; DIRECT Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 4/25/2017 6/23/2017 85025 BLOOD COUNT; COMPLETE(CBQ, AUTOMATED(HGB, Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 C! HCE,RBC,WBCAND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL N DIFFERENTIAL W BC COUNT OR 6/26/2017 4/26/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL ARTERY INPATIENT /HOSPITAL (82310)CARBON DIOXIDE(82374) CHLDRIDE(82435) CREATI NINE (82565) GLUCOSE(82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6/26/2017 4/26/2017 6/23/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 w HCT,RBC,WBCAND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 6/26/2017 4/26/2017 6/23/2017 86140 C- REACTIVE PROTEIN; Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL L CL 6126/2017 4/27/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENDS15 OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 Q, MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL ARTERY INPATIENT /HOSPITAL (82310)CARBON DIOXIDE(82374) CHLORIDE(82435) v CREATI NINE (92565) GLUCOSE(82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 'Q 6/26/2017 4/27/2017 6/23/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(5) 4256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 16CC 3559 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE ARTERY INPATIENT /HOSPITAL LIJ 6/26/2017 4/27/2017 6/23/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 6/26/2017 4/27/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HDSPITAL _ 6/26/2017 4/28/2017 6123/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL ARTERY INPATIENT /HOSPITAL (82310)CARBON DIOXIDE(82374) CHLORIDE(82435) Q CREATI NINE (82565) GLUCOSE(82947) POTASSIUM uj (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6/26/2017 4/28/2017 6/23/2017 82247 BILIRUBIN; TOTAL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $19.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 0 6126/2017 4/28/2017 6/23/2017 82248 BILIRUBIN; DIRECT Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $8.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL W 6/26/2017 4/28/2017 6/23/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) Q256 STEN0515 OF PULMONARY PROFESSIONAL $0.00 $24.00 FEMALE DEPENDENT 1 BCC 3559 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE ARTERY INPATIENT /HOSPITAL Q . J 6/26/2017 4/28/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); 4256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $7.00 FEMALE DEPENDENT 16CC 3559 ARTERY INPATIENT/HOSPITAL v 6/26/2017 4/29/2017 6/23/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 CLEARED BY THE FDA SPECIFICALLY FOR HOME USE ARTERY INPATIENT /HOSPITAL W 6/26/2017 4/30/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL ARTERY INPATIENT/HOSPITAL (82310) CARBON DIOXIDE (92374) CHLORIDE (82435) CREATININE(82565) GLUCOSE (82947) POTASSIUM F (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6/26/2017 4/30/2017 6/23/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) Q256 STENOSIS OF PULMONARY PR0FE55IONAL $0.00 $12.00 FEMALE DEPENDENT 1BCC 3559 CLEARED BYTHE FDASPECIFICALL Y FOR HOME USE ARTERY INPATIENT /HOSPITAL N 6/26/2017 4/30/2017 6/23/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 = ARTERY INPATIENT /HOSPITAL {� 6/26/2017 4130/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STEN05I5 OF PULMONARY PROFESSIONAL $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 5/1/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL 1 BCC ARTERY INPATIENT /HOSPITAL $0.00 (82310) CARBON DIOXIDE (82374) CHLOR I UP (82435) 1 BCC 3559 $0.00 CREATININE(82565) GLUCOSE (82947) POTASS I UM 1 BCC 3559 $0.00 (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 1 BCC 3559 6/26/2017 5/1/2017 6/23/2017 80076 HEPATIC FUNCTION PANELTHIS PANEL MUST INCLUDE Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL 1 BCC ARTERY INPATIENT /HOSPITAL $0.00 (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, 1 BCC 3559 $0.00 ALKALINE (84075), PROTEIN, TOTAL (84155), 1 BCC 3559 TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) 6/26/2017 5/1/2017 6/23/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) Q256 STENOSIS OF PULMONARY PROFESSIONAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE ARTERY INPATIENT /HOSPITAL 6126/2017 5/1/2017 6/23/2017 85025 BLOOD COUNT; COMPLETE(CBQ, AUTOMATED(HGB, Q256 STEN0S150F PULMONARY PROFESSIONAL HCF, BBC, WBC AND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT 6/26/2017 5/1/2017 6/23/2017 85045 BLOOD COUNT; RETICULOCYTE, AUTOMATED Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 5/3/2017 6/23/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) Q256 STENOSIS OF PULMONARY PROFESSIONAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE ARTERY INPATIENT /HOSPITAL 6/26/2017 5/8/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL ARTERY INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (92374) CHLORIDE (92435) CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6/26/2017 5/8/2017 6/23/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE Q256 STENOSIS OF PULMONARY PROFESSIONAL THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL ARTERY INPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SOOT) (84450) 6/26/2017 5/8/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 5/8/2017 612312017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, Q256 STENOSIS OF PULMONARY PROFESSIONAL HOT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT 6/26/2017 5/8/2017 6/23/2017 85045 BLOOD COUNT; RETICULOCYTE, AUTOMATED Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 5/12/2017 6/23/2017 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(5) 0256 STENOSIS OF PULMONARY PROFESSIONAL CLEARED BY THE FDA SPECIFICALLY FOR HOME USE ARTERY INPATIENT /HOSPITAL 6/26/2017 5/12/2017 6/23/2017 84439 THYROXINE; FREE Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 5/12/2017 6/23/2017 84443 THYROID STIMULATING HORMONE (TSH) Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 5/12/2017 6/23/2017 85025 BLOOD COUNT; COMPLETE(CBQ, AUTOMATED(HGB, Q256 STENOSIS OF PULMONARY PROFESSIONAL HOT, BBC, WBC AND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT 6/26/2017 5/12/2017 6123/2017 86140 C- REACTIVE PROTEIN; Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 5/12/2017 6/23/2017 86923 COMPATIBILITY TEST EACH UNIT; ELECTRONIC Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC C.7.f 3559 $0.00 $29.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $11.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $29.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $11.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $19.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $33.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $24.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $24.00 FEMALE DEPENDENT 1 BCC 3559 $0.00 $27.00 FEMALE DEPENDENT 1 BCC 3559 C.7.f 6/26/2017 5/13/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL ARTERY INPATIENT /HOSPITAL (82310)CARBON DIOXIDE(82374) CHLDRIDE(82435) CREATI NINE (82565) GLUCOSE(82947) POTASSIUM N (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) m 4D 6/26/2017 5/13/2017 6/23/2017 82962 GLUCOSE, BLOOD BYGLUCOSE MONITORING DEVICE(S) Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $1100 FEMALE DEPENDENT 1BCC 3559 CLEARED BYTHE FDASPECIFICALLY FOR HOME USE ARTERY INPATIENT /HOSPITAL 6/26/2017 5/13/2017 6123/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $9.00 FEMALE DEPENDENT 1 BCC 3559 "a ARTERY INPATIENT /HOSPITAL 6/26/2017 5/13/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STENOSIS OF PULMONARY PROFE55IONAL $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 5/14/2017 6/23/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL $aCD $9.00 FEMALE DEPENDENT 1 BCC 3559 fl } ARTERY INPATIENT /HOSPITAL 6/26/2017 5/14/2017 6/23/2017 80048 BASICMETABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 N. CL MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL ARTERY INPATIENT /HOSPITAL Q, (82310)CARBON DIOXIDE(82374) CHLORIDE(82435) CREATI NINE (82565) GLUCOSE(82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6/26/2017 5/14/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $7.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 5/15/2017 6/23/2017 80076 HEPATIC FUNCTION PANELTHIS PANEL MUST INCLUDE Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $29.00 FEMALE DEPENDENT 1 BCC 3559 Lij THE FOLLOWING: ALBUMIN (82040), BILIRUBIN,TOTAL ARTERY INPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SCOT) (84450) 6/26/2017 5/22/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $25.00 FEMALE DEPENDENT 1 BCC 3559 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL ARTERY INPATIENT /HDSPITAL II. (82310)CARBON DIOXIDE(82374) CHLORIDE(82435) ui CREATI NINE (82565) GLUCOSE(82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) (fJ 6/26/2017 5/22/2017 6/23/2017 80076 HEPATIC FUNCTION PANELTHIS PANEL MUST INCLUDE Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $29.00 FEMALE DEPENDENT 1 BCC 3559 THE FOLLOWING: ALBUMIN (82040), BILIRUBIN,TOTAL ARTERY INPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, LLJ ALKALINE PROTEIN, TOTAL (84075), (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SPOT) (84450) 6/26/2017 5/22/2017 6/23/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 V HCT, BBC, WBCAND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL DIFFERENTIAL WEE COUNT 6/26/2017 5/22/2017 6/23/2017 85027 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, Q256 STENOSIS OF PULMONARY PROFE55IONAL $0.00 $13.00 FEMALE DEPENDENT 1 BCC 3559 LLJ HCT, RBC,WBCAND PLATELETCOUNT) ARTERY INPATIENT /HOSPITAL 6/26/2017 5/22/2017 6/23/2017 85045 BLOOD COUNT; RETICULOCYTE, AUTOMATED Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $11.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL (' 6/26/2017 5/29/2017 6/23/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED HEGE Q256 STENOSIS OF PULMONARY PROFESSIONAL $0.00 $12.00 FEMALE DEPENDENT 1 BCC 3559 HUT, BBC, WBCAND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HDSPITAL DIFFERENTIAL W BC COUNT < 6/26/2017 5/29/2017 6/23/2017 85045 BLOOD COUNT; RETICULOCYFE, AUTOMATED Q256 STENOSIS OF PULMONARY PROFE55IONAL $0.00 $11.00 FEMALE DEPENDENT 1 BCC 3559 ARTERY INPATIENT /HOSPITAL 6/26/2017 6/1/2017 6/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FORTHE H3S113 RETINOPATHY OF PROFESSIONAL $131.55 $240.00 FEMALE DEPENDENT 1BCC N 3559 EVALUATION AND MANAGEMENT OF A PATIENT, WHICH PREMATURITY, STAGE 0, INPATIENT /HOSPITAL = REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A BIIA.TERAL DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. .0 COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM �, 6/26/2017 6/5/2017 6/23/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL Q256 STENOSIS OF PULMONARY PROFESSIONAL $7.00 FEMALE DEPENDENT MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL $0.00 ARTERY INPATIENT /HOSPITAL $0.00 (82310) CARBON DIOXIDE (82374) CHLOR I UP (82435) 1 BCC $230.97 $858.00 FEMALE DEPENDENT 1 BCC CREATININE(82565) GLUCOSE (82947) POTASS I UM $240.00 FEMALE DEPENDENT 1 BCC (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 6/26/2017 6/5/2017 6/23/2017 80076 HEPATIC FUNCTION PANELTHIS PANEL MUST INCLUDE Q256 STENOSIS OF PULMONARY PROFESSIONAL THE FOLLOW ING: ALBUMIN (82040), BILIRUBIN, TOTAL ARTERY INPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PHOSPHATASE, ALKALINE (84075), PROTEIN, TOTAL (84155), TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460), TRANSFERASE, ASPARTATE AMINO (AST) (SECT) (84450) 6/26/2017 6/5/2017 6/23/2017 83735 MAGNESIUM Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 6/5/2017 6/23/2017 84100 PHOSPHORUS INORGANIC (PHOSPHATE); Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6126/2017 6/5/2017 6/23/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, Q256 STENOSIS OF PULMONARY PROFESSIONAL HC, DEC, WED AND PLATELET COUNT) AND AUTOMATED ARTERY INPATIENT /HOSPITAL DIFFERENTIAL WBC COUNT 6/26/2017 6/5/2017 6/23/2017 85045 BLOOD COUNT; RETICULOCYTE, AUTOMATED Q256 STENOSIS OF PULMONARY PROFESSIONAL ARTERY INPATIENT /HOSPITAL 6/26/2017 6/8/2017 6/23/2017 92586 AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE Z135 ENCOUNTER FOR PROFESSIONAL AUDIOMETRY AND /OR TESTING OF THE CENTRAL SCREENING FOR EYE AND INPATIENT /HOSPITAL NERVOUS SYSTEM; LIMITED EAR DISORDERS 6/26/2017 6/8/2017 6/23/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE H35123 RETINOPATHY OF PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH PREMATURITY, STAGE I, INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS :A BILATERAL DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROM 6/26/2017 6/22/2017 6/23/2017 92014 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H35113 RETINOPATHY OF PROFESSIONAL OFFICE AND EVALUATION, WITH INITIATION OR CONTINUATION PREMATURITY, STAGE 0, OF DIAGNOSTIC AND TREATMENT PROGRAM; BILATERAL COMPREHENSIVE, ESTABLISHED PATIENT, ONE OR MORE VISITS 6/26/2017 6122/2017 612312017 92225 OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING H35113 RETINOPATHY OF PROFESSIONAL OFFICE (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH PREMATURITY, STAGE 0, INTERPRETATION AND REPORT; INITIAL BILATERAL 6/28/2017 6/5/2017 6/27/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER Q221 CONGENITAL PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A PULMONARY VALVE INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS STENOSIS THROUGH 24 MONTHS OF AGE 6/28/2017 6/6/2017 6/27/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER Q221 CONGENITAL PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A PULMONARY VALVE INPATIENT /HOSPITAL CRITICALLY ILL INFANT DR YOUNG CHILD, 29 DAYS STENOSIS THROUGH 24 MONTHS OF AGE 6/28/2017 6/7/2017 6/27/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER Q221 CONGENITAL PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A PULMONARY VALVE INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS STENOSIS THROUGH 24 MONTHS OF AGE 6/28/2017 618/2017 6/27/2017 99479 SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE Q221 CONGENITAL PROFESSIONAL EVALUATION AND MANAGEMENT OF THE RECOVERING PULMONARY VALVE INPATIENT /HOSPITAL LOW BIRTH WEIGHT INFANT (PRESENT BODY WEIGHT OF STENOSIS 1500 -25DD GRAMS) $0.00 $25.00 FEMALE DEPENDENT 1 BCC $0.00 $29.00 FEMALE DEPENDENT 1 BCC $0.00 $9.00 FEMALE DEPENDENT 1 BCC $0.00 $7.00 FEMALE DEPENDENT 1 BCC $0.00 $12.00 FEMALE DEPENDENT 1 BCC $0.00 $11.00 FEMALE DEPENDENT 1 BCC $230.97 $858.00 FEMALE DEPENDENT 1 BCC $131.55 $240.00 FEMALE DEPENDENT 1 BCC $144.03 $225.00 FEMALE DEPENDENT 1 BCC $64.52 $230.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $1,160.03 $4,409.00 FEMALE DEPENDENT 1 BCC $349.93 $4,160.00 FEMALE DEPENDENT 1 BCC C.7.f 3559 im 3559 3559 3559 3559 3559 .MIT 3559 3559 3559 3559 3559 3559 6/28/2017 6/9/2017 6/26/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL 1 BCC EVALUATION AND MANAGEMENT OF PATIENT, WHICH $7,237.00 FEMALE DEPENDENT 1 BCC INPATIENT /HOSPITAL $4,409.00 FEMALE DEPENDENT REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A $20.54 $1,056.00 FEMALE DEPENDENT 1 BCC $1,120.80 DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; 1 BCC $20.54 $352.00 FEMALE DEPENDENT 1 BCC MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/28/2017 6/9/2017 6/27/2017 99479 SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE Q221 CONGENITAL PROFESSIONAL EVALUATION AND MANAGEMENT OF THE RE COVERING PULMONARY VALVE INPATIENT /HDSPITAL LOW BIRTH WEIGHT INFANT (PRESENT BODY WEIGHT OF STENOSIS 1500 -250D GRAMS) 6/28/2017 6/10/2017 6/26/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7881 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 6/28/2017 6/10/2017 6/27/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE Q221 CONGENITAL PROFESSIONAL THAN 30 MINUTES PULMONARY VALVE INPATIENT /HOSPITAL STENOSIS 6/29/2017 4/14/2017 6/27/2017 99255 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED D649 ANEMIA, UNSPECIFIED PROFESSIONAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT/HOSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. CDUNSELING AND /OR CDDRDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSI 6/29/2017 6/26/2017 6/28/2017 99391 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION, CCU NSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; INFANT (AGE (OUNGERTHAN 1YEAR) 7/3/2017 4/14/2017 6/19/2017 * *' ** 71312017 4/14/2017 6/30/2017 99465 Delivery /birthing room resuscitation, provision of positive P191 METABOLIC ACIDEMIA IN PROFESSIONAL pressoreventilation and /or chest compressions in the NEWBORN FIRST NOTED INPATIENT /HOSPITAL presence of acute inadequate ventilation and /or cardiac DURING LABOR output 7/3/2017 4/14/2017 6/30/2017 99468 INITIAL INPATIENT NEONATAL CRITICAL CARE, PER DAY, P0726 EXTREME IMMATURITY OF PROFESSIONAL FOR THE EVALUATION AND MANAGEMENT OF A NEWBORN, GESTATIONAL INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS AGE 27 COMPLETED WEEKS 71312017 4/15/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P399 INFECTION SPECIFIC TO PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A THE PERINATAL PERIOD, INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS UNSPECIFIED 7/3/2017 4/15/2017 6130/2017 97028 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; P599 NEONATAL JAUNDICE, PROFESSIONAL ULTRAVIOLET UNSPECIFIED INPATIENT /HOSPITAL 7/3/2017 4/16/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P399 INFECTION SPECIFIC TO PROFESSIONAL DAY, FOR THE EVALUATION AND MANAGEMENT OF A THE PERINATAL PERIOD, INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS UNSPECIFIED 71312017 4/16/2017 6/30/2017 97028 APPLICATION OF A MODALITY TO l OR MORE AREAS; P599 NEONATAL JAUNDICE, PROFESSIONAL ULTRAVIOLET UNSPECIFIED INPATIENT /HOSPITAL $160.23 $925.00 FEMALE DEPENDENT 1 BCC $34933 $4,160.00 FEMALE DEPENDENT 1 BCC $16013 $925.00 FEMALE DEPENDENT 1 BCC $299.59 $1,748.00 FEMALE DEPENDENT 1 BCC $257.30 $542.00 FEMALE DEPENDENT 1 BCC $113.41 $155.00 FEMALE DEPENDENT 1 BCC 4/14/2017 4####K4# $0.00 $454,157.00 FEMALE DEPENDENT 1 BCC $427.09 $1,705.00 FEMALE DEPENDENT 1 BCC $2,800.63 $7,237.00 FEMALE DEPENDENT 1 BCC $1,120.80 $4,409.00 FEMALE DEPENDENT 1 BCC $20.54 $1,056.00 FEMALE DEPENDENT 1 BCC $1,120.80 $4,409.00 FEMALE DEPENDENT 1 BCC $20.54 $352.00 FEMALE DEPENDENT 1 BCC C.7.f 3559 3559 3559 3559 3559 ME 3559 3559 3559 9MVI 3559 3559 3559 71312017 4/17/2017 6/30/2017 99469 SUBS EQU ENT INPATIENT NEONATAL CRITICAL CARE, PER P740 LATE METABOLIC PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA ACIDOSIS OF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 4/17/2017 6/30/2017 97028 APPLICATION OF A MODALITY TO I OR MORE AREAS; P599 NEONATAL JAUNDICE, PROFESSIONAL $20.54 $1,056.00 FEMALE DEPENDENT 1 BCC ULTRAVIOLET UNSPECIFIED INPATIENT /HOSPITAL 7/3/2017 4/18/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P740 LATE METABOLIC PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA ACIDOSIS OF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 4/18/2017 6/30/2017 97028 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; P599 NEONATAL JAUNDICE, PROFESSIONAL $20.54 $352.00 FEMALE DEPENDENT 1BCC ULTRAVIOLET UNSPECIFIED INPATIENT /HOSPITAL 7/3/2017 4/19/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P740 LATE METABOLIC PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA ACIDOSIS OF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 71312017 4/20/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P740 LATE METABOLIC PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA ACIDOSIS OF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 4/21/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 4/22/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT / HDSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 4/23/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 4/24/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1 BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 4/25/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 71312017 4/26/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 4/27/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 71312017 4/28/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1 BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT / HDSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 4/29/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 4/30/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 71312017 5/1/2017 6/30/2017 99469 SUBS EQU ENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1 BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 5/2/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 5/3/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1BCC DAY, FORTHE EVALUATIDNAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HDSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 5/4/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P220 RESPIRATORY DISTRESS PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT IBCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA SYNDROMEOF NEWBORN INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 71312017 5/5/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1 BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA FROM FETAL BLOOD LOSS INPATIENT/HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 5/6/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1 BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA FROM FETAL BLOOD LOSS INPATIENT /HOSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 5/7/2017 6/30/2017 99469 SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER P613 CONGENITAL ANEMIA PROFESSIONAL $1,120.80 $4,409.00 FEMALE DEPENDENT 1 BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA FROM FETAL BLOOD LOSS INPATIENT /HDSPITAL CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS 7/3/2017 5/11/2017 6/30/2017 99254 INPATIENT CONSULTATION FOR A NEW DR ESTABLISHED H35113 RETINOPATHY OF PROFESSIONAL $222.84 $392.00 FEMALE DEPENDENT 1BCC PATIENT,WHICH REQUIRESTHESE3 KEYCOMPONENTS :A PREMATURITY, STAGE 0, INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE BILATERAL EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED C 7/3/2017 6/5/2017 6/30/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER Q221 CONGENITAL PROFESSIONAL $0.00 $4,409.00 FEMALE DEPENDENT 1 BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA PULMONARYVALVE INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS STENOSIS THROUGH 24 MONTHS OF AGE 7/3/2017 6/6/2017 6/30/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER Q221 CONGENITAL PROFESSIONAL $0.00 $4,409.00 FEMALE DEPENDENT 1 BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA PULMONARYVALVE INPATIENT /HOSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS STENOSIS THROUGH 24 MONTHS OF AGE 7/3/2017 6/7/2017 6/30/2017 99472 SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER Q221 CONGENITAL PROFESSIONAL $0.00 $4,409.00 FEMALE DEPENDENT 1 BCC DAY, FORTHE EVALUATIONAND MANAGEMENTOFA PULMONARYVALVE INPATIENT /HDSPITAL CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS STENOSIS THROUGH 24 MONTHS OF AGE 7/3/2017 6/8/2017 6/30/2017 99479 SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE Q221 CONGENITAL PROFESSIONAL $0.00 $4,160.00 FEMALE DEPENDENT 1BCC EVALUATION AND MANAGEMENTOFTHE RE COVERING PULMONARYVALVE INPATIENT /HDSPITAL LOW BIRTH WEIGHT INFANT (PRESENT BODY WEIGHT OF STENOSIS 1500 -2500 GRAMS) 7/3/2017 6/9/2017 6/30/2017 99479 SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE Q221 CONGENITAL PROFESSIONAL $0.00 $4,160.00 FEMALE DEPENDENT IBCC EVALUATION AND MANAGEMENTOFTHE RECOVERING PULMONARYVALVE INPATIENT /HOSPITAL LOW BIRTH WEIGHT INFANT (PRESENT BODY WEIGHT OF STENOSIS 1500 -2500 GRAMS) 71312017 6/10/2017 6/30/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE Q221 CONGENITAL PROFESSIONAL $0.00 $1,748.00 FEMALE DEPENDENT 1 BCC THAN 30 MINUTES PULMONARY VALVE INPATIENT/HOSPITAL STENOSIS 7/12/2017 7/10/2017 7/11/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE P928 OTHER FEEDING PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PROBLEMS OF NEWBORN PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 7/17/2017 6/8/2017 7/14/2017 92587 DISTORTION PRODUCT EVOKED OTOACOUSTIC 700110 HEALTH EXAMINATION PROFESSIONAL EMISSIONS; LIMITED EVALUATION (TO CONFIRM THE FOR NEWBORN UNDER 8 INPATIENT / HDSPITAL PRESENCE OR ABSENCE OF HEARING DISORDER, 3 -6 DAYS OLD FREQUENCIES) OR TRANSIENT EVOKED OTOACOUSTIC EMISSIONS, WITH INTERPRETATION AND REPORT 711912017 6/22/2017 7/13/2017 93000 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 Q211 ATRIAL SEPTAL DEFECT PROFE55IONAL OFFICE LEADS; WITH INTERPRETATION AND REPORT 7119/2017 6/22/2017 7/13/2017 93306 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH Q211 ATRIALSEPTALDEFECT PROFESSIONAL OFFICE IMAGE DOCUMENTATION )2D), INCLUDES M -MODE RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 7/19/2017 6/22/2017 7/13/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 7/19/2017 7/12/2017 7/18/2017 99244 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED H35173 RETROLENTAL PROFESSIONAL OFFICE PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A FIBROPLASIA, BILATERAL COMPREHENSIVE HISTORY; A COMPREH ENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONS 7/20/2017 5/25/2017 7/18/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R7981 BACTEREMIA PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 7/24/2017 7/19/2017 7/21/2017 92014 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H35123 RETINOPATHY OF PROFESSIONAL OFFICE AND EVALUATION, WITH INITIATION OR CONTINUATION PREMATURITY, STAGE 1, OF DIAGNOSTIC AND TREATMENT PROGRAM; BILATERAL COMPREHENSIVE, ESTABLISHED PATIENT, ONE OR MORE VISITS 7/24/2017 7/19/2017 7/21/2017 92226 OPHTHALMOSC OPY, EXTENDED, W ITH RETINAL DRAWING H35123 RETINOPATHY OF PROFESSIONAL OFFICE ITS, FOR RETINAL DETACHMENT, MEIANDMA), WITH PREMATURITY, STAGE 1, INTERPRETATION AND REPORT; SUBSEQUENT BILATERAL $97.25 $180.00 FEMALE DEPENDENT 1 BCC $5036 $702.00 FEMALE DEPENDENT 1 BCC $25.25 $499.00 FEMALE DEPENDENT 1 BCC $373.51 $2,703.00 FEMALE DEPENDENT 1 BCC $122.30 $429.00 FEMALE DEPENDENT 1 BCC $253.70 $350.00 FEMALE DEPENDENT 1 BCC $16023 $925.00 FEMALE DEPENDENT 1 BCC $144.03 $225.00 FEMALE DEPENDENT 1 BCC $56.90 $230.00 FEMALE DEPENDENT 1 BCC C.7.f 7/31/2017 7/28/2017 7/30/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE P928 OTHER FEEDING PROFESSIONAL OFFICE $144.94 $260.00 FEMALE DEPENDENT 1BICE 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED PROBLEMS OF NEWBORN PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED N EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER t 8/8/2017 8/2/2017 8/7/2017 92014 OPHTHALM0L0GI CAL SERVICES: MEDICAL EXAMINATION H35113 RETINOPATHY OF PROFESSIONAL OFFICE $144.03 $225.00 FEMALE DEPENDENT 1BCC 3559 7 AND EVALUATIDN,WITH INITIATION ORCONTINUATION PREMATURITY, STAGE 0, OF DIAGNOSTIC AND TREATMENT PROGRAM; BILATERAL COMPREHENSIVE, ESTABLISHED PATIENT, ONE OR MORE VISITS 8/8/2017 8/2/2017 8/7/2017 92226 OPHTHALM0SC0PY , EXTENDED, WITH RETINAL DRAWING H35113 RETINOPATHY OF PROFESSIONAL OFFICE $56.90 $230.00 FEMALE DEPENDENT 1EGG 3559 } (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH PREMATURITY, STAGE O, INTERPRETATION AND REPORT; SUBSEQUENT BILATERAL iL CL CL 8/9/2017 8/7/2017 8/8/2017 * * * "* * * * ** * * * ** F #fii * * * ** $144.94 $260.00 FEMALE DEPENDENT 1 BCC 3559 811112017 8/8/2017 8/10/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 80683 SNORING PROFESSIONAL OFFICE $179.52 $634.00 FEMALE DEPENDENT IBCC 3559 v EVALUATION AND MANAGEMENTOFAN ESTABLISHED PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR F COORDINATION OF CARE WITH OTHER D 8/18/2017 8/18/2017 4/14/2017 4/14/2017 6/19/2017 * * * ** 6/19/2017 * * * ** * * * ** * * * ** * * * ** * " * ** * * * *" * * * ** * * * ** * * * ** 4/14/2017 # # # # # # ## $293,194.20 4/14/2017 # # # # # # ## $0.00 $454,157.00 FEMALE DEPENDENT ($4E4,1S,WJ) FEMALE DEPENDENT 1 BCC 1 BCC 3559 3559 8/25/2017 8/22/2017 8124/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE P0732 PRETERM NEWBORN, PROFESSIONAL OFFICE $179.52 $634.00 FEMALE DEPENDENT 1BCC _ 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED GESTATIONAL AGE 29 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPLETED WEEKS COMPONENTS: A DETAILED HISTORY; A DETAILED Q EXAMINATION; MEDICAL DECISION MAKING OF Lli MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER UJ 8128/2017 8/23/2017 8/25/2017 92014 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION H35113 RETINOPATHY OF PROFESSIONAL OFFICE $144.03 $225.00 FEMALE DEPENDENT 1 BCC 3559 AND EVALUATION, WITH INITIATION ORCONTINUATION PREMATURITY, STAGE 0, OF DIAGNOSTIC AND TREATMENT PROGRAM; BILATERAL e LLJ COMPREHENSIVE, ESTABLISHED PATIENT, ONE OR MORE VISITS q 8/29/2017 8/24/2017 8/28/2017 90460 IMMUNIZATI0N ADMINISTRATION THROUGH 18 YEARS Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $108.81 $150.00 FEMALE DEPENDENT 16CC 3559 J OFAGEVIAANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH EXAMINATION WITHOUT v CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF ABNORMAL FINDINGS EACH VACCINE DR TOXOID ADMINISTERED W 8/29/2017 8/24/2017 812812017 90461 IMMUNIZATI0N ADMINISTRATION THROUGH 18 YEARS Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $73.52 $120.00 FEMALE DEPENDENT 1BCC 3559 OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH COUNSELING BY PHYSICIAN DR OTHER QUALIFIED HEALTH EXAMINATION WITHOUT (' CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR ABNORMAL FINDINGS TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURES CNj N 8/29/2017 8/24/2017 8/28/2017 90648 HEMOPHILUS INFLUENZA BVACCINE(HIB), PRP -T Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $15.00 $65.00 FEMALE DEPENDENT 1 BCC 3559 CONJUGATE (4 D0SE SCHEDULE), FOR INTRAMUSCULAR ROUTINE CHILD HEALTH = USE EXAMINATION WITHOUT ABNORMAL FINDINGS 8/29/2017 8/24/2017 812812017 90670 PNEUCOCOCCALCONIUGATEVACCINE, 13 VALE NT, FOR Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE INTRAMUSCULAR USE ROUTINE CHILD HEALTH EXAMINATION WITHOUT ABNORMAL FINDINGS 8/29/2017 8/24/2017 812812017 90723 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS ROUTINE CHILD HEALTH VACCINE (DTAP- HEPB -IPV(, FOR INTRAMUSCULAR USE EXAMINATION WITHOUT ABNORMAL FINDINGS 8/29/2017 8/24/2017 8/28/2017 99391 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; INFANT (AGE YOUNGER THAN I YEAR) 101212017 9/27/2017 9/29/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE P0726 EXTREM E I M MATU RITY O F P ROE ESS IO NAL OF F ICE E VALUATIO N AN D MANAG EM E NT OF AN ESTAB LISH E D NEWBORN, GESTATIONAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY AGE 27 COMPLETED COMPONENTS: AN EXPANDED PROBLEM FOCUSED WEEKS HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 10/13/2017 10/10/2017 10/1212017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE P0726 EXTRE M E I M MATU RITY O F P ROE ESS IO NAL OF F ICE E VALUATIO N AN D MANAG EM E NT OF AN FATAL LISH E D NEWBORN, GESTATIONAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY AGE 27 COMPLETED COMPONENTS: AN EXPANDED PROBLEM FOCUSED WEEKS HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 11/17/2017 10/25/2017 11/9/2017 93000 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE LEADS; WITH INTERPRETATION AND REPORT 11/17/2017 10/25/2017 11/9/2017 93306 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH Q211 ATRIALSEPTALDEFECT PROFESSIONAL OFFICE IMAGE DOCUMENTATION (2D), INCLUDES M -MODE RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 11/17/2017 10/25/2017 11/9/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Q211 ATRIAL SEPTAL DEFECT PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 11/20/2017 11/14/2017 11116/2017 90460 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS Z23 ENCOUNTER FOR PROFESSIONAL OFFICE OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH IMMUNIZATION COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE OR TOXOID ADMINISTERED 1112012017 11/14/2017 11/16/2017 90685 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLITVIRUS, Z23 ENCOUNTERFOR PROFESSIONAL OFFICE PRESERVATIVE FREE, WHEN ADMINISTERED TO CHILDREN IMMUNIZATION 6 -35 MONTHS OF AGE, FOR INTRAMUSCULAR USE $186.00 $255.00 FEMALE DEPENDENT 1 BCC $80.00 $180.00 FEMALE DEPENDENT 1 BCC $11341 $155.00 FEMALE DEPENDENT 1 BCC $122.30 $429.00 FEMALE DEPENDENT 1 BCC $12230 $429.00 FEMALE DEPENDENT 1 BCC $25.25 $499.00 FEMALE DEPENDENT 1 BCC $373.51 $2,703.00 FEMALE DEPENDENT 1 BCC $122.30 $429.00 FEMALE DEPENDENT 1 BCC $41.83 $82.00 FEMALE DEPENDENT 1 BCC $20.00 $126.00 FEMALE DEPENDENT 1 BCC 1112012017 11/14/2017 11/16/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z23 ENCOUNTER FOR PROFESSIONAL OFFICE $122.30 $429.00 FEMALE DEPENDENT 1 BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED IMMUNIZATION PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 12/15/2017 12/13/2017 12/14/2017 90460 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $145.08 $200.00 FEMALE DEPENDENT 1BCC OFAGEVIAANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH EXAMINATION WITHOUT CARE PROFESSIONAL; FIRST OR ONLY COMPONENT OF ABNORMAL FINDINGS EACH VACCINE OR TOXOID ADMINISTERED 12/15/2017 12/13/2017 12/14/2017 90461 IMMUNIZATION ADMINISTRATION THROUGH I8 YEARS Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $73.52 $120.00 FEMALE DEPENDENT 1BCC OFAGEVIAANY ROUTE OF ADMINISTRATION, WITH ROUTINE CHILD HEALTH COUNSELING BY PHYSICIAN OR OTHER QUALIFIED HEALTH EXAMINATION WITHOUT CARE PROFESSIONAL; EACH ADDITIONAL VACCINE OR ABNORMAL FINDINGS TOXOID COMPONENT ADMINISTERED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 12/15/2017 12/13/2017 12/14/2017 90648 HEMOPHILUS INFLUENZA BVACCINE(HIS), PRP -T Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $15.00 $65.00 FEMALE DEPENDENT 1 BCC CONJUGATE (4 DOSE SCHEDULE), FOR INTRAMUSCULAR ROUTINE CHILD HEALTH USE EXAMINATION WITHOUT ABNORMAL FINDINGS 12/15/2017 12/13/2017 12/14/2017 90670 PNEUCOCOCCALCONJUGATE VACCINE, I3VALENT, FOR Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $186.00 $255.00 FEMALE DEPENDENT 1 BCC INTRAMUSCULAR USE ROUTINE CHILD HEALTH EXAMINATION WITHOUT ABNORMAL FINDINGS 12/15/2017 12/13/2017 12/14/2017 90685 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPUTVIRUS, Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $20.00 $70.00 FEMALE DEPENDENT 1 BCC PRESERVATIVE FREE, WHEN ADMINISTERED TO CHILDREN ROUTINE CHILD HEALTH 6 -35 MONTHS OF AGE, FOR INTRAMUSCULAR USE EXAMINATION WITHOUT ABNORMAL FINDINGS 12/15/2017 12/13/2017 12/14/2017 90723 DIPHTHERIA, TETANUSTOXOIDS, ACELLULAR PERTUSSIS Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $80.00 $180.00 FEMALE DEPENDENT 1 BCC VACCINE, HEPATITIS B, AND INACTIVATED POLIOVIRUS ROUTINE CHILD HEALTH VACCINE)DTAP -HEPB- IPV), FOR INTRAMUSCULAR USE EXAMINATION WITHOUT ABNORMAL FINDINGS 12/15/2017 12/13/2017 12/14/2017 99391 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z00129 ENCOUNTER FOR PROFESSIONAL OFFICE $113.41 $155.00 FEMALE DEPENDENT 1 BCC REEVALUATIDNAND MANAGEMENTOFAN INDIVIDUAL ROUTINE CHILD HEALTH INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; INFANT (AGE YOUNGER THAN 1 YEAR) Sub Total $368,205.15 $845,418.00 6.5E +10 3/30/2017 3/23/2017 3/29/2017- - R55 SYNCOPE AND COLLAPSE HOSPITAL OUTPATIENT $5,234.23 $9,980.85 MALE SPOUSE 1CCC 3/30/2017 3/25/2017 3/29/2017 * * * ** " " *'* *• " *+ " ""` "' " *" 3/25/2017 # # # # # # ## $7,699.82 $20,279.55 MALE SPOUSE 1 CCC 3/31/2017 3/23/2017 3/30/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 RSS SYNCOPE AND COLLAPSE PROFESSIONAL $0.00 $138.00 MALE SPOUSE 1 CCC LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 3/31/2017 3/23/2017 3/30/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R55 SYNCOPE AND COLLAPSE PROFESSIONAL $235.06 $1,481.00 MALE SPOUSE 1 CCC AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF TH E PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 3/31/2017 3/25/2017 3/30/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R001 BRADYCARDIA, PROFESSIONAL $0.00 $69.00 MALE SPOUSE 1 CCC LEADS; INTERPRETATION AND REPORT ONLY UNSPECIFIED OUTPATIENT /HOSPITAL 3/31/2017 3/25/2017 3/30/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R001 BRADYCARDIA, PROFESSIONAL $235.06 $1,481.00 MALE SPOUSE 1 CCC AND MANAGEMENTOFA PATIENT, WHICH REQUIRES UNSPECIFIED OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 3/31/2017 3/25/2017 3/30/2017 83090 HOMOCYSTEINE R55 SYNCOPE AND COLLAPSE PROFESSIONAL $0.00 $20.00 MALE SPOUSE 1 CCC INPATIENT /HOSPITAL 3/31/2017 3/26/2017 3/30/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITHATLEAST 12 1454 NONSPECIFIC PROFESSIONAL $7.06 $29.00 MALE SPOUSE 1 CCC LEADS; INTERPRETATION AND REPORT ONLY INTRAVENTRICULAR INPATIENT /HOSPITAL BLOCK 3/31/2017 3/27/2017 3/30/2017 93458 Catheter placement l n coronary a,t,,y(,) for coronary 1208 OTHER FORMS OF PROFESSIONAL $237.13 $1,238.00 MALE SPOUSE 1 CCC angiography, including intraprocedural injections ) for ANGINA PECTORIS INPATIENT /HOSPITAL ovary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 4/3/2017 3/23/2017 3/31/2017 * * * ** * * * ** *' * ** * * * ** * * * ** $63.94 $202.00 MALE SPOUSE 1 CCC 4/3/2017 3/24/2017 3/31/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R0602 SHORTNESSOFBREATH PROFESSIONAL $1110 $36.00 MALE SPOUSE 1 CCC FRONTAL INPATIENT /HOSPITAL 4/4/2017 3/26/2017 4/3/2017 - - 12510 ATHEROSCLEROTIC HEART HOSPITAL INPATIENT 3/26/2017 # # # # # # ## $21,222.16 $77,446.88 MALE SPOUSE 1 CCC DISEASE OF NATIVE CORONARY ARTERY W ITHOUT ANG I NA PECTORIS 4/4/2017 3/28/2017 4/3/2017 537 ANESTHESIA FOR CARDIAC ELECTROPHYSIOLOGIC R55 SYNCOPE AND COLLAPSE PROFESSIONAL $886.05 $1,800.00 MALE SPOUSE 1 CCC PROCEDURES INCLUDING RADIOFREQUENCY ABLATION INPATIENT /HOSPITAL 4/5/2017 3/25/2017 4/4/2017 99223 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION R55 SYNCOPE AND COLLAPSE PROFESSIONAL $189.81 $893.00 MALE SPOUSE 1CCC AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGED 4/5/2017 3/26/2017 4/4/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE R55 SYNCOPE AND COLLAPSE PROFESSIONAL $99.29 $467.00 MALE SPOUSE 1 CCC THAN 30 MINUTES INPATIENT /HOSPITAL 4/10/2017 3/27/2017 4/7/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION R55 SYNCOPE AND COLLAPSE PROFESSIONAL $ODD $435.00 MALE SPOUSE 1 CCC AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 4/10/2017 3/28/2017 4/7/2017 33282 IMPLANTATION OF PATIENT- ACTIVATED CARDIAC EVENT R55 SYNCOPE AND COLLAPSE PROFESSIONAL $0.00 $805.00 MALE SPOUSE 1 CCC RECORDER INPATIENT /HOSPITAL C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 III C.7.f 4/10/2017 3/28/2017 4/7/2017 76937 ULTRASOUND GU I DANCE FOR VASCULAR ACCESS R55 SYNCOPE AND COLLAPSE PROFESSIONAL $0.00 $80.00 MALE SPOUSE 1 CCC 3559 REQUIRING ULTRASOUND EVALUATION OF POTENTIAL INPATIENT /HOSPITAL ACCESS SITES, DOCUMENTATION OF SELECFED VESSEL Z PATENCY, CONCURRENT REACTIVE ULTRASOUND N VISUALIZATION OF VASCULAR NEEDLE ENTRY, Q! 4/10/2017 3/28/2017 4/7/2017 93620 COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION R55 SYNCOPE AND COLLAPSE PROFESSIONAL $0.00 $3,570.00 MALE SPOUSE 1 CCC 3559 INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE INPATIENT /HOSPITAL ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED } INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUND 4/10/2017 3/28/2017 4/7/2017 93623 PROGRAMMED STIMULATION AND PACINGAFTER KISS SYNCOPE AND COLLAPSE PROFESSIONAL $0.00 $895.00 MALE SPOUSE 1 CCC 3SS9 } INTRAVENOUS DRUG INFUSION (LIST SEPARATELY IN INPATIENT /HOSPITAL ADDITION TO CODE FOR PRIMARY PROCEDURE) iL CL 4110/2017 3/28/2017 4/7/2017 93660 EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT R55 SYNCOPE AND COLLAPSE PROFESSIONAL $0.00 $340.00 MALE SPOUSE 1 CCC 3559 Q, TABLE EVALUATION, WITH CONTINUOUS ECG INPATIENT /HOSPITAL MONITORING AND INTERMITTENT BLOOD PRESSURE MON ITORING, W ITH OR WITHOUT PHARMACOLOGICAL INTERVENTION 4 4/11/2017 3/25/2017 4/10/2017 99245 OFFICE CONSULTATION FORANEW OR ESTABLISHED R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $335.01 $623.00 MALE SPOUSE 1CCC 3559 PATIENT, W H ICH REQUIRES THESE 3 KEY COMPONENTS: A OUTPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR CDDRDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTE 4/11/2017 3/26/2017 4/10/2017 93306 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $106.40 $216.00 MALE SPOUSE 1 CCC 3559 IMAGE DOCUMENTATION (213), INCLUDES M -MODE OUTPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH ui SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY UJ 4/13/2017 3/28/2017 4/11/2017 93880 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE R55 SYNCOPE AND COLLAPSE PROFESSIONAL $56.32 $135.00 MALE SPOUSE 1 CCC 3559 BILATERAL STUDY INPATIENT /HOSPITAL 4/14/2017 3/24/2017 4/12/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITHATLEAST12 R55 SYNCOPE AND COLLAPSE PROFESSIONAL $11.07 $70.00 MALE SPOUSE 1 CCC 3559 IELJ LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL °✓ 4/14/2017 3/25/2017 4/12/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R55 SYNCOPE AND COLLAPSE PROFESSIONAL $11.07 $70.00 MALE SPOUSE 1 DEC 3559 LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL v 4/14/2017 3/26/2017 4/13/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION R001 BRADVCARDIA, PROFESSIONAL $0.00 $285.00 MALE SPOUSE 1 CCC 3559 AND MANAGEMENTOFA PATIENT,WHICH REQUIRES UNSPECIFIED INPATIENT /HOSPITAL THESE 3 KEYCOMPONENTS: A COMPREHENSIVE HISTORY; uj A COMPREHENSIVE EXAMINATIDN; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH (' OTHER PROVIDERS OR 4/14/2017 3/27/2017 4113/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R001 BRADVCARDIA, PROFESSIONAL $0.00 $150.00 MALE SPOUSE 1CCC 3559 EVALUATION AND MANAGEMENTOFA PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY CUM PO ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN Cy EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL = DECISION MAKING OF MODERATE COMPLEXITY. y COUNSELING AND /OR L 4/14/2017 3/28/2017 4/13/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE R55 SYNCOPE AND COLLAPSE PROFESSIONAL $0.00 $215.00 MALE SPOUSE 1 CCC 3559 THAN 30 MINUTES INPATIENT /HOSPITAL 4/24/2017 3/26/2017 412012017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL 12510 ATHEROSCLEROTIC HEART PROFESSIONAL $0.00 MUST INCLUDETHE FOLLOWING: CALCIUM,TOTAL SPOUSE DISEASE OF NATIVE INPATIENT /HOSPITAL $30.00 MALE (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) $0.00 CORONARY ARTERY SPOUSE CREATININE(82565) GLUCOSE (82947) POTASSIUM $20.00 MALE WITHOUTANGINA $0.00 (84132) SODIUM (84295) UREA NITROGEN (BUN)(84520) SPOUSE PECTORIS 4/24/2017 3/26/2017 4/20/2017 80061 LIPID PANEL 12510 ATHEROSCLEROTIC HEART PROFESSIONAL DISEASE OF NATIVE INPATIENT /HOSPITAL CORONARYARTERY WITHOUTANGINA PECTORIS 4/24/2017 3/26/2017 4/20/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, 12510 ATHEROSCLEROTIC HEART PROFESSIONAL HCT BBC, WBCAND PLATELETCDUNT) AND AUTOMATED DISEASE OF NATIVE INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT CORONARYARTERY WITHOUTANGINA PECTORIS 4124/2017 3/26/2017 4/20/2017 85730 THR0MB0PLASTIN TIME, PARTIAL(PTT); PLASMA OR 12510 ATHEROSCLEROTIC HEART PROFESSIONAL WHOLE BLOOD DISEASE OF NATIVE INPATIENT /HOSPITAL CORONARY ARTERY WITHOUTANGINA PECTORIS 4/24/2017 3/27/2017 4/20/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, 12510 ATHEROSCLEROTIC HEART PROFESSIONAL HCT,RBC,WBCAND PLATELETCDUNT) AND AUTOMATED DISEASE OF NATIVE INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT CORONARYARTERY WITHOUTANGINA PECTORIS 4/24/2017 3/27/2017 4/20/2017 85730 THR0MB0PLASTIN TIME, PARTIAL(PTT); PLASMA OR 12510 ATHEROSCLEROTIC HEART PROFESSIONAL WHOLE BLOOD DISEASE OF NATIVE INPATIENT / HDSPITAL CORONARY ARTERY WITHOUT ANGINA PECTORIS 4/24/2017 3/28/2017 4/20/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL 12510 ATHEROSCLEROTIC HEART PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL DISEASE OF NATIVE INPATIENT /HOSPITAL (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CORONARY ARTERY CREATININE(BESSE) GLUCOSE (82947) POTASSIUM WITHOUTANGINA (84132) SODIUM (84295) UREA NITROGEN (BUN)(84520) PECTORIS 4/24/2017 3128/2017 4/20/2017 80076 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE 12510 ATHEROSCLEROTIC HEART PROFESSIONAL THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, T0TAL DISEASE OF NATIVE INPATIENT /HOSPITAL (82247), BILIRUBIN, DIRECT (82248), PH0SPHATASE, CORONARY ARTERY ALKALINE (84075), PROTEIN, TOTAL (84155), WITHOUT ANGINA TRANSFERASE, ALANINE AMINO (ALT)(SGPT)(84460), PECTORIS TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) 4/24/2017 3/28/2017 4/20/2017 84443 THYROID STIMULATING HORMONE(TSH) 12510 ATHEROSCLEROTIC HEART PROFESSIONAL DISEASE OF NATIVE INPATIENT /HOSPITAL CORONARYARTERY WITHOUTANGINA PECTORIS 4/24/2017 3/28/2017 4/20/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, 12510 ATHEROSCLEROTIC HEART PROFESSIONAL HCT RBC, WBCAND PLATELETCDUNT )ANDAUTOMATED DISEASE OF NATIVE INPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT CORONARYARTERY WITHOUT ANGINA PECTORIS 4/24/2017 3/28/2017 4120/2017 85610 PROTHROMBIN TIME; 12510 ATHEROSCLEROTIC HEART PROFESSIONAL DISEASE OF NATIVE INPATIENT /HOSPITAL CORONARYARTERY WITHOUT ANGINA PECTORIS $0.00 $26.00 MALE SPOUSE 1 CCC $0.00 $40.00 MALE SPOUSE $0.00 $11.00 MALE SPOUSE $0.00 $30.00 MALE SPOUSE $0.00 $11.00 MALE SPOUSE $0.00 $20.00 MALE SPOUSE $0.00 $26.00 MALE SPOUSE $0.00 $57.00 MALE SPOUSE $0.00 $26.00 MALE SPOUSE $0.00 $11.00 MALE SPOUSE $0.00 $10.00 MALE SPOUSE 1 CCC 1 CCC 1 CCC 1 CCC 1 CCC 1 CCC 1 CCC 1 CCC 1 CCC 1 CCC 4/24/2017 3/28/2017 412012017 85730 THROMBOPLASTINTIME , PARTIAL (PET); PLASMA OR 12510 ATHEROSCLEROTIC HEART PROFESSIONAL 3559 WHOLE BLOOD $215.00 MALE DISEASE OF NATIVE INPATIENT /HOSPITAL 1 DEC 3559 $7.50 CORONARY ARTERY SPOUSE 1 CCC 3559 W ITHOUT ANG I NA $358.67 MALE SPOUSE 1 CCC PECTORIS 5/1/2017 3/23/2017 4/28/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R55 SYNCOPE AND COLLAPSE PROFESSIONAL 3559 LEADS; INTERPRETATION AND REPORT ONLY $337.00 MALE OUTPATIENT /HOSPITAL 5/5/2017 3/26/2017 4113/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION R001 BRADYCARDIA, PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES UNSPECIFIED INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 5/5/2017 3/26/2017 5/1/2017 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION 3001 BRADYCARDIA, PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES UNSPECIFIED INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR S/5/2017 3/27/2017 4/13/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R001 BRADYCARDIA, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COM PO ENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 5/5/2017 3/27/2017 5/1/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R001 BRADYCARDIA, PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 5/5/2017 3/28/2017 4/13/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE R55 SYNCOPE AND COLLAPSE PROFESSIONAL THAN 30 MINUTES INPATIENT /HOSPITAL 5/5/2017 3/28/2017 5/1/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE R55 SYNCOPE AND COLLAPSE PROFESSIONAL THAN 30 MINUTES INPATIENT /HOSPITAL 5/9/2017 3/26/2017 5/8/2017 A0425 GROUND MILEAGE, PER STATUTE MILE R079 CHEST PAIN, UNSPECIFIED OTHER MEDICAL 5/9/2017 3/26/2017 5/8/2017 A0429 AMBULANCE SERVICE , BASIC LIFE SUPPORT, EMERGENCY R079 CHEST PAIN, UNSPECIFIED OTHER MEDICAL TRANSPORT (BLS- EMERGENCY) 5/23/2017 5/15/2017 5/22/2017 93000 ELECTRDCARDIDGRAM, ROUTINE ECG WITH AT LEAST 12 R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE LEADS; WITH INTERPRETATION AND REPORT 5/23/2017 5/15/2017 5/22/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 5/25/2017 3/26/2017 412612017 * * °'" " "" "` *' ° " *' " " "" $0.00 $10.00 MALE SPOUSE 1 CCC C.7.f 3559 $11.07 $70.00 MALE SPOUSE 1 CCC 3559 $0.00 ($285.00) MALE SPOUSE 1 CCC 3559 $166.73 $285.00 MALE SPOUSE 1 CCC 3559 $0.00 ($150.00j MALE SPOUSE 1 CCC 3559 $86.65 $150.00 MALE SPOUSE 1 CCC 3559 $0.00 ($215.00} MALE SPOUSE 1 CCC 3559 $128.50 $215.00 MALE SPOUSE 1 DEC 3559 $7.50 $7.50 MALE SPOUSE 1 CCC 3559 $339.32 $358.67 MALE SPOUSE 1 CCC 3559 $33.01 $66.00 MALE SPOUSE 1 CCC 3559 $188.81 $337.00 MALE SPOUSE 1 CCC 3559 $7,724.00 $25,200.00 MALE SPOUSE 1 CCC ME 6/14/2017 5/12/2017 6/13/2017 93298 INTERROGATION DEVICE EVALUATION(SE (REMOTE) UP R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE 1 CCC TO 30 DAYS; IMPLANTABLE LOOP RECORDER SYSTEM, $80.00 MALE SPOUSE INCLUDING ANALYSIS OF RECORDED HEART RHYTHM $863.91 $3,570.00 MALE DATA, PHYSICIAN ANALYSIS, REVIEW(S) AND REPORT(S) 1 COG 6/14/2017 5/12/2017 6/13/2017 93299 INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR MONITOR SYSTEM OR IMPLANTABLE LOOP RECORDER SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORTAND DISTRIBUTION OF RESULTS 6/19/2017 6/12/2017 6/16/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R002 PALPITATIONS PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 71612017 6/5/2017 7/5/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E785 HYPERLIPIDEMIA, OTHER MEDICAL UNSPECIFIED 7/14/2017 7/5/2017 7/13/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R002 PALPITATIONS PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 7/17/2017 3/27/2017 7/6/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION R55 SYNCOPE AND COLLAPSE PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 7/17/2017 3/28/2017 7/6/2017 33282 IMPLANTATI0N OF PATIENT- ACTIVATED CARDIAC EVENT R55 SYNCOPE AND COLLAPSE PROFESSIONAL RECORDER INPATIENT /HOSPITAL 7/17/2017 3/28/2017 7/6/2017 76937 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS R55 SYNCOPE AND COLLAPSE PROFESSIONAL REQUIRING ULTRASOUND EVALUATION OF POTENTIAL INPATIENT /HOSPITAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION OF VASCULAR NEEDLE ENTRY, 7/17/2017 3/28/2017 7/6/2017 93620 COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION R55 SYNCOPE AND COLLAPSE PROFESSIONAL INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE INPATIENT / HDSPITAL ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHTATRIAL PACING AND RECORDING, RIGHTVENTRICUTAR PACING AND RECORDING, HIS BEND 7/17/2017 3/28/2017 7/6/2017 93623 PROGRAMMED STIMULATION AND PACING AFTER RSS SYNCOPE AND COLLAPSE PROFESSIONAL INTRAVENOUS DRUG INFUSION (LIST SEPARATELY IN INPATIENT /HOSPITAL ADDITION TO CODE FOR PRIMARY PROCEDURE) 7/17/2017 3/28/2017 7/6/2017 93660 EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT R55 SYNCOPE AND COLLAPSE PROFESSIONAL TABLE EVALUATION, WITH CONTINUOUS ECG INPATIENT /HOSPITAL MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION $32.07 $60.00 MALE SPOUSE 1 FCC $42.02 $75.00 MALE SPOUSE 1 DEC $188.81 $337.00 MALE SPOUSE 1 CCC $0.00 $32.00 MALE SPOUSE 1 DEC $188.81 $337.00 MALE SPOUSE 1 CCC $0.00 $435.00 MALE SPOUSE 1 CCC $15277 $805.00 MALE SPOUSE 1 CCC $17.50 $80.00 MALE SPOUSE 1 CCC $863.91 $3,570.00 MALE SPOUSE 1 COG $219.64 $895,00 MALE SPOUSE 1 CCC $5545 $340.00 MALE SPOUSE 1 CCC C.7.f 712712017 3/27/2017 7/26/2017 99254 INPATIENT CONSULTATION FOR ANEW OR ESTABLISHED R55 SYNCOPE AND COLLAPSE PROFESSIONAL $0.00 $435.00 MALE SPOUSE 1CCC 3559 PATIENT, W H ICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF N MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED C 8/2/2017 7/24/2017 8/1/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R001 BRADVCARDIA, PROFESSIONAL $0.00 $69.00 MALE SPOUSE 1 CCC 3559 7 LEADS; INTERPRETATION AND REPORT ONLY UNSPECIFIED OUTPATIENT /HOSPITAL 8/2/2017 7/24/2017 8 /1/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R001 BRADVCARDIA, PROFESSIONAL $313.41 $1,481.00 MALE SPOUSE 1 CCC 3559 AND MANAGEMENTOFA PATIENT,WHICH REQUIRES UNSPECIFIED OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS } IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE iL CL HISTORY; A COMPREHENSIVE EXAMINATION; AND Q, MEDICAL DECIS 8/2/2017 7/24/2017 8/1/2017 * *x'* * * * ** 7/24/2017 NNHkk### $6,207.00 $16,957.08 MALE SPOUSE 1 CCC 3559 8/3/2017 7/1D/2017 7/28/2017 958065LEEPSTUDY ,SIMULTANEOUS RECORDINGOF G4733 OBSTRUCTIVE SLEEP PROFESSIONAL OFFICE $191.00 $191.00 MALE SPOUSE 1CCC 3559 VENTILATION, RESPIRATORY EFFORT, ECG OR HEART RATE, APNEA (ADULT) AND OXYGEN SATURATION, UNATTENDED BY (PEDIATRIC) TECHNOLOGIST h 8/3/2017 7/24/2017 8/2/2017 70450 COMPUTED TOMOGRAPHY, HEADOR BRAIN; WITHOUT R42 DIZZINESS AND GIDDINESS PROFESSIONAL $70.32 $166.00 MALE SPOUSE 1CCC 3559 8/3/2017 7/24/2017 8/2/2017 CONTRAST MATERIAL 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 80989 OTHER SPECIFIED INPATIENT /HOSPITAL PROFESSIONAL $14.94 $36.00 MALE SPOUSE 1 CCC 3559 FRONTAL SYMPTOMS AND SIGNS OUTPATIENT /HOSPITAL INVOLVING THE CIRCU LATORV AND RESPIRATORY SYSTEMS 8/9/2017 7/24/2017 8/8/2017 99223 INITIAL HOSPITALCARE, PER DAY, FORTHE EVALUATION R001 BRADVCARDIA, OTHER MEDICAL $161.34 $893.00 MALE SPOUSE 1 CCC 3559 Q AND MANAGEMENT OF A PATIENT, WHICH REQUIRES UNSPECIFIED uj THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL UJ DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN W 8/9/2017 7/25/2017 8/8/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE R001 BRADVCARDIA, OTHER MEDICAL $84.40 $467.00 MALE SPOUSE 1 CCC 3559 THAN 30 MINUTES UNSPECIFIED 811012017 811/2017 8/9/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 8002 PALPITATIONS PROFESSIONAL OFFICE $188.81 $337.00 MALE SPOUSE 1CCC 3559 J EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY v COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR LLJ COORDINATION OF CARE WITH OTHER 8/14/2017 7/25/2017 811112017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R001 BRADVCARDIA, PROFESSIONAL $68.07 $128.00 MALE SPOUSE 1CCC 3559 (' EVALUATION AND MANAGEMENT OF A PATIENT, WHICH UNSPECIFIED INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM Q FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT 15 STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ N C.7.f 8/16/2017 3/27/2017 81812017 99254 INPATIENT CONSULTATION FOR ANEW OR ESTABLISHED R55 SYNCOPE AND COLLAPSE PROFESSIONAL $198.91 $435.00 MALE SPOUSE 1CCC 3559 PATIENT, W H ICH REQUIRES THESE 3 KEY COMPONENTS: A INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED C 8/28/2017 8/7/2017 8/27/2017 A7030 FULLFACE MASKUSEDWITH POSITIVE AIRWAY PRESSURE G4733 OBSTRUCTIVE SLEEP OTHER MEDICAL $136.46 $136.46 MALE SPOUSE 1CCC 3559 DEVICE, EACH APNEA (ADULT) (PEDIATRIC) 8/28/2017 8/712017 8/27/2017 A7035 HEADGEAR USED WITH POSITIVE AIRWAY PRESSURE 64733 OBSTRUCTIVE SLEEP OTHER MEDICAL $28.90 $28.90 MALE SPOUSE 1CCC 3559 DEVICE APNEA (ADULT) (PEDIATRIC) 8/28/2017 8/7/2017 8/27/2017 A7038 FILTER, DISPOSABLE, USED WITH POSITIVE AIRWAY 64733 OBSTRUCTIVE SLEEP OTHER MEDICAL $14.61 $29.25 MALE SPOUSE 1 CCC 3559 PRESSURE DEVICE APNEA (ADULT) (PEDIATRIC) 812812017 81712017 8/27/2017 E0562 HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY G4733 OBSTRUCTIVE SLEEP OTHER MEDICAL $30.20 $30.20 MALE SPOUSE 1CCC 3559 PRESSURE DEVICE APNEA (ADULT) (PEDIATRIC) 8/28/2017 8/7/2017 8/27/2017 E0601 CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICE G4733 OBSTRUCTIVE SLEEP OTHER MEDICAL $64.86 $64.86 MALE SPOUSE 1 CCC 3559 APNEA (ADULT) (PEDIATRIC) 8/30/2017 8/25/2017 812912017 99283 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION H6091 UNSPECIFIED OTITIS PROFESSIONAL $111.53 $520.00 MALE SPOUSE 1 CCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES EXTERNA, RIGHT EAR OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH 9/18/2017 8/26/2017 9/15/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H6091 UNSPECIFIED OTITIS OTHER MEDICAL $225.00 $300.00 MALE SPOUSE 1CCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED EXTERNA, RIGHT EAR PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 9/18/2017 8/26/2017 9/15/2017 55001 PRESCRIPTION DRUG, BRAND NAME H6091 UNSPECIFIED OTITIS OTHER MEDICAL $0.00 $6.00 MALE SPOUSE 1 CCC 3559 EXTERNA, RIGHT EAR 9/18/2017 8/29/2017 9/15/2017 96372 Therapeutic, prophylactic, oL diagnostic injection (specify H6091 UNSPECIFIED OTITIS OTHER MEDICAL $0.00 $77.00 MALE SPOUSE 1 CCC 3559 substanceordrug);subcutaneous DF intramuscular EXTERNA, RIGHT EAR 9/18/2017 8/29/2017 9/15/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H6091 UNSPECIFIED OTITIS OTHER MEDICAL $225.00 $300.00 MALE SPOUSE 1CCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED EXTERNA, RIGHT EAR PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 9/18/2017 8/29/2017 9/15/201710696 INJECTION, CEFTRIAX0NE SODIUM, PER 250 MG H6091 UNSPECIFIED OTITIS OTHER MEDICAL $0.00 $2.00 MALE SPOUSE 1 CCC 3559 EXTERNA, RIGHT EAR 9/25/2017 8/25/2017 9/22/2017 - - H6090 UNSPECIFIED OTITIS HOSPITAL OUTPATIENT $1,187.55 $1,187.55 MALE SPOUSE 1 CCC 3559 EXTERNA, UNSPECIFIED EAR 10/5/2017 8110/2017 10/4/2017 93298 INTERROGATION DEVICE EVALUATI0N(5), (REMOTE) UP R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE $32.07 $60.00 MALE SPOUSE 1 CCC 3559 TO 30 DAYS; IMPLANTABLE LOOP RECORDER SYSTEM, INCLUDING ANALYSIS OF RECORDED HEART RHYTHM DATA, PHYSICIAN ANALYSIS, REVIEW(S) AND REPORTS) C.7.f 101 8/10/2017 101 93299 INTERROGATION DEVICE EVALUATION(SE (REMOTE( UP R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE $23.00 MALE SPOUSE 1 CCC TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR MONITOR $11.07 $70.00 MALE SPOUSE 1 CCC 3559 $11.07 SYSTEM OR IMPLANTABLE LOOP RECORDER SYSTEM, SPOUSE 1 CCC 3559 $129.02 $228.00 MALE SPOUSE REMOTE DATA ACQUISITION(SE RECEIPT OF 3559 TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORTAND DISTRIBUTION OF RESULTS 101 8/28/2017 10/6/2017 96372 Therapeutic, prophylactic, or diagnostic injection (specify H9209 OTALGIA, UNSPECIFIED OTHER MEDICAL substance or drug); s,b,,taneousor'mtramuscular EAR 101 8/28/2017 101 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H9209 OTALGIA, UNSPECIFIED OTHER MEDICAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED EAR PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 101 8/28/2017 10/6/2017 10696 INJECTION, CEFTRIAXONE SODIUM, PER 250 MG H9209 OTALGIA, UNSPECIFIED OTHER MEDICAL EAR 101 8/28/2017 101 11170 INJECTION, HYDROMORPHONE, UPTO4 MG H9209 OTALGIA, UNSPECIFIED OTHER MEDICAL EAR 10/30/2017 7/24/2017 10/27/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL 10/30/2017 7/25/2017 10/27/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL 11/7/2017 11/1/2017 11/6/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND GOURD 11110/2017 11/1/2017 11/9/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 11/13/2017 11/6/2017 11/10/2017 *Ytl "* + + +ar —1— r + + +« 1.1- 11/14/2017 3/26/2017 111812017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 1454 NONSPECIFIC PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY INTRAVENTRICULAR INPATIENT /HOSPITAL BLOCK 11/14/2017 3/27/2017 3/30/2017 93458 Catheter placement In coronary a rtary(s) to, coronary 1208 OTHER FORMS OF PROFESSIONAL amgi0graphy, includingintraproced ural injection(s) in, ANGINA PECTORIS INPATIENT / HDSPITAL coronarV angiography, imaging supervision and interpretation; with left heart catheterization including intrap roced ural injection(,) for left ventriculography, when performed $42.02 $75.00 MALE SPOUSE 1 CCC 3559 W N Q! $0.00 $154.00 MALE SPOUSE 1 CCC 3559 7 $225.00 $300.00 MALE SPOUSE 1 CCC 3559 W } fl i® CL CL Q $0.00 $2.00 MALE SPOUSE 1 CCC 3559 $0.00 $23.00 MALE SPOUSE 1 CCC 3559 $11.07 $70.00 MALE SPOUSE 1 CCC 3559 $11.07 $70.00 MALE SPOUSE 1 CCC 3559 $129.02 $228.00 MALE SPOUSE 1 CCC 3559 $0.00 $228.00 MALE SPOUSE 1 CCC III $0.00 $415.00 MALE SPOUSE 1 CCC 3559 $0.00 $29.00 MALE SPOUSE 1 CCC 3559 $237.13 $1,238.00 MALE SPOUSE 1 CCC 3559 11/14/2017 3/27/2017 3/30/2017 93458 Catheter placement in coronary artery(,) for coronary 1208 OTHER FORMS OF PROFESSIONAL (S23713i angiagraphy, including intraprocedural injection(s )for SPOUSE ANGINA PECTORIS INPATIENT /HOSPITAL ($7 coronary angiography, imaging supervision and SPOUSE 1 CCE 3559 $4739 interpretation; with left heart catheterization including SPOUSE 1 CCC 3559 intraprocedural injection(,) for left ventriculography, when performed 11/14/2017 3/27/2017 11/8/2017 93458 Catheter placement l n mronar, artery(,) forcoronary 1208 OTHER FORMS OF PROFESSIONAL angiagraphy, including i ntraprocedural nj— mr(s)for ANGINA PECTORIS INPATIENT / HDSPITAL caronarV angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(,) for left ventriculography, when performed 11/14/2017 7/24/2017 11/13/2017 99221 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION R001 BRADYCARDIA, PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES UNSPECIFIED INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND /OR 11/14/2017 11/6/2017 11/13/2017 537 ANESTHESIA FOR CARDIAC ELECTROPHYSIOLOGIC 1471 SUPRAVENTRICULAR PROFESSIONAL PROCEDURES INCLUDING RADIOFREQUENCY ABLATION TACHYCARDIA OUTPATIENT /HOSPITAL 11/15/2017 3/26/2017 3/30/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 1454 NONSPECIFIC PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY INTRAVENTRICULAR INPATIENT /HOSPITAL BLOCK 11/15/2017 3/26/2017 3130/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 1454 NONSPECIFIC PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY INTRAVENTRICULAR INPATIENT /HOSPITAL BLOCK 11/15/2017 11/7/2017 11/14/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 1495 SICK SINUS SYNDROME PROFESSIONAL EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 11/17/2017 11/1/2017 11/6/2017 93291 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE PHYSICIAN ANALYSIS, REVIEW AND REPORT, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; IMPLANTABLE LOOP RECORDER SYSTEM, INCLUDING HEART RHYTHM DERIVED DATA ANALYSIS 11/17/2017 11/1/2017 11/6/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 11/17/2017 11/1/2017 11/6/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 4! N 4f 4! N $0.00 $1,238.00 MALE SPOUSE 1 CCE 3559 W } $0.00 $334.00 MALE SPOUSE 1 CCC 3559 53 $1,692.74 $2,600.00 MALE SPOUSE 1 CCC C.7.f (S23713i ($1,238.00) MALE SPOUSE 1 CCC 3559 4! N 4f 4! N $0.00 $1,238.00 MALE SPOUSE 1 CCE 3559 W } $0.00 $334.00 MALE SPOUSE 1 CCC 3559 53 $1,692.74 $2,600.00 MALE SPOUSE 1 CCC 3559 $9.42 $29.00 MALE SPOUSE 1 CCC 3559 ($7 ($39.00) MALE SPOUSE 1 CCE 3559 $4739 $85.00 MALE SPOUSE 1 CCC 3559 $34.76 $71.00 MALE SPOUSE 1 CCC 3559 $0.00 $228.00 MALE SPOUSE 1 CCC 3559 ($129.021 (.$228.001 MALE SPOUSE 1 CCC 3559 C.7.f 11/1]/201] 11/1/2017 11/13/2017 93291 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE $0.00 $71.00 MALE SPOUSE 1CCC 3559 PHYSICIAN ANALYSIS, REVIEW AND REPORT, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER {U PATIENT ENCOUNTER; IMPLANTABLE LOOP RECORDER N SYSTEM, INCLUDING HEART RHYTHM DERIVED DATA ANALYSIS 11/21/2017 11/15/2017 11/20/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 1495 SICK SINUS SYNDROME PROFESSIONAL OFFICE $129.02 $228.00 MALE SPOUSE 1 CCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED r PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY "a COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD W } fl 11/22/2017 11/5/2017 11/21/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITHATLEAST12 1495 SICK SINUS SYNDROME PROFESSIONAL $0.00 $95.00 MALE SPOUSE 1 CCC 3559 E. CL LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL Q, Q 1112212017 11/6/2017 11/21/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 1495 SICK SINUS SYNDROME PROFESSIONAL $0.00 $95.00 MALE SPOUSE 1 CCC 3559 v LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL 11/27/2017 11/1/2017 11/6/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE $94.26 $228.00 MALE SPOUSE 1CCC 3559 EVALUATION AND MANAGEMENTOFAN ESTABLISHED PATIENT, W H ICH REQUIRES AT LEAST 2 OF THESE 3 KEY h COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD _ 11/27/2017 11/6/2017 11122/2017 33208 INSERTION OF NEW OR REPLACEMENT OF PERMANENT 1471 SUPRAVENTRICULAR PROFESSIONAL $361.11 $1,330.00 MALE SPOUSE 1 CCC 3559 PACEMAKER WITH TRANSVENOUS ELECTRODE(S);ATRIAL TACHYCARDIA OUTPATIENT /HOSPITAL AND VENTRICULAR Q 11/27/2017 11/6/2017 11/22/2017 33282 IMPLANTATION OF PATIENT ACTIVATED CARDIAC EVENT 1471 SUPRAVENTRICULAR PROFESSIONAL $15237 $805.00 MALE SPOUSE 1 CCC 3559 LU RECORDER TACHYCARDIA OUTPATIENT /HOSPITAL 11/27/2017 11/6/2017 11/22/2017 75820 VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL 1471 SUPRAVENTRICULAR PROFESSIONAL $42.98 $275.00 MALE SPOUSE 1 CCC 3559 SUPERVISION AND INTERPRETATION TACHYCARDIA OUTPATIENT /HOSPITAL 0 1112]1201] 11/6/2017 1112212017 76937 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS 1471 SUPRAVENTRICULAR PROFESSIONAL $17.50 $80.00 MALE SPOUSE 1 CCC 3559 LLJ REQUIRING ULTRASOUND EVALUATION OF POTENTIAL TACHYCARDIA OUTPATIENT /HOSPITAL e ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL � PATENCY, CONCURRENT REALTIME ULTRASOUND J VISUALIZATION OF VASCULAR NEEDLE ENTRY, v 1112]1201] 11/6/2017 11/22/2017 93286 PERI- PROCEDURAL DEVICE EVALUATION AND 1471 SUPRAVENTRICULAR PROFESSIONAL $1].]3 $150.00 MALE SPOUSE 1 CCC 3559 r PROGRAMMING OF DEVICESYSTEM PARAMETERS BEFORE TACHYCARDIA OUTPATIENT /HOSPITAL Z OR AFTER A SURGERY, PROCEDURE, OR TEST WITH LLJ PHYSICIAN ANALYSIS, REVIEW AND REPORT; SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM U 11/27/2017 11/6/2017 11/22/2017 93602 INTRA - ATRIAL RECORDING 1471 SUPRAVENTRICULAR PROFESSIONAL $0.00 $330.00 MALE SPOUSE 1 CCC 3559 TACHYCARDIA OUTPATIENT /HOSPITAL 11/27/2017 11/6/2017 11/22/2017 93603 RIGHT VENTRICULAR RECORDING 1471 SUPRAVENTRICULAR PROFESSIONAL $0.00 $380.00 MALE SPOUSE 1 CCC 3559 TACHYCARDIA OUTPATIENT /HOSPITAL fV 1112712017 11/6/2017 1112212017 93610 INTRA- ATRIAL PACING 1471 SUPRAVENTRICULAR PROFESSIONAL $0.00 $450.00 MALE SPOUSE 1 CCC 3559 C TACHYCARDIA OUTPATIENT /HOSPITAL y E 11/27/2017 11/6/2017 11/22/2017 93612 INTRAVENTRICULAR PACING 1471 SUPRAVENTRICULAR PROFESSIONAL $0.00 $475.00 MALE SPOUSE 1 CCC 3559 .0 TACHYCARDIA OUTPATIENT /HOSPITAL m 1112712017 11/6/2017 1112212017 93620 COMP RE HE NSIVE ELECTROPHYSIOLOG I C EVALUATION 1471 SUPRAVENTRICULAR PROFESSIONAL 3559 INCLUDING INSERTIONAND REPOSITIONING OF MULTIPLE $60.00 MALE TACHYCARDIA OUTPATIENT /HOSPITAL 1 CCC ELECTRODE CATHETERS WITHIN DUCTION OR ATTEMPTED $42.02 $75.00 MALE SPOUSE INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING 3559 $0.00 $11.00 MALE AND RECORDING, RIGHTVENTRICUTAR PACING AND 1 CCC 3559 $0.00 RECORDING, HIS BEND SPOUSE 1 CCC 11/27/2017 11/6/2017 11/22/2017 93623 PROGRAMMED STIMULATION AND PACING AFTER 1471 SUPRAVENTRICULAR PROFESSIONAL 1 CCC INTRAVENOUS DRUG INFUSION (LIST SEPARATELY IN $0.00 TACHYCARDIA OUTPATIENT /HOSPITAL SPOUSE ADDITION TO CODE FOR PRIMARY PROCEDURE) 3559 $0.00 11/30/2017 11/5/2017 1112912017 93298 INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE $0.00 TO 30 DAYS; IMPLANTABLE LOOP RECORDER SYSTEM, SPOUSE 1 CCC 3559 INCLUDING ANALYSIS OF RECORDED HEART RHYTHM $10.00 MALE SPOUSE 1 CCC DATA, PHYSICIAN ANALYSIS, REVIEW(S) AND REPORT(S) $0.00 $10.00 MALE 11/30/2017 11/5/2017 11/29/2017 93299 INTERROGATION DEVICE EVALUATION(S), )REMOTE) UP R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR MONITOR SYSTEM OR IMPLANTABLE LOOP RECORDER SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS 11/30/2017 11/7/2017 11/17/2017 * * " ** * * *'* * * * ** ' * * ** * * * *' 12/4/2017 11/5/2017 12/1/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E7800 PURE PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL HYPE RCHOLESTE ROLEM IA ,OUTPATIENT /HOSPITAL (82310) CARBON DIOXIDE (92374) CHLORIDE (92435) UNSPECIFIED CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM )84295) UREA NITROGEN (BUN) (84520) 12/4/2017 11/5/2017 12/1/2017 84484 TROPONIN, QUANTITATIVE E7800 PURE PROFESSIONAL HYPE RCHOLESTE ROLEM IA, OUTPATIENT /HOSPITAL UNSPECIFIED 12/4/2017 11/5/2017 12/1/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED (HOD, E7800 PURE PROFESSIONAL HCT,RBC,WBC AND PLATELET COUNT) AND AUTOMATED HYPE RCHOLESTE ROLEM I A ,OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT UNSPECIFIED 12/4/2017 11/5/2017 12/1/2017 85610 PROTHROMBIN TIME; E7800 PURE PROFESSIONAL HYPE RCHOLESTE ROLEM IA, OUTPATIENT/HOSPITAL UNSPECIFIED 12/4/2017 11/5/2017 12/1/2017 85730 THROMBOPLHSTIN TIME, PARTIAL (PTT); PLASMA OR E7800 PURE PROFESSIONAL WHOLE BLOOD HYPE RCHOLESTE ROLEM IA, OUTPATIENT /HOSPITAL UNSPECIFIED 12/4/2017 11/6/2017 12/1/2017 80048 BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL E7800 PURE PROFESSIONAL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL HYPE RCHOLESTE ROLEM IA ,OUTPATIENT /HOSPITAL (92310) CARBON DIOXIDE (92374) CHLORIDE (92435) UNSPECIFIED CREATININE(82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) 12/4/2017 11/6/2017 12/1/2017 84484 TROPONIN, QUANTITATIVE E7800 PURE PROFESSIONAL HYPE RCHOLESTE ROLEM IA, OUTPATIENT /HOSPITAL UNSPECIFIED 12/4/2017 11/6/2017 12/1/2017 85025 BLOOD COUNT; COMPLETE(CBC), AUTOMATED(HGB, E7800 PURE PROFESSIONAL HCT, BBC, NBC AND PLATELET COUNT) AND AUTOMATED HYPE RCHOLESTE ROLEM I A ,OUTPATIENT /HOSPITAL DIFFERENTIAL W BC COUNT UNSPECIFIED 12/4/2017 11/6/2017 12/1/2017 85610 PROTHROMBIN TIME; E7800 PURE PROFESSIONAL HYPE RCHOLESTE ROLEM IA, OUTPATIENT /HOSPITAL UNSPECIFIED 12/4/2017 11/6/2017 12/1/2017 85730 THROMBOPLHSTIN TIME, PARTIAL (PTT); PLASMA OR E7800 PURE PROFESSIONAL WHOLE BLOOD HYPE RCHOLESTE ROLEM IA, OUTPATIENT /HOSPITAL UNSPECIFIED $863.91 $3,570.00 MALE SPOUSE 1 CCC C.7.f 3559 $219.64 $895.00 MALE SPOUSE 1 CCC 3559 $32.07 $60.00 MALE SPOUSE 1 CCC 3559 $42.02 $75.00 MALE SPOUSE 1 CCC 3559 $32,061.10 $75,991.18 MALE SPOUSE 1 CCC 3559 $0.00 $26.00 MALE SPOUSE 1 CCC 3559 $0.00 $32.00 MALE SPOUSE 1 CCC 3559 $0.00 $11.00 MALE SPOUSE 1 CCC 3559 $0.00 $10.00 MALE SPOUSE 1 CCC 3559 $0.00 $10.00 MALE SPOUSE 1 CCC 3559 $0.00 $26.00 MALE SPOUSE 1 DEC 3559 $0.00 $32.00 MALE SPOUSE 1 CCC 3559 $0.00 $11.00 MALE SPOUSE 1 CCC 3559 $0.00 $10.00 MALE SPOUSE 1 CCC 3559 $0.00 $10.00 MALE SPOUSE 1 CCC 3559 12/4/2017 11/6/2017 12/1/2017 88300 LEVEL I - SORGI CAL PATHOLOGY, GROSS EXAM I NATION E7800 PURE PROFESSIONAL $57.20 $317.34 MALE SPOUSE ONLY 3559 HYPE RCHOLESTE ROLEM I A, OUTPATIENT /HOSPITAL SPOUSE 1 CCC 3559 $40.40 $170.00 MALE UNSPECIFIED 12/11/2017 12/5/2017 12/8/2017 20550 1 N ECFI ON IS); SINGLE TENDON SHEATH, OR LIGAMENT, N17731 CALCANEALSPUR, RIGHT PROFESSIONAL OFFICE 3559 $14.46 $25.84 MALE APONEUROSIS'EG, PLANTAR "FASCIA') 1 CCC FOOT 12/11/2017 12/5/2017 12/8/2017 73630 RADIOLOGIC EXAMINATION, FOOT; COMPLETE, M7731 CALCANEAL SPUR, RIGHT PROFESSIONAL OFFICE MINIMUM OF THREE VIEWS FOOT 12/11/2017 12/5/2017 12/8/2017 99244 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED M7731 CALCANEAL SPUR, RIGHT PROFESSIONAL OFFICE PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A FOOT COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF W MODERATE COMPLEXITY. COUNSELING AND /OR } COORDINATION OF CARE WITH OTHER PROVIDERS OR fl $95.48 $200.00 MALE SPOUSE AGENCIES ARE PROVIDED CONS 3559 CL 12/11/2017 12/5/2017 12/8/2017 L4397 STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING M7731 CALCANEAL SPUR, RIGHT PROFESSIONAL OFFICE SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR FOOT POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED, OFF- THE -SHELF 12/11/2017 12/5/2017 12/8/2017 29540 STRAPPING; ANKLE M722 PLANTAR FASCIAE PROFESSIONAL OFFICE FIBROMATOSIS 12/11/2017 12/5/2017 12/8/2017 97035 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; M722 PLANTAR FASCIAE PROFESSIONAL OFFICE ULTRASOUND, EACH 15 MINUTES FIBROMATOSIS 12/11/2017 12/5/2017 12/8/2017 11030 INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG M722 PLANTAR FASCIAE PROFESSIONAL OFFICE FIBROMATOSIS 12/12/2017 12/7/2017 12/11/2017 29540 STRAPPING; ANKLE M722 PLANTAR FASCIAE PROFESSIONAL OFFICE FIBROMATOSIS 12/12/2017 121712017 12/11/2017 76882 Ultrasound, extremity, non - ular, real -time with image M722 PLANTAR FASCIAE PROFESSIONAL OFFICE documentation; limited, anatomic specific FIBROMATOSIS 12/12/2017 12/7/2017 12/11/2017 97035 APPLICATION OF MODALITY TO 1 DR MORE AREAS; M722 PLANTAR FASCIAE PROFESSIONAL OFFICE ULTRASOUND, EACH 15 MINUTES FIBROMATOSIS 12/15/2017 11/1/2017 11/9/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY, COUNSELING AND COORD 12/15/2017 11/1/2017 121812017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 12/15/2017 11/1/2017 12/8/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 12/15/2017 12/11/2017 1211412017 29540 STRAPPING; ANKLE M24572 CONTRACTURE, LEFT PROFESSIONAL OFFICE ANKLE 12/15/2017 12/11/2017 12/14/2017 97035 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; M24572 CONTRACTURE, LEFT PROFESSIONAL OFFICE ULTRASOUND, EACH 15 MINUTES ANKLE C.7.f $15.25 $95.00 MALE SPOUSE 1 CCC 3559 $0.00 $170.00 MALE SPOUSE 1 DEC 3559 41 $57.20 $317.34 MALE SPOUSE 1 CCC 3559 N SPOUSE 1 CCC 3559 $40.40 $170.00 MALE SPOUSE $51.12 $200.00 MALE SPOUSE 1 DEC 3559 1 DEC 3559 $14.46 $25.84 MALE SPOUSE 1 CCC 3559 $130.81 $500.00 MALE SPOUSE 1 CCC 3559 W } fl $95.48 $200.00 MALE SPOUSE 1 CCC 3559 CL $0.00 $170.00 MALE SPOUSE 1 DEC 3559 $14.46 $25.84 MALE SPOUSE 1 CCC 3559 $12.68 $14.00 MALE SPOUSE 1 CCC 3559 $40.40 $170.00 MALE SPOUSE 1 DEC 3559 $25.89 $75.00 MALE SPOUSE 1 DEC 3559 $14.46 $25.84 MALE SPOUSE 1 CCC 3559 $0.00 (5228.001 MALE SPOUSE 1 CCC 3559 $129.02 $228.00 MALE SPOUSE 1 DEC 3559 $0.00 $228.00 MALE SPOUSE 1 CCC 3559 $40.40 $170.00 MALE SPOUSE 1 CCC 3559 $14.46 $25.84 MALE SPOUSE 1 CCC 3559 12/15/2017 12/11/2017 12/14/2017 L4397 STATIC OR DYNAMIC ANKLE FOOT ORTHOS IS, IN CLUB ING M24572 CONTRACTURE, LEFT PROFESSIONAL OFFICE 1 CCC SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR $170.00 MALE ANKLE 1 DEC POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, $25.84 MALE SPOUSE 1 CCC PREFABRICATED, OFF- THE -SHELF $112.00 MALE SPOUSE 12/18/2017 12/13/2017 12/15/2017 29540 STRAPPING; ANKLE M722 PLANTAR FASCIAE PROFESSIONAL OFFICE 1 CCC $376.94 $2,275.00 MALE FIBROMATOSIS 12/18/2017 12/13/2017 12/15/2017 97035 APPLICATION OF A MODALITY TO I OR MORE AREAS; M722 PLANTAR FASCIAE PROFESSIONAL OFFICE ULTRASOUND, EACH 15 MINUTES FIBROMATOSIS 12/19/2017 11/5/2017 12118/2017 93030 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 12/19/2017 11/5/2017 12/18/2017 99053 SERVICES( PROVIDED BETWEEN 10: 00 PM AND 8: 00 AM R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL AT 24 -HOUR FACILITY, IN ADDITION TO BASIC SERVICE OUTPATIENT /HOSPITAL 12/19/2017 11/5/2017 12/18/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DELIS 12/20/2017 11/1/2017 11/6/2017 93291 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE PHYSICIAN ANALYSIS, REVIEW AND REPORT, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; IMPLANTABLE LOOP RECORDER SYSTEM, INCLUDING HEART RHYTHM DERIVED DATA ANALYSIS 12/20/2017 11/1/2017 11/6/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 1212012017 11/1/2017 12/11/2017 93291 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE PHYSICIAN ANALYSIS, REVIEW AND REPORT, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; IMPLANTABLE LOOP RECORDER SYSTEM, INCLUDING HEART RHYTHM DERIVED DATA ANALYSIS 12/20/2017 11/1/2017 12/11/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 12/20/2017 11/1/2017 12/11/2017 93291 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH R55 SYNCOPE AND COLLAPSE PROFESSIONAL OFFICE PHYSICIAN ANALYSIS, REVIEW AND REPORT, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; IMPLANTABLE LOOP RECORDER SYSTEM, INCLUDING HEART RHYTHM DERIVED DATA ANALYSIS 1212012017 12/15/2017 12/19/2017 29540 STRAPPING; ANKLE M722 PLANTAR FASCIAE PROFESSIONAL OFFICE FIBROMATOSIS $95.48 $200.00 MALE SPOUSE 1 CCC $40.40 $170.00 MALE SPOUSE 1 DEC $14.46 $25.84 MALE SPOUSE 1 CCC $0.00 $112.00 MALE SPOUSE 1 CCC $0.00 $52.00 MALE SPOUSE 1 CCC $376.94 $2,275.00 MALE SPOUSE 1 CCC U534'6j ($71.00j MALE SPOUSE 1 CCC $0.00 ($228.001 MALE SPOUSE 1 CCC $34.76 $71.00 MALE SPOUSE 1 CCC $0.00 $228.00 MALE SPOUSE 1 CCC $0.00 $71.00 MALE SPOUSE 1 COO $4040 $170.00 MALE SPOUSE 1 CCC C.7.f 12/20/2017 12/15/2017 12/19/2017 97035 APPLICATION OF A MODALITY TO l OR MORE AREAS; M722 PLANTAR FASCIAE PROFESSIONAL OFFICE $14.46 $25.84 MALE SPOUSE 10EO 3559 ULTRASOUND, EACH 15 MINUTES FIBROMATO515 12/22/2017 11/5/2017 12120/2017 71020 RADIDLOGIC EXAMINATION, CHEST, TWO VIEWS, 1495 SICK SINUS SYNDROME PROFESSIONAL $14.70 $47.00 MALE SPOUSE 1 CCC 3559 FRONTAL AND LATERAL; OUTPATIENT /HOSPITAL N 12/22/2017 11/6/2017 12/20/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 1495 SICK SINUS SYNDROME PROFESSIONAL $12.45 $39.00 MALE SPOUSE 1 CEO 3559 FRONTAL OUTPATIENT /HOSPITAL SUb Total $93,993.47 $278,158.47 7 7.75E +10 9/6/2017 9/1/2017 9/5/2017 51784 ELECTROMYOGRAPHY STUDIES NEMG) OF ANAL OR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $330.85 $570.00 MALE SUBSCRIBER 1 BCC 3559 "a URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY OF PROSTATE TECHNIQUE 9/6/2017 9/1/2017 9/5/2017 97032 APPLICATION OF A MODALITY TO I DR MORE AREAS; C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 $50.00 MALE SUBSCRIBER 1BCC 3559 ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES OF PROSTATE } fl 9/6/2017 91112017 9/5/2017 97750 PHYSICAL PERFORMANCE TEST OR MEASUREMENT)EG, C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $49.28 $100.00 MALE SUBSCRIBER 1 BCC 3559 N. CL MUSCULOSKELETAL , FUNCTIONAL CAPACITY), WITH OF PROSTATE Q, WRITTEN REPORT, EACH 15 MINUTES 10/2/2017 9/22/2017 9/28/2017 - - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $4,053.00 $6,755.00 MALE SUBSCRIBER 1 BCC 3559 OF PROSTATE 10/4/2017 9/26/2017 101212017 - - R42 DIZZINESS AND GIDDINESS HOSPITAL OUTPATIENT $5,759.25 $7,679.00 MALE SUBSCRIBER 1 BCC 3559 F 10/5/2017 9/22/2017 10/4/2017 72197 MAGNETIC RESONANCE DEG, PROTON) IMAGING, PELVIS; C61 MALIGNANT NEOPLASM PROFESSIONAL $202.59 $458.00 MALE SUBSCRIBER 1BCC 3559 h WITHOUT CONTRAST MATERIAL)S), FOLLOWED BY OF PROSTATE OUTPATIENT /HOSPITAL CONTRAST MATERIAL(S) AND FURTHER SEQUENCES 10/9/2017 9/26/2017 101 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R42 DIZZINESS AND GIDDINESS PROFESSIONAL $0.00 $35.00 MALE SUBSCRIBER 1 BCC 3559 _ LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 10/9/2017 9/26/2017 10/6/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R42 DIZZINESS AND GIDDINESS PROFESSIONAL $268.82 $665.00 MALE SUBSCRIBER 1 BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT/HOSPITAL Q THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS LU IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREHENSIVE UJ HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS J 10/10/2017 9/26/2017 101 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT R42 DIZZINESS AND GIDDINESS PROFESSIONAL $73.20 $322.00 MALE SUBSCRIBER 1 BCC 3559 LLJ CONTRAST MATERIAL OUTPATIENT /HOSPITAL e 1012712017 10/23/2017 10/25/2017 51741 COMPLEX UROFLOWMETRY)EG, CALIBRATED ELECTRONIC C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $140.40 $246.00 MALE SUBSCRIBER 1 BCC 3559 EQUIPMENT) OF PROSTATE v 10/27/2017 10/23/2017 10/25/2017 51798 MEASUREMENT , POST - VOIDING RESIDUAL URINE & /OR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $31.36 $73.00 MALE SUBSCRIBER 16CC 3559 BLADDER CAPACITY, US, NON IMAGING OF PROSTATE W 10/27/2017 10/23/2017 10/25/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.93 $13.00 MALE SUBSCRIBER 1 BCC 3559 BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, OF PROSTATE LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, U UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY 10/27/2017 10/23/2017 10/25/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $163.14 $250.00 MALE SUBSCRIBER 1 BCC 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE hl PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED = EXAMINATION; MEDICAL DECISION MAKING OF y MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER .G 11/1/2017 10/23/2017 10/30/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL $0.00 EVALUATION AND MANAGEMENT OF AN ESTABLISHED SUBSCRIBER OF PROSTATE OUTPATIENT /HOSPITAL $49.28 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SUBSCRIBER 1 BCC 3559 $330.85 COMPONENTS: AN EXPANDED PROBLEM FOCUSED SUBSCRIBER 1 BCC 3559 $0.00 HISTORY; AN EXPANDED PROBLEM FOCUSED SUBSCRIBER 1 BCC 3559 $0.00 EXAMINATION; MEDICAL DECISION MAKING OF LOW SUBSCRIBER 1 BCC 3559 COMPLEXITY. COUNSELING AND COOED 11/6/2017 11/1/2017 11/3/2017 51784 ELECTROMYOGRAPHY STUDIES )EMG)OF ANAL OR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY OF PROSTATE TECHNIQUE 11/6/2017 11/1/2017 11/3/2017 97032 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES OF PROSTATE 11/6/2017 11/1/2017 11/3/2017 97750 PHYSICAL PERFORMANCE TEST OR MEASUREMENT LEG, C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE MUSCULOSKELETAL , FUNCTIONAL CAPACITY), WITH OF PROSTATE WRITTEN REPORT, EACH 15 MINUTES 11/13/2017 111712017 11/9/2017 51784 ELECTROMYOGRAPHY STUDIES )EMG)OF ANAL OR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY OF PROSTATE TECHNIQUE 11/13/2017 11/7/2017 11/9/2017 97032 APPLICATION OF A MODALITY T010R MORE AREAS; C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES OF PROSTATE 11/17/2017 6/5/2017 11/15/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF A NEW PATIENT, OF PROSTATE OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE 11/20/2017 11/15/2017 11/17/2017 97032 APPLICATION OF A MODALITY TO l OR MORE AREAS; C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES OF PROSTATE 11/27/2017 7/7/2017 11/14/2017 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING M7989 OTHER SPECIFIED SOFT PROFESSIONAL RESPONSES TO COMPRESSION AND OTHER MANEUVERS; TISSUE DISORDERS INPATIENT /HOSPITAL COMPLETE BILATERAL STUDY 1112812017 11/22/2017 11/27/2017 51784 ELECTROMYOGRAPHY STUDIES )EMG)OF ANAL OR Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY MALIGNANT NEOPLASM TECHNIQUE OF PROSTATE 11/28/2017 11/22/2017 11/27/2017 97032 APPLICATION OF A MODALITY TO I OR MORE AREAS; 78546 PERSONAL HISTORY OF PROFESSIONAL OFFICE ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES MALIGNANT NEOPLASM OF PROSTATE 11/28/2017 11/22/2017 11/27/2017 97750 PHYSICAL PERFORMANCE TEST OR MEASUREMENT AEG, Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH MALIGNANT NEOPLASM WRITTEN REPORT, EACH 15 MINUTES OF PROSTATE 11/28/2017 11/22/2017 11/27/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MALIGNANT NEOPLASM PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY OF PROSTATE COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER $61.61 $168.00 MALE SUBSCRIBER 1 BCC C.7.f 3559 $330.85 $570.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $50.00 MALE SUBSCRIBER 1 BCC 3559 $49.28 $100.00 MALE SUBSCRIBER 1 BCC 3559 $330.85 $570.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $50.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $661.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $50.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $200.00 MALE SUBSCRIBER 1 BCC 3559 $330.85 $570.00 MALE SUBSCRIBER 1 BCC 3559 $0.00 $50.00 MALE SUBSCRIBER 1 BCC 3559 $49.28 $100.00 MALE SUBSCRIBER 1 BCC 3559 $163.14 $250.00 MALE SUBSCRIBER 1 BCC 3559 12/1/2017 11/22/2017 11/29/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL $2,935.00 MALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED 1 BCC OF PROSTATE OUTPATIENT /HOSPITAL SUBSCRIBER PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY $0.00 $50.00 MALE SUBSCRIBER 1 BCC COMPONENTS: A DETAILED HISTORY; A DETAILED $100.00 MALE SUBSCRIBER 1 BCC $158.62 EXAMINATION; MEDICAL DECISION MAKING OF SUBSCRIBER 1 BCC MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/4/2017 10/23/2017 11/29/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 12/7/2017 11/22/2017 12/4/2017 - - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 12/11/2017 12/6/2017 12/7/2017 51784 ELECTROMYOGRAPHY STUDIES )EMG)OFANAL OR Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY MALIGNANT NEOPLASM TECHNIQUE OF PROSTATE 12/11/2017 12/6/2017 12/7/2017 97032 APPLICATION OF A MODALITY T010R MORE AREAS; Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES MALIGNANT NEOPLASM OF PROSTATE 12/11/2017 12/6/2017 12/7/2017 97750 PHYSICAL PERFORMANCE TEST OR MEASUREMENT AEG, Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE MUSCULOSKELETAL , FUNCTIONAL CAPACITY), WITH MALIGNANT NEOPLASM WRITTEN REPORT, EACH 15 MINUTES OF PROSTATE 12/15/2017 12/8/2017 12/13/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM OTHER MEDICAL EVALUATION AND MAN.AGEMENTOF A NEW PATIENT, OF PROSTATE WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 12/15/2017 12/13/2017 12/14/2017 51784 ELECTROMYOGRAPHY STUDIES )EMG)OF ANAL OR Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY MALIGNANT NEOPLASM TECHNIQUE OF PROSTATE 12/15/2017 12/13/2017 12/14/2017 97032 APPLICATION OF A MODALITY T010R MORE AREAS; Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES MALIGNANT NEOPLASM OF PROSTATE 12/15/2017 12/13/2017 12/14/2017 97750 PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE MUSCULOSKELETAL , FUNCTIONAL CAPACITY), WITH MALIGNANT NEOPLASM WRITTEN REPORT, EACH 15 MINUTES OF PROSTATE 12/27/2017 12/20/2017 12/22/2017 51784 ELECTROMYOGRAPHY STUDIES )EMG)OF ANAL OR Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY MALIGNANT NEOPLASM TECHNIQUE OF PROSTATE 12/27/2017 12/20/2017 12/22/2017 97032 APPLICATION OF A MODALITY TO 1 OR MORE AREAS; Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES MALIGNANT NEOPLASM OF PROSTATE 12/27/2017 12/20/2017 12/22/2017 97750 PHYSICAL PERFORMANCE TEST OR MEASUREMENT LEG, Z8546 PERSONAL HISTORY OF PROFESSIONAL OFFICE MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH MALIGNANT NEOPLASM WRITTEN REPORT, EACH 15 MINUTES OF PROSTATE $94.49 $258.00 MALE SUBSCRIBER 1 BCC $1,588.20 $2,647.00 MALE SUBSCRIBER 1 BCC $1,761.00 $2,935.00 MALE SUBSCRIBER 1 BCC $80.81 $570.00 MALE SUBSCRIBER 1 BCC $0.00 $50.00 MALE SUBSCRIBER 1 BCC $37.69 $100.00 MALE SUBSCRIBER 1 BCC $158.62 $362.00 MALE SUBSCRIBER 1 BCC $80.81 $570.00 MALE SUBSCRIBER 1 BCC $0.00 $50.00 MALE SUBSCRIBER 1 BCC $37.69 $100.00 MALE SUBSCRIBER 1 BCC $330.85 $570.00 MALE SUBSCRIBER 1 BCC $0.00 $50.00 MALE SUBSCRIBER 1 BCC $49.28 $100,00 MALE SUBSCRIBER 1 BCC C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 12/29/2017 12/18/2017 12/27/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL $61.61 $168.00 MALE SUBSCRIBER 1 BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF PROSTATE OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 11512017 12/28/2016 1/4/2017 99211 OFFICE OR OTHER OUTPATIENT VISIT FOR THE Z0000 ENCOUNTER FOR PROFESSIONAL OFFICE $2348 $100.00 MALE SPOUSE 1 BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED GENERAL ADULT MEDICAL PATIENT,THATMAY NOTREQUIRETHE PRESENCEOFA EXAMINATION WITHOUT PHYSICIAN. USUALLY, THE PRESENTING PROBLEM(S) ARE ABNORMAL FINDINGS MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING OR SUPERVISING THESE SERVICES. 1/30/2017 1/3/2017 1/10/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N401 BENIGN PROSTATIC PROFESSIONAL OFFICE $55.56 $175.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED HYPERPLASIA WITH PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LOWER URINARY TRACT COMPONENTS: AN EXPANDED PROBLEM FOCUSED SYMPTOMS HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 1/30/2017 1/13/2017 1/22/2017 76770 ULTRASOUND, RETROPERITONEAL(EG, RENAL, AORTA, N401 BENIGN PROSTATIC OTHER MEDICAL $0.00 $350.00 MALE SPOUSE 1 BCC NODES), REALTIME WITH IMAGE DOCUMENTATION; HYPERPLASIA WITH COMPLETE LOWER URINARYTRACT SYMPTOMS 2/13/2017 1/24/2017 1/30/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR N401 BENIGN PROSTATIC PROFESSIONAL OFFICE $1.93 $13.00 MALE SPOUSE 1 BCC BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, HYPERPLASIA WITH LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, LOWER URINARYTRACT UROBILINOGEN,ANY NUMBER OF THESE CONSTITUENTS; SYMPTOMS AUTOMATED, WITHOUT MICROSCOPY 2/13/2017 1/24/2017 1130/2017 99244 OFFICE CONSULTATION FORA NEW OR ESTABLISHED N401 BENIGN PROSTATIC PROFESSIONAL OFFICE $286.18 $504.00 MALE SPOUSE 1 BCC PATIENT,WHICH REQUIRESTHESE3 KEYCOMPONENTS :A HYPERPLASIAWITH COMPREHENSIVE HISTORY; A COMPREHENSIVE LOWER URINARYTRACT EXAMINATION;AND MEDICALDECISION MAKING OF SYMPTOMS MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONS 3/8/2017 2/28/2017 3/1/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR N401 BENIGN PROSTATIC PROFESSIONAL OFFICE $0.00 $13.00 MALE SPOUSE 1BCC BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, HYPERPLASIA WITH LEUIOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, LOWER URINARYTRACT UROBILINOGEN,ANY NUMBER OF THESE CONSTITUENTS; SYMPTOMS AUTOMATED, WITHOUT MICROSCOPY 3/8/2017 2/28/2017 3/1/2017 99214 OFFICE OROTHER OUTPATIENT VISIT FOR THE N401 BENIGN PROSTATIC PROFESSIONAL OFFICE $138.14 $250.00 MALE SPOUSE 1BCD EVALUATION AND MANAGEMENTOFAN ESTABLISHED HYPERPLASIA WITH PATIENT,WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY LOWER URINARYTRACT COMPONENTS: A DETAILED HISTORY; A DETAILED SYMPTOMS EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 3/17/2017 2/16/2017 3/14/2017 - - E559 VITAMIN D DEFICIENCY, HOSPITAL OUTPATIENT $0.00 $135.89 MALE SPOUSE 1 BCC UNSPECIFIED 3/21/2017 3/16/2017 3/20/2017 55700 BIOPSY, PROSTATE; NEEDLEORPUNCH, SINGLEOR N401 BENIGN PROSTATIC PROFE55IONAL OFFICE $364.80 $652.00 MALE SPOUSE 1BCC MULTIPLE, ANY APPROACH HYPERPLASIA W ITH LOWER URINARYTRACT SYMPTOMS 3/21/2017 3/16/2017 3/20/2017 76872 ULTRASOUND, TRANSRECTAL; N401 BENIGN PROSTATIC PROFESSIONAL OFFICE $46.80 $401.00 MALE SPOUSE 1 BCC 3559 HYPERPLASIA WITH UNSPECIFIED 411012017 2/16/2017 4/7/2017 - LOWER URINARYTRACT E559 VITAMIN D DEFICIENCY, HOSPITAL OUTPATIENT $0.00 $3,442.22 MALE SPOUSE 1 BCC 3559 SYMPTOMS UNSPECIFIED 3/21/2017 3/16/2017 3/20/2017 76942 ULTRASONIC GUIDANCE FOR NEEDLE PIACEMENT(EG, N401 BENIGN PROSTATIC PROFESSIONAL OFFICE $195.41 $512.00 MALE SPOUSE 1 BCC $1,934.19 $3,442.22 MALE SPOUSE BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), 3559 HYPERPLASIA WITH UNSPECIFIED IMAGING SUPERVISION AND INTERPRETATION LOWER URINARYTRACT 5/5/2017 5/1/2017 5/4/2017 82565 CREATININE; BLOOD C61 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $22.05 MALE SPOUSE SYMPTOMS 3559 3/21/2017 3/16/2017 3/20/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR N401 BENIGN PROSTATIC PROFESSIONAL OFFICE $145 $13.00 MALE SPOUSE 1 BCC 84520 UREA NITROGEN; QUANTITATIVE C61 MALIGNANT NEOPLASM BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, $ODD HYPERPLASIA WITH SPOUSE 1 BCC 3559 LEUIKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, LOWER URINARYTRACT 5/15/2017 5/4/2017 5111/2017 - - UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; MALIGNANT NEOPLASM SYMPTOMS $3,608.10 $8,018.00 MALE SPOUSE 1 BCC 3559 AUTOMATED, WITHOUT MICROSCOPY OF PROSTATE 3/21/2017 3/16/2017 3/20/2017 96372 Therapeutic, prophylactic, ordiagnostfc Infection (specify N401 BENIGN PROSTATIC PROFESSIONAL OFFICE $26.48 $75.00 MALE SPOUSE 1 BCC 1 BCC 3559 substance or drug); subcutaneous or Intramuscular HYPERPLASIA WITH OF PROSTATE OUTPATIENT /HOSPITAL LOWER URINARYTRACT SYMPTOMS 3/23/2017 2/11/2017 3/22/2017 81539 Oncolagy (high -grade prostate cancer), biochemical assay R9720 ELEVATED PROSTATE OTHER MEDICAL $0.00 $1,900.00 MALE SPOUSE 1 BCC offour p,Pteirs[TOt,l PSA, Free PSA, Intact PSA,and SPECIFIC ANTIGEN [PSA] human kallikrein -2 AhK2A'), u•Ii,ing plasma or serum, prognostic algorithm reported as a probability score 3/23/2017 2/11/2017 3/22/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE R9720 ELEVATED PROSTATE OTHER MEDICAL $0.00 $8.20 MALE SPOUSE 1 BCC SPECIFIC ANTIGEN [PSA] 3/31/2017 3/28/2017 3/29/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $1.45 $13.00 MALE SPOUSE 1 BCC BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, OF PROSTATE LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY 3/31/2017 3/28/2017 3129/2017 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $195.63 $350.00 MALE SPOUSE 1BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH C.7.f 3559 w K�1 N 3559 Q! 3559 7 fl } 3559 i® CL CL Q 3559 v 3559 3559 III 4/10/2017 2/16/2017 3/14/2017 - - E559 VITAMIN D DEFICIENCY, HOSPITAL OUTPATIENT $0.00 (,$135.89! MALE SPOUSE 1 BCC 3559 UNSPECIFIED 411012017 2/16/2017 4/7/2017 - - E559 VITAMIN D DEFICIENCY, HOSPITAL OUTPATIENT $0.00 $3,442.22 MALE SPOUSE 1 BCC 3559 UNSPECIFIED 4/10/2017 2/16/2017 4/8/2017 - - E559 VITAMIN D DEFICIENCY, HOSPITAL OUTPATIENT $1,934.19 $3,442.22 MALE SPOUSE 1 BCC 3559 UNSPECIFIED 5/5/2017 5/1/2017 5/4/2017 82565 CREATININE; BLOOD C61 MALIGNANT NEOPLASM OTHER MEDICAL $0.00 $22.05 MALE SPOUSE 1 BCC 3559 OF PROSTATE 5/5/2017 5/1/2017 5/4/2017 84520 UREA NITROGEN; QUANTITATIVE C61 MALIGNANT NEOPLASM OTHER MEDICAL $ODD $17.00 MALE SPOUSE 1 BCC 3559 OF PROSTATE 5/15/2017 5/4/2017 5111/2017 - - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $3,608.10 $8,018.00 MALE SPOUSE 1 BCC 3559 OF PROSTATE 5/16/2017 5/4/2017 5/15/2017 78306 BONE AND /OR JOINT IMAGING; WHOLE BODY C61 MALIGNANT NEOPLASM PROFESSIONAL $56.94 $176.00 MALE SPOUSE 1 BCC 3559 OF PROSTATE OUTPATIENT /HOSPITAL 5/16/2017 5/4/2017 5/15/2017 72197 MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; C61 MALIGNANT NEOPLASM PROFESSIONAL $31.36 WITHOUT CONTRAST MATERIAL(SE FOLLOWED BY SPOUSE OF PROSTATE OUTPATIENT /HOSPITAL $13.00 MALE CONTRAST MATERIAL(S) AND FURTHER SEQUENCES 1 BCC $138.74 $250.00 MALE 5/24/2017 5/16/2017 5/22/2017 51798 MEASUREMENT, PDST - VOIDING RESIDUAL URINE & /OR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE BLADDER CAPACITY, US, NON IMAGING OF PROSTATE 5/24/2017 5/16/2017 5/22/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, OF PROSTATE LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY 5/24/2017 5/16/2017 5/22/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/1/2017 5/24/2017 5/30/2017 99245 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED C61 MALIGNANT NEOPLASM PROFESSIONAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS :A OF PROSTATE OUTPATIENT /HOSPITAL COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTE 6/8/2017 5/23/2017 6/7/2017 * * * ** 6/9/2017 5/23/2017 6/8/2017 99202 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF ANEW PATIENT, OF PROSTATE OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING, COUNSELING AND /OR COORDINATION OF CARE WITH 0 6/9/2017 5/26/2017 6/7/2017 99242 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED C61 MALIGNANT NEOPLASM OTHER MEDICAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: OF PROSTATE AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES 6/9/2017 5/26/2017 6/8/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 6/15/2017 5/22/2017 6/14/2017 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF A NEW PATIENT, OF PROSTATE OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE P $151.94 $458.00 MALE SPOUSE 1 BCC $31.36 $73.00 MALE SPOUSE 1 BCC $1.45 $13.00 MALE SPOUSE 1 BCC $138.74 $250.00 MALE SPOUSE 1 BCC $184.97 $559.00 MALE SPOUSE 1 BCC $957.00 $1,940.00 MALE SPOUSE 1 BCC $51.86 $308.00 MALE SPOUSE 1 BCC $58.45 $264.01 MALE SPOUSE 1 BCC $157.27 $496.91 MALE SPOUSE 1 BCC $79.54 $398.00 MALE SPOUSE 1 BCC 6/15/2017 5/23/2017 6/14/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL $160.00 MALE EVALUATION AND MANAGEMENT OF ANEW PATIENT, 1 BCC 3559 OF PROSTATE OUTPATIENT /HOSPITAL SPOUSE WHICH REQUIRES THESE 3 KEY COMPONENTS: A SPOUSE 1 BCC 3559 COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR 6/21/2017 6/5/2017 6/19/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF A NEW PATIENT, OF PROSTATE OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGE 6/27/2017 6/19/2017 6/26/2017 99211 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN. USUALLY, THE PRESENTING PROBLEM(S) ARE MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING OR SUPERVISING THESE SERVICES. 6/28/2017 6/23/2017 6/27/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, C61 MALIGNANT NEOPLASM PROFESSIONAL FRONTAL AND LATERAL; OF PROSTATE OUTPATIENT /HOSPITAL 6/29/2017 6/23/2017 6/28/2017 93000 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE LEADS; WITH INTERPRETATION AND REPORT OF PROSTATE 6/29/2017 6/23/2017 6128/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 7/5/2017 6/23/2017 7/3/2017- - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT OF PROSTATE 711012017 5/22/2017 7/7/2017 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL EVALUATION AND MANAGEMENT OF A NEW PATIENT, OF PROSTATE OUTPATIENT /HOSPITAL WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR CDDRDINATION OF CARE WITH OTHER PROVIDERS OR AGE 711112017 2/11/2017 3/22/2017 81539 Oncology (high -grade prostate cancer), biochemical assay R9720 ELEVATED PROSTATE OTHER MEDICAL of four proteins [Total PEA, Free PSA, Intact PEA, and SPECIFIC ANTIGEN [PSA] human kallikrein -2 9hK2A - ), o•lizing plasma or serum, prognostic algorithm reported as a probability score 7/11/2017 2/11/2017 3/22/2017 81539 Oncology (high -grade prostate cancer), biochemical assay R9720 ELEVATED PROSTATE OTHER MEDICAL of four proteins )Total PEA, Free PEA, Intact PEA, and SPECIFIC ANTIGEN [PSA] human kallikrein -2 Ah K2A - ), o•lizing plasma or serum, prognostic algorithm reported as a probability score 7/11/2017 7/5/2017 7/10/2017 38770 PELVIC ITYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, C61 MALIGNANT NEOPLASM PROFESSIONAL HYPOGASTRIC, AND OBTURATOR NODES (SEPARATE OF PROSTATE INPATIENT /HOSPITAL PROCEDURE) C.7.f $135.68 $599.00 MALE SPOUSE 1 SCC 3559 41 N Q! A 4 $11933 $661.00 MALE SPOUSE 1 BCC 3559 7 fl } fl CL $0.00 $100.00 MALE SPOUSE 1 BCC 3559 CL R $14.42 $67.00 MALE SPOUSE 1 BCC 3559 $18.93 $160.00 MALE SPOUSE 1 BCC 3559 $95.06 $255.00 MALE SPOUSE 1 BCC 3559 $343.12 $610.00 MALE SPOUSE 1 BCC 3559 $174.22 $777.00 MALE SPOUSE 1 BCC 3559 $0.00 $1,900.00 MALE SPOUSE 1 BCC 3559 $0.00 ($1,900.001 MALE SPOUSE 1 BCC 3559 $520.11 $2,100.00 MALE SPOUSE 1 BCC 3559 7/11/2017 7/5/2017 7/10/2017 55866 LAPAROSCOPY, SURGICAL PROSTATECTOMY,RETROPUBIC C61 MALIGNANT NEOPLASM PROFESSIONAL SPOUSE 1 BCC $134.68 RADICAL, INCLUDING NERVESPARING, INCLUDES SPOUSE OF PROSTATE INPATIENT /HOSPITAL RO BOTIC ASS ISTA N CE, WHEN PERFORMED 7/14/2017 7/5/2017 7/12/2017 865 AN ESTH ESIA FO R EXTRA P ERITO N FAIL P ROCEDU R ES I N C61 MALIG DART N EOPLASM OTHER MEDICAL LOWER ABDOMEN, INCLUDING URINARY TRACT; RADICAL OF PROSTATE PROSTATECTOMY (SUPRAPUBIC, RETROPUBIC) 7/14/2017 7/5/2017 7/12/2017 99251 INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED G8918 OTHER ACUTE PROFESSIONAL PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A POSTPROCEDURAL PAIN INPATIENT / HDSPITAL PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONS 712112017 7/6/2017 7/20/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE 08918 OTHER ACUTE PROFESSIONAL EVALUATION AND MANAGEMENT OF A PATIENT, WHICH POSTPROCEDURAL PAIN INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT 15 STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/ 7/24/2017 7/5/2017 7/13/2017 *. * ** 7/24/2011 7/5/2017 7/21/2017 7/24/2017 7/6/2017 7/21/2017 7/24/2017 7/14/2017 7/21/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 8/7/2017 8/1/2017 8/3/2017 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, OF PROSTATE LE UI(OCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, U ROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY 8/7/2017 811/2017 8/3/2017 99024 POSTOPERATIVE FOLLOW -UP VISIT, NORMALLY INCLUDED C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE IN THE SURGICAL PACKAGE, TO INDICATE THAT AN OF PROSTATE EVALUATION AND MANAGEMENT SERVICE WAS PERFORMED DURING A POSTOPERATIVE PERIOD FOR A REASON(S) RELATED TO THE ORIGINAL PROCEDURE 8/9/2017 6/7/2017 8/7/2017 * * * ** * * * ** ... ++ ..... ..... 811812017 7/14/2017 7/21/2017 992140FFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER $2,316.40 $6,056.00 MALE SPOUSE 1 BCC $2,831.07 $6,188.00 MALE SPOUSE 1 BCC $134.68 $506.00 MALE SPOUSE 1 BCC $143.66 $349.00 MALE SPOUSE 1 BCC 7/5/2017 7/7/2017 $55,804.29 $88,564.00 MALE SPOUSE 1 BCC $1,663.73 $2,822.01 MALE SPOUSE 1 BCC $0.00 $53.00 MALE SPOUSE 1 BCC $0.00 $250.00 MALE SPOUSE 1 BCC $1.93 $13.00 MALE SPOUSE 1 BCC $0.00 $0.00 MALE SPOUSE 1 BCC $293.40 $489.00 MALE SPOUSE 1 BCC $0.00 i$250.00I MALE SPOUSE 1 BCC 811812017 7/14/2017 8/3/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE $0.00 EVALUATION AND MANAGEMENT OF AN ESTABLISHED SPOUSE OF PROSTATE 3559 $49.28 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SPOUSE 1 BCC 3559 $61.61 COMPONENTS: A DETAILED HISTORY; A DETAILED SPOUSE 1 BCC 3559 EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 8/21/2017 5/24/2017 8/18 /2017 88321 CONSULTATION AND REPORT ON REFERRED SLIDES Z0000 ENCOUNTER FOR PROFESSIONAL PREPARED ELSEWHERE GENERAL ADULT MEDICAL OUTPATIENT /HOSPITAL EXAMINATION WITHOUT ABNORMAL FINDINGS 8/21/2017 6/7/2017 811812017 84153 PROSTATE SPECIFIC ANTIGEN(PSA); TOTAL Z0000 ENCOUNTER FOR PROFESSIONAL GENERALADULT MEDICAL OUTPATIENT /HOSPITAL EXAMINATION WITHOUT ABNORMAL FINDINGS 8/21/2017 6/7/2017 8/18/2017 84403 TESTOSTERON E; TOTAL 70000 ENCOUNTER FOR PROFESSIONAL GENERALADULT MEDICAL OUTPATIENT /HOSPITAL EXAMINATION WITHOUT ABNORMAL FINDINGS 8/23/2017 8/16/2017 8/22/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE OF PROSTATE 8/23/2017 8/16/2017 8/22/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE PATIENT, W ITCH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY, COUNSELING AND COORD 8/25/2017 8/23/2017 812412017 51784 ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE URETHRAL SPHINCTER, OTHER THAN NEEDLE, ANY OF PROSTATE TECHNIQUE 8/25/2017 8/23/2017 8/24/2017 97032 APPLICATION OF A MODALITY TO I OR MORE AREAS; C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES OF PROSTATE 8/25/2017 8/23/2017 8/24/2017 97750 PHYSICAL PERFORMANCE TEST OR MEASUREMENT(EG, C61 MALIGNANT NEOPLASM PROFESSIONAL OFFICE MUSCULOSKELETAL , FUNCTIONAL CAPACITY), WITH OF PROSTATE WRITTEN REPORT, EACH 15 MINUTES 8/31/2017 8/24/2017 8/29/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE C61 MALIGNANT NEOPLASM PROFE55IONAL EVALUATION AND MANAGEMENT OF AN ESTABLISHED OF PROSTATE OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD C.7.f $0.00 $250.00 MALE SPOUSE 1 ECG 3559 41 N Q! A 4 $308.58 $319.00 MALE SPOUSE 1 BCC 3559 7 f0 } $0.00 $41.00 MALE SPOUSE 1 BCC 3559 E. CL CL Q $0.00 $18.00 MALE SPOUSE 1 BCC 3559 $2.34 $25.00 MALE SPOUSE 1 BCC 3559 $8036 $190.00 MALE SPOUSE 1 BCC 3559 $330.85 $570.00 MALE SPOUSE 1 BCC 3559 $0.00 $50.00 MALE SPOUSE 1 BCC 3559 $49.28 $100.00 MALE SPOUSE 1 BCC 3559 $61.61 $168.00 MALE SPOUSE 1 BCC 3559 9/11/2017 8/24/2017 9/7/2017 - - C61 MALIGNANT NEOPLASM HOSPITAL OUTPATIENT $994.80 $1,658.00 MALE SPOUSE 1 BCC 3559 OF PROSTATE 9/20/2017 8/24/2017 9/18/2017 9/20/2017 8/24/2017 9/18/2017 9/20/2017 8/24/2017 9/18/2017 9/20/2017 8/24/2017 9/18/2017 11/13/2017 10/23/2017 111912017 Sub Total $2,647.00 MALE SUBSCRIBER 8.75E +10 1/27/2017 12/21/2016 1/26/2017 1/27/2017 12/21/2016 1/26/2017 2/13/2017 1/31/2017 2/3/2017 2/20/2017 1/26/2017 2/11/2017 2/20/2017 1/26/2017 2/11/2017 3/27/2017 2/24/2017 3/24/2017 80053 COMP RE HE NSIVE METABOLIC PANEL THIS PANEL MUST C61 MALIGNANT NEOPLASM PROFESSIONAL INCLUDE THE FOLLOWING: ALBUMIN (82040), BILIRUBIN, $41.00 MALE OF PROSTATE OUTPATIENT /HOSPITAL TOTAL (82247), CALCIUM, TOTAL (82310), CARBON $18.00 MALE SPOUSE 1 BCC DIOXIDE (BICARBONATE) (82374), CHLORIDE (82435), $2,647.00 MALE SUBSCRIBER 1 BCC CREATININE( 82565), GLUCOSE (82947), PHOSPHATASE, $170,861.62 ALKALINE (84075), POTASSIUM (84132), PROTEIN, $25.00 MALE SUBSCRIBER 1 OSO 83615 LACTATE DEHYDROGENASE (ED), (LDH); C61 MALIGNANT NEOPLASM PROFESSIONAL $0.00 $1,625.00 MALE OF PROSTATE OUTPATIENT /HOSPITAL 84153 PROSTATE SPECIFIC ANTIGEN(PSA); TOTAL C61 MALIGNANT NEOPLASM PROFESSIONAL $28.17 $145.00 MALE OF PROSTATE OUTPATIENT /HOSPITAL 84403 TESTOSTERONE; TOTAL C61 MALIGNANT NEOPLASM PROFESSIONAL OF PROSTATE OUTPATIENT /HOSPITAL - Z5111 ENCOUNTER FOR HOSPITAL OUTPATIENT ANTINEOPLASTIC CHEMOTHERAPY 90471 IMMUNIZATION ADMINISTRATION (INCLUDES Z23 ENCOUNTER FOR PROFESSIONAL OFFICE PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR IMMUNIZATION INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE /TOXOID) 90686 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLITVIRUS, Z23 ENCOUNTER FOR PROFESSIONAL OFFICE PRESERVATIVE FREE, WHEN ADMINISTERED TO IMMUNIZATION INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR USE 73221 MAGNETIC RESONANCE(EG, PROTON) IMAGING, ANY M25511 PAIN IN RIGHT SHOULDER PROFESSIONAL OFFICE JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIALS) 73030 RADIOLOGIC EXAM I NATION, SHOULDER; COMPLETE, M7581 OTHER SHOULDER PROFESSIONAL OFFICE MINIMUM OF TWO VIEWS LESIONS, RIGHT SHOULDER 99201 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M7S81 OTHER SHOULDER PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF A NEW PATIENT, LESIONS, RIGHT WHICH REQUIRES THESE 3 KEY COMPONENTS :A SHOULDER PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AG 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE M7591 OTHER SHOULDER PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LESIONS, RIGHT PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY SHOULDER COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND /OR COORDINATION OF CARE WIT $0.00 $35.00 MALE SPOUSE 1 BCC $0.00 $21.00 MALE SPOUSE 1 BCC $0.00 $41.00 MALE SPOUSE 1 BCC $0.00 $18.00 MALE SPOUSE 1 BCC $0.00 $2,647.00 MALE SUBSCRIBER 1 BCC $91,857.30 $170,861.62 $0.00 $25.00 MALE SUBSCRIBER 1 OSO $0.00 $25.00 MALE SUBSCRIBER 1 OSO $0.00 $1,625.00 MALE SUBSCRIBER 1050 $0.00 $125.00 MALE SUBSCRIBER 1 OSO $28.17 $145.00 MALE SUBSCRIBER 1 050 $27.17 $125.00 MALE SUBSCRIBER 1 PSG C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 ®' 4/13/2017 4/7 /2017 4112/2017 - - ZO1818 ENCOUNTER FOR OTHER HOSPITAL OUTPATIENT $627.20 $1,869.58 MALE SUBSCRIBER 1 050 3559 PREPROCEDURAL EXAMINATION 4/17/2017 4/7/2017 4/14/2017 71020 RADIOLDGIC EXAMINATION, CHEST, TWO VIEWS, 201818 ENCOUNTER FOR OTHER PROFESSIONAL $17.64 $42.00 MALE SUBSCRIBER 1050 3559 FRONTALAND LATERAL; PREPROCEDURAL OUTPATIENT /HOSPITAL EXAMINATION 4/17/2017 4/10/2017 4/14/2017 88304 LEVEL III - SURG I CAL PATHOLOGY, GROSS AND M75101 UNSPECIFIED ROTATOR PROFESSIONAL 1050 $240.29 $5,000.00 MALE MICROSCOPIC EXAMINATION ABORTION, INDUCED, 1050 CUFF TEAR OR RUPTURE OUTPATIENT /HOSPITAL SUBSCRIBER 1 OSO $32,649.04 ABSCESS, ANEURYSM ARTERIAL/VENTRICULAR, ANUS, SUBSCRIBER OF RIGHT SHOULDER, NOT $380.80 $1,806.00 MALE SUBSCRIBER 1050 TAG, APPENDIX, OTHER THAN INCIDENTAL, ARTERY, $2,340.00 MALE SPECIFIED AS TRAUMATIC 1050 $0.00 $2,325.00 MALE SUBSCRIBER ATHEROMATOUS PLAQUE, BARTHOLIN'S GLAND CYST, $0.00 $69.00 MALE SUBSCRIBER 1 OSO $313.41 $1,481.00 MALE BONE FRAGMENTS), OTHER THAN PATHOLOGIC 1050 FRACTURE, BURSA/SYNOVIAL 5/1/2017 4/7/2017 4/28/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 Z01818 ENCOUNTER FOR OTHER PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY PREPROCEDURAL OUTPATIENT /HOSPITAL EXAMINATION S/5/2017 4/10/2017 5/4/2017 29806 ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY M25S11 PAIN IN RIGHT SHOULDER PROFESSIONAL OUTPATIENT /HOSPITAL 5/5/2017 4/10/2017 5/4/2017 29826 ARTHROSCOPY, SHOULDER, SURGICAL; M25511 PAIN IN RIGHT SHOULDER PROFESSIONAL DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL OUTPATIENT /HOSPITAL ACROMIOPLASTY, WITH OR WITHOUT CORACOACROMIAL RELEASE 5/5/2017 4/10/2017 5/4/2017 29827 ARTHROSCOPY, SHOULDER, SURGICAL; W /ROTATOR CUFF N125511 PAIN IN RIGHT SHOULDER PROFESSIONAL REPAIR OUTPATIENT /HOSPITAL 5/8/2017 4/10/2017 4/13/2017 ..... ..... .ww.x .. ". .x... 9/27/2017 4/10/2017 9/26/2017 1630 ANESTHESIA FOR OPEN OR SURGICALARTHROS COPIC M24111 OTHER ARTICULAR OTHER MEDICAL PROCEDURES ON HUMERAL HEAD AND NECK, CARTILAGE DISORDERS, STERN OCLAVIC ULAR JOINT, ACROMIOCLAVICULAR JOINT, RIGHTSHOULDER AND SHOULDER JOINT; NOT OTHERWISE SPECIFIED 10/16/2017 4/10/2017 10113/2017 1630 ANESTHESIA FOR OPEN OR SURGICALARTHROS COPIC M24111 OTHER ARTICULAR PROFESSIONAL PROCEDURES ON HUMERAL HEAD AND NECK, CARTILAGE DISORDERS, OUTPATIENT /HOSPITAL STERNOCLAVICULAR JOINT, ACROMIOCLAVICULAR JOINT, RIGHTSHOULDER AND SHOULDER JOINT; NOT OTHERWISE SPECIFIED 10/16/2017 4/10/2017 30/13/2017 64415 INJECTION, ANESTHETIC AGENT; BRACHIALPLEXUS M24111 OTHER ARTICULAR PROFESSIONAL CARTILAGE DISORDERS, OUTPATIENT /HOSPITAL RIGHT SHOULDER 1212212017 12/15/2017 1212112017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R072 PRECORDIAL PAIN PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 12/22/2017 12/15/2017 12/21/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R072 PRECORDIAL PAIN PROFESSIONAL AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /DR MENTALSTATUS: ACDMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECIS 12/27/2017 12/15/2017 12/21/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R0789 OTHER CHEST PAIN PROFESSIONAL FRONTAL OUTPATIENT /HOSPITAL 12/27/2017 12/16/2017 12/26/2017 xxxxx r... w. xxxxx w.... w...w 12/27/2017 12/21/2017 12/22/2017 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST I2 I10 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE LEADS; WITH INTERPRETATION AND REPORT HYPERTENSION $16.09 $345.00 MALE SUBSCRIBER 1 OSD $11.07 $70.00 MALE SUBSCRIBER 1 050 $1,415.30 $5,000.00 MALE SUBSCRIBER 1050 $240.29 $5,000.00 MALE SUBSCRIBER 1050 $75545 $10,000.00 MALE SUBSCRIBER 1 OSO $32,649.04 $80,985.17 MALE SUBSCRIBER 1050 $380.80 $1,806.00 MALE SUBSCRIBER 1050 $0.00 $2,340.00 MALE SUBSCRIBER 1050 $0.00 $2,325.00 MALE SUBSCRIBER 1050 $0.00 $69.00 MALE SUBSCRIBER 1 OSO $313.41 $1,481.00 MALE SUBSCRIBER 1050 $14.94 $45.00 MALE SUBSCRIBER 1 OSO $17,779.00 $21,067.27 MALE SUBSCRIBER 1050 $17.15 $65.00 MALE SUBSCRIBER 1 OSO C.7.f 3559 WA 3559 3559 3559 3559 3559 III 3559 3559 3559 1 12/27/2017 12/21/2017 12/2212017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 110 ESSENTIAL (PRIMARY) PROFESSIONAL OFFICE $76.53 $276.00 MALE SUBSCRIBER 1050 EVALUATION AND MANAGEMENTOFAN ESTABLISHED HYPERTENSION PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 12/28/2017 12/15/2017 12/27/2017 99220 INITIAL OBSERVATION CARE, PER DAY, FOR THE R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $17231 $813.00 MALE SUBSCRIBER 1050 EVALUATION AND MANAGEMENT OF PATIENT, WHICH OUTPATIENT /HOSPITAL REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR A 12/28/2017 12/15/2017 12/27/2017 99255 INPATIENT CONSULTATION FOR A NEW 0R ESTABLISHED 89431 ABNORMAL PROFESSIONAL $238.13 $781.00 MALE SUBSCRIBER 1OSO PATIENT, WHICH REQUIRESTHESE 3 KEY COMPONENTS: A ELECTROCARDIOGRAM INPATIENT /HOSPITAL COMPREHENSIVE HISTORY; ACOMPREHENSIVE [ECG] [EKG] EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED C0N51 12/28/2017 12/16/2017 12/27/2017 99217 OBSERVATION CARE DISCHARGE DAY MANAGEMENT R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL $67.69 $319.00 MALE SUBSCRIBER 1050 [THIS CODE ISTD BE UTILIZED BYTHE PHYSICIAN TO OUTPATIENT /HOSPITAL REPORT ALL SERVICES PROVIDED TO A PATI ENT ON DISCHARGE FROM OBSERVATION STATUS IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF OBSERVATION STATUS. TO REPORT SERVICES TO A PATIENT DESIGNAT 12/28/2017 12/16/2017 12/27/2017 93306 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL -TIME WITH R9431 ABNORMAL PROFESSIONAL $5836 $239.00 MALE SUBSCRIBER 1 050 IMAGE DOCUMENTATION (213), INCLUDES M -MODE ELECTROCARDIOGRAM INPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, COMPLETE, WITH [ECG] [EKG[ SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY 12/29/2017 12/23/2017 1212812017 99236 OBSERVATION 0R INPATIENT HOSPITAL CARE, FOR THE 1214 NON ST ELEVATION OTHER MEDICAL $203.01 $955.00 MALE SUBSCRIBER 1OSO EVALUATION AND MANAGEMENTOFA PATIENT (NSTEMI[ MYOCARDIAL INCLUDING ADMISSION AND DISCHARGE ON THE SAME INFARCTION DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELI Sub TOt,I $55,109.15 $137,963.02 8.75E +10 1/4/2017 12/21/2016 1/3/2017 A0425 GROUND MILEAGE, PER STATUTE MILE R5381 OTHER MALAISE OTHER MEDICAL $15.00 $29.00 MALE SUBSCRIBER R01 050 1/4/2017 12/21/2016 1/3/2017 A0429 AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY R5381 OTHER MALAISE OTHER MEDICAL $254.49 $600.00 MALE SUBSCRIBER R01 050 TRANSPORT (BLS - EMERGENCY) 1/4/2017 12/21/2016 1/3/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, 1959 HYPOTENSION, PROFESSIONAL $11.17 $36.00 MALE SUBSCRIBER R01 OSO FRONTAL UNSPECIFIED INPATIENT /HOSPITAL 1/4/2017 12/21/2016 1/3/2017 99285 E MERGENCY DEPARTMENT VISIT FOR THE EVALUATION 1959 HYPOTENSION, PROFESSIONAL $234.00 $1,481.00 MALE SUBSCRIBER R01 050 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES UNSPECIFIED OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DELIS 1/5/2017 12/27/2016 1/4/2017 76700 ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE 8188 OTHER ASCITES PROFESSIONAL $49.12 $158.00 MALE SUBSCRIBER RO1 OSO DOCUMENTATION; COMPLETE INPATIENT /HOSPITAL 1/6/2017 12/21/2016 12/30/2016 * * " ** x *. x. ° " " ** * * * ** x * *.x 12/21/2016 # # # # # # ## $4,745.05 $32,983.55 MALE SUBSCRIBER R01 050 C.7.f 3559 Im WE mm Im 9MMI I C.7.f 1/9/2017 12/22/2016 1/6/2017 *xx»* * * * ** * » » ** * * * ** * * * ** $141.37 $887.00 MALE SUBSCRIBER R01 050 3559 1/9/2017 12/23/2016 1/fi/2017 * * * ** * * » »* ° " " ** " * * ** * * * *» $72.23 $453.00 MALE SUBSCRIBER I 110 3559 11912017 12/24/2016 1/6/2017 *xx»+ *xx.x +«» +* . *xxx *xx ». $72.23 $453.00 MALE SUBSCRIBER RO1 RISC 3559 1/9/201] 12/25/2016 1/6/2017 * » * ** * * * ** " » » ** * * * ** * * * ** $72.23 $453.00 MALE SUBSCRIBER RO1 OSO 3559 N 1/9/2017 12/26/2016 1/6/2017 *` * ** * * » ** *` * *` » * * *» * * * *» $49.81 $313.00 MALE SUBSCRIBER RO1 050 3559 1/9/2017 12/27/2016 1/6/2017 * * * »* * * * ** * * » ** * * * *` * * * "* $73.7] $463.00 MALE SUBSCRIBER RO1 OSO 3559 1/30/2017 1/5 /2017 1/6/2017 xx * ** * * " ** * " * ** * * "` * *` "* $248.10 $465.00 MALE SUBSCRIBER RO1 OSO 3559 1/30/2017 1/16/2017 1117/2017 - * * » ** *`w *• » * * ** * * * *» $59.52 $155.00 MALE SUBSCRIBER RO1 OSO 3559 1/30/2017 1/16/2017 1/24/2017 49082 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR 8188 OTHER ASCITES PROFE55IONAL $104.12 $648.00 MALE SUBSCRIBER R01 RISC 3559 r THERAPEUTIC); WITHOUT IMAGING GUIDANCE OUTPATIENT /HOSPITAL "a 1/30/2017 1/16/2017 1/24/2017 99284 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R188 OTHER ASCITES PROFESSIONAL $158.82 $994.00 MALE SUBSCRIBER R01 050 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES OUTPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A fl } DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING s CL AND /OR COORDINATION OF CARE WITH OTHER Q. PROVIDERS OR AGENCIES ARE PR 1/30/2017 1/20/2017 1/24/2017 - - R198 OTHER ASCITES HOSPITAL OUTPATIENT $1,454.75 $1,939.68 MALE SUBSCRIBER RO1 OSO 3559 1/30/2017 1/20/2017 1/24/2017 * * * ** * * » »* *` * ** » * * ** * * * *» $102.07 $270.00 MALE SUBSCRIBER RO1 050 3559 11311201] 1/20/2017 1/26/2017 12001 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, 531114A LACERATION WITHOUT PROFESSIONAL $62.36 $387.00 MALE SUBSCRIBER RO1 OSO 3559 �- NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND /OR FOREIGN BODY OF OUTPATIENT/HOSPITAL Lij EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM 0R ABDOMINAL WALL, LEFT h LESS LOWER QUADRANT WITHOUT PENETRATION INTO PERITONEAL CAVITY, INITIAL ENCOUNTER 1/31/2017 1/20/2017 1/26/2017 99283 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION 531114A LACERATION WITHOUT PROFESSIONAL $83.65 $520.00 MALE SUBSCRIBER R01 OSO 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES FOREIGN BODY OF OUTPATIENT /HOSPITAL IL THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM ABDOMINAL WALL, LEFT LU FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED LOWER QUADRANT EXAMINATION; AND MEDICAL DECISION MAKING OF WITHOUT PENETRATION CJ"J MODERATE COMPLEXITY. COUNSELING AND /OR INTO PERITONEAL CAVITY, COORDINATION OF CARE WITH INITIAL ENCOUNTER 21212017 1/16/2017 112012017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT $3,760.46 $5,713.94 MALE SUBSCRIBER R01 OSO 3559 LLJ V 2/17/2017 21712017 211112017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, R0602 SHORTNESS OF BREATH PROFESSIONAL $13.32 $41.00 MALE SUBSCRIBER R01 050 3559 FRONTAL AND LATERAL; INPATIENT /HOSPITAL J 2/20/2017 2/7/2017 2/14/2017 * * * ** * * » ** * " "** 1.". $230.81 $783.00 MALE SUBSCRIBER RO1 050 3559 212012017 218/2017 211112017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR 8188 OTHER ASCITES PROFE55IONAL $131.92 $437.00 MALE SUBSCRIBER RO1 RISC 3559 v THERAPEUTIC); WITH IMAGING GUIDANCE INPATIENT /HOSPITAL 2/20/201] 2/9/201] 2/14/2017 * * * »* * *` ** * » » ** * * *" * *` "* $240.43 $700.00 MALE SUBSCRIBER RO1 OSO 3559 2/20/2017 2/9/2017 2115/2017 76700 ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE K7460 UNSPECIFIED CIRRHOSIS PROFESSIONAL $49.24 $153.00 MALE SUBSCRIBER RO1 OSO 3559 LLJ DOCUMENTATION; COMPLETE OF LIVER INPATIENT / HDSPITAL 2/20/2017 2/9/2017 2/15/2017 93975 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS K7460 UNSPECIFIED CIRRHOSIS PROFESSIONAL $114.79 $218.00 MALE SUBSCRIBER R01 OSO 3559 OUTFLOW OFABDOMINAL, PELVIC, SCROTALCONTENTS OF LIVER INPATIENT /HOSPITAL (' AND /OR RETROPERITONEAL ORGANS; COMPLETE STUDY 2/20/2017 2/10/201] 2/14/201] $111.40 $399.00 MALE SUBSCRIBER R01 OSO 3559 2/20/2017 2/11/2017 2/14/2017 * * * "* * * » ** *` " ** » * * ** * * * ** $111.40 $399.00 MALE SUBSCRIBER RO1 050 3559 2/20/2017 2/12/2017 2/14/2017 * " ** *x + »* *' * ** * * + ** * *` ** $11140 $399.00 MALE SUBSCRIBER R01 OSO 3559 2/20/2017 2/13/2017 2/16/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R198 OTHER ASCITES PROFESSIONAL $131.92 $437.00 MALE SUBSCRIBER RO1 OSO hl 3559 THERAPEUTIC); WITH IMAGING GUIDANCE INPATIENT /HOSPITAL = 2/27/2017 1/30/2017 212112017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R198 OTHER ASCITES PROFESSIONAL $139.50 $412.00 MALE SUBSCRIBER R01 OSO 3559 y THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL L 2/2]/2017 2181201] 2/20/2017 * * * »* .xx ** *x* ** » * * ** *xx ** $84.70 $2]6.00 MALE SUBSCRIBER RO1 OSO 3559 2/2]/201] 2/9/201] 2/20/2017 * * * »' * * * ** .xx +* *.. »» + * * ». $84.70 $2]6.00 MALE SUBSCRIBER RO1 OSO 3559 �, C.7.f 2/27/2017 2/10/2017 212012017 ** » ** * * * ** * * * ** 2/27/2017 2/11/2017 2/20/2017 $84.70 2/27/2017 2/13/2017 2/21/201] 3559 * * » »« 2/27/2017 2/14/2017 212112017 SUBSCRIBER R01 OSO 2/27/2017 2/21/2017 2/22/2017 $78.34 $279.00 MALE 3/1/201] 2/12/2017 2/18/201] » * * *« * * * *» 3/1/2017 2/14/2017 2/18/2017 * « * "* ISO 3559 3/2/2017 2/8/2017 2118/2017 88108 CYTOPATHOLOGY, CONCENTRATION TECHNIQUE, SMEARS R188 0 3559 AND INTERPRETATION (EG, SACCOMANNO TECHNIQUE) $111.40 3/3/2017 2/7/2017 2/23/2017 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION R0602 PROFESSIONAL $32.22 $86.00 MALE AND MANAGEMENT OF A PATIENT, WHICH REQUIRES ISO 3559 INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS } IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE SHORTNESS OF BREATH PROFESSIONAL $308.08 HISTORY; A COMPREHENSIVE EXAMINATION; ANO SUBSCRIBER R01 ISO 3559 MEDICAL DECIS 3/6/201] 12/16/2016 3/3/27 3/6/2017 12/21/2016 3/3/20 3/8/2017 2/24/2017 3/1/2017 * * * ** * * * ** *« « ** 3/8/2017 312/2017 3/3/2017 3/8/2017 3/2/2017 3/4/2017 fl s® 3/13/2017 1/30/2017 2/2/2017 * * « «* * * + +* *« « ** 3/13/2017 21712017 212012017 3/13/2017 2/7/2017 3/9/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R079 LEADS; INTERPRETATION AND REPORT ONLY 3/13/2017 31 /201] 31]1201] $8.28 $70.00 MALE 3/16/2017 3/2/201] 3/]/201] * * * ** * * * ** 3/17/2017 3/3/2017 3113/2017 * * * ** * * * ** * « * ** 3/17/2017 3/4/2017 3/8/2017 76770 ULTRASOUND, RETROPERITONEAL(EG, RENAL, AORTA, R188 050 3559 NODES), REALTIME WITH IMAGE DOCUMENTATION; $3.07 $19.00 MALE SUBSCRIBER RO1 050 COMPLETE * * * ** 3/17/2017 3/4/2017 3/14/2017 SUBSCRIBER RO1 0 3/17/2017 3/5/2017 3/9/2017 $991.18 $1,321.57 MALE 3/17/2017 3/6/2017 3/912017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR 3188 2/7/2017 # # # # # # ## $8,]64.86 $80,338.22 MALE SUBSCRIBER RO1 THERAPEUTIC); WITH IMAGING GUIDANCE 3559 3/17/2017 3/6/201] 3/10/2017 $60.00 MALE SUBSCRIBER RO1 3/17/2017 3/6/2017 3/15/2017 88108 CYTOPATHOLOGI, CONCENTRATION TECHNIQUE, SMEARS R188 AND INTERPRETATION (EG, SACCOMANNO TECHNIQUE) 3/17/2017 3/]/201] 3/10/2017 ** » ** * * * ** * « » ** 3/17/2017 3/13/2017 3/14/2017 69210 REMOVAL IMPACTED CERUMEN REQUIRING H9313 SUBSCRIBER RO1 ISO 3559 Q*' INSTRUMENTATION, UNILATERAL * * * *» 3/17/2017 3/13/2017 3/14/2017 99204 OFF I CE OR OTHER OUTPATIENT VISIT FOR THE H9313 OTHER ASCITES PROFESSIONAL $44.38 EVALUATION AND MANAGEMENT OF A NEW PATIENT, SUBSCRIBER 301 ISO 3559 a. WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF » * * ** * * * *+ MODERATE COMPLEXITY. COUNSELING AND /OR $595.00 MALE SUBSCRIBER RO1 ISO 3559 COORDINATION OF CARE WITH OTHER PROVIDERS OR + + + ++ 3/27/2017 3/22/2017 3/23/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E782 3/28/2017 3/24/2017 3/27/2017 99358 PROLONGED EVALUATION AND MANAGEMENT SERVICE E971 050 3559 BEFORE AND /OR AFTER DIRECT PATIENT CARE; FIRST $103.51 $276.00 MALE SUBSCRIBER R ISO HOUR 3/30/2017 3/25/2017 3/29/2017 * * * ** + + + +* * * * ** 3/30/2017 3/27/2017 3/28/201] $42.96 $86.00 MALE * * * ** * * * ** $84.70 $276.00 MALE SUBSCRIBER R OSO 3559 $84.70 $276.00 MALE SUBSCRIBER R ISO 3559 * * » »« * * » »* $77.63 $276.00 MALE SUBSCRIBER R01 OSO 3559 {U * * * ** * * * ** $78.34 $279.00 MALE SUBSCRIBER RO1 OSO 3559 N » * * *« * * * *» $191.69 $330.00 MALE SUBSCRIBER RO1 ISO 3559 $84.70 $276.00 MALE SUBSCRIBER R01 0 3559 $111.40 $399.00 MALE SUBSCRIBER RO1 0 3559 OTHER ASCITES PROFESSIONAL $32.22 $86.00 MALE SUBSCRIBER RO1 ISO 3559 INPATIENT /HOSPITAL } SHORTNESS OF BREATH PROFESSIONAL $308.08 $1,714.00 MALE SUBSCRIBER R01 ISO 3559 OUTPATIENT /HOSPITAL fl } fl s® CL CL Q » * * ** * * * ** $8.28 $70.00 MALE SUBSCRIBER RO1 OSO 3559 v * * * ** * * * ** $8.28 $70.00 MALE SUBSCRIBER RO1 OSO 3559 » * * ** * * *.. $2.34 $55.00 MALE SUBSCRIBER RO1 050 3559 $3.07 $19.00 MALE SUBSCRIBER RO1 050 3559 �+ * * * ** * * * ** $24.06 $157.00 MALE SUBSCRIBER RO1 0 3559 » * * ** * * * *» $991.18 $1,321.57 MALE SUBSCRIBER RO1 050 3559 Lij 2/7/2017 # # # # # # ## $8,]64.86 $80,338.22 MALE SUBSCRIBER RO1 OSO 3559 CHEST PAIN, UNSPECIFIED PROFESSIONAL $6.92 $60.00 MALE SUBSCRIBER RO1 ISO 3559 OUTPATIENT /HOSPITAL $25.67 $379.96 MALE SUBSCRIBER R01 OSO 3559 * * * ** * * * ** $81.33 $299.06 MALE SUBSCRIBER RO1 ISO 3559 Q*' » * * ** * * * *» 3/3/2017 3/7/2017 $13,404.19 $44,179.92 MALE SUBSCRIBER RO1 OSO 3559 OTHER ASCITES PROFESSIONAL $44.38 $135.00 MALE SUBSCRIBER 301 ISO 3559 a. INPATIENT /HOSPITAL ui » * * ** * * * *+ $260.78 $595.00 MALE SUBSCRIBER RO1 ISO 3559 + + +x+ + + + ++ $77.63 $276.00 MALE SUBSCRIBER RO1 ISO 3559 0 OTHER ASCITES PROFESSIONAL $131.92 $437.00 MALE SUBSCRIBER RO1 050 3559 INPATIENT /HOSPITAL $103.51 $276.00 MALE SUBSCRIBER R ISO 3559 LLJ OTHER ASCITES PROFESSIONAL $42.96 $86.00 MALE SUBSCRIBER RO1 ISO 3559 INPATIENT /HOSPITAL J * * * ** * * * ** $81.21 $276.00 MALE SUBSCRIBER R 050 3559 TINNITUS, BILATERAL PROFESSIONAL OFFICE $57.24 $110.00 MALE SUBSCRIBER RO1 ISO 3559 (, TIN NITUS, BILATERAL PROFESSIONAL OFFICE $189.45 $280.00 MALE SUBSCRIBER ROl ISO 3559 W U Q Q MIX ED HYPER LI PIDEMIA PROFE551O NAL OFFICE $2.34 $8.00 MALE SUBSCRIBER R01 ISO 3559 CFJ hl HYPO - OSMOLALITY AND PROFESSIONAL OFFICE $134.67 $230.00 MALE SUBSCRIBER RO1 ISO 3559 HYPONATREMIA C $260.13 $260.13 MALE SUBSCRIBER RO1 ISO 3559 » * » ** * * * ** $84.52 $155.00 MALE SUBSCRIBER R01 ISO 3559 3/31/2017 3/]/201] 3/30/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N179 ACUTE KIDNEY FAILURE, PROFESSIONAL « * *rr EVALUATION AND MANAGEMENTOFA PATIENT, WHICH $113.25 UNSPECIFIED INPATIENT /HOSPITAL 0 REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN 4/4/2017 2/27/2017 4/2/2017 * " : ** * * * ** EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN « * * *« * * * ** $373.74 $373.74 MALE EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL OSO 3559 4/4/2017 2/28/2017 DECISION MAKING OF MODERATE COMPLEXITY. * * * ** * * * ** " * * *« * * * ** COUNSELING AND /OR $107.60 MALE SUBSCRIBER R01 OSO 4/3/2017 3/4/2017 3/31/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION N179 ACUTE KIDNEY FAILURE, PROFESSIONAL R188 AND MANAGEMENTOF A PATIENT, WHICH REQUIRES HOSPITAL OUTPATIENT UNSPECIFIED INPATIENT /HDSPITAL SUBSCRIBER R01 THESE 3 KEYCOMPONENTS: A COMPREHENSIVE HISTORY; 3559 4/10/2017 3/17 /2017 4/7/2017 - A COMPREHENSIVE EXAMINATION; AND MEDICAL R188 OTHER ASCITES HOSPITAL OUTPATIENT $1,321.57 DECISION MAKING OF HIGH COMPLEXITY. COUNSELING SUBSCRIBER R01 050 3559 4/10/2017 AND /OR COORDINATION OF CARE WITH OTHER 4/7/2017 .... *rw.* ***** PROVIDERS OR AGES 4/1/2017 4/4/2017 $12,126.97 $23,338.27 MALE SUBSCRIBER R01 4/3/2017 3/5/2017 3/31/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N179 ACUTE KIDNEY FAILURE, PROFESSIONAL 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR EVALUATION AND MANAGEMENTOFA PATIENT, WHICH OTHER ASCITES UNSPECIFIED INPATIENT/HOSPITAL $412.00 MALE REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: AN OSO 3559 EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. 3/27/2017 4/10/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R198 COUNSELING AND /OR PROFESSIONAL $186.00 $412,00 MALE 4/3/2017 3/6/2017 3/31/2017 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE N179 ACUTE KIDNEY FAILURE, PROFESSIONAL EVALUATION AND MANAGEMENTOFA PATIENT, WHICH UNSPECIFIED INPATIENT /HDSPITAL REQUIRES AT LEAST 2 OF TH ESE 3 KEY COMPONENTS: A 4/11/201] PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM 4/10/201] * *' ** -- x** ** . * * ** FOCUSED EXAMINATION; MEDICAL DECISION MAKING $17.64 $42.00 MALE SUBSCRIBER RO1 OSO THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. 4/12/201] 3/14/2017 4/11/201] * * * "' * * * ** COUNSELING AND/ w.. »» + * * ». $124.58 4/3/2017 3/30/2017 3/31/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R188 OTHER ASCITES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 4/3/2017 3/30/2017 3/31/2017 99354 PROLONGED SERVICE IN THE OFFICE OR OTHER R188 OTHER ASCITES PROFESSIONAL OFFICE OUTPATIENT SETTING REQUIRING DIRECT PATIENT CONTACT BEYOND THE USUAL SERVICE; FIRST HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR OFFICE OR OTHER OUTPATIENT EVALUATION AND MANAGEMENT SERVICE) $62.88 $157.54 MALE SUBSCRIBER R01 050 $176.13 $446.60 MALE SUBSCRIBER R01 050 $62.88 $157.54 MALE SUBSCRIBER R01 O5O $35.03 $86.90 MALE SUBSCRIBER R01 OSO $82.01 $145.00 MALE SUBSCRIBER R01 OSO $116.99 $190.00 MALE SUBSCRIBER R01 050 C.7.f 3559 ®' WE mm ®' WE 4/4/2017 2/16/2017 4/2/2017 * * « ** .« « +* « * *rr $113.25 $113.26 MALE SUBSCRIBER ROl 0 3559 4/4/2017 2/27/2017 4/2/2017 * " : ** * * * ** ° " " ** « * * *« * * * ** $373.74 $373.74 MALE SUBSCRIBER RO1 OSO 3559 4/4/2017 2/28/2017 4/2/2017 * «» ** * * * ** * * * ** " * * *« * * * ** $107.60 $107.60 MALE SUBSCRIBER R01 OSO 3559 4/7/2017 3/2]/201] 4/5/2017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT $1,321.57 $1,321.57 MALE SUBSCRIBER R01 OSO 3559 4/10/2017 3/17 /2017 4/7/2017 - - R188 OTHER ASCITES HOSPITAL OUTPATIENT $1,321.57 $1,321.57 MALE SUBSCRIBER R01 050 3559 4/10/2017 4/1/2017 4/7/2017 .... *rw.* ***** ** *a* 4/1/2017 4/4/2017 $12,126.97 $23,338.27 MALE SUBSCRIBER R01 OSO 3559 4/11/2017 311712017 4/10/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFE55IONAL $186.00 $412.00 MALE SUBSCRIBER R01 OSO 3559 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 4/11/2017 3/27/2017 4/10/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R198 OTHER ASCITES PROFESSIONAL $186.00 $412,00 MALE SUBSCRIBER R01 O5O 3559 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 4/11/201] 411/201] 4/10/201] * *' ** -- x** ** . * * ** ... ** $17.64 $42.00 MALE SUBSCRIBER RO1 OSO 3559 4/12/201] 3/14/2017 4/11/201] * * * "' * * * ** * "x +* w.. »» + * * ». $124.58 $124.58 MALE SUBSCRIBER RO1 050 3559 C.7.f 4/12/2017 3/16/2017 411112017 * * * ** $215.20 MALE SUBSCRIBER I 4/12/2017 3/23/2017 4/11/2017 $107.60 4/12/2017 4/1/2017 4/11/2017 99285 EMER6ENCV DEPARTMENT VISIT FOR THE EVALUATION E871 OTHER MEDICAL $313.41 $1,481.00 MALE AND MANAGEMENT OF A PATIENT, WHICH REQUIRES DID 3559 {U HYPONATREMIA O50 THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS $549.92 $1,677.00 MALE N IMPOSED BY THE DRGENCY OF THE PATIENT'S CLINICAL 3559 OTHER DISORDERS OF PROFESSIONAL $17.64 $42.00 MALE CONDITION AND /OR MENTAL STATUS: A COMPREH ENSIVE ISO 3559 LUNG OUTPATIENT /HOSPITAL HISTORY; A COMPREHENSIVE EXAMINATION; AND Q! PLEURAL EFFUSION, NOT HOSP17A L OUTPATIENT ME DICAL DECIS $849.00 MALE 4/13/2017 4/3/2017 4/11/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE R188 EVALUATION AND MANAGEMENT OF PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER ASCITES OTHER PROVI $12342 4/13/2017 4/4/2017 4/11/2017 99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES R188 INPATIENT /HOSPITAL OR LESS 4/14/2017 4/11/201] 4/12/2017 4/18/2017 4/1/2017 4/12/2017 4/21/2017 4/1/2017 4/20/2017 * * * ** * * * ** *« « ** 4/24/2017 4/18/2017 4/21/2017 - - 8188 4/28/2017 4/1/2017 4/12/2017 4/28/2017 4/1/2017 4/12/2017 CL 5/3/2017 4/18/2017 5/2/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR 3188 CL THERAPEUTIC); WITH IMAGING GUIDANCE S/9/2"7 411/1111 4/12/2017 OTHER ASCITES PROFESSIONAL 5/15/2017 5/11/2017 5/12/2011 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR R188 INPATIENT /HOSPITAL SIDE U BIN, GLUCOSE, HEMOGLOBIN, KETONES, * * * ** LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, $305.72 $465.00 MALE SUBSCRIBER RO1 ISO UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; $611.39 $611.39 MALE AUTOMATED, WITHOUT MICROSCOPY ISO 5115/2017 5/11/2017 5/12/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R188 SUBSCRIBER R ISO 3559 F EVALUATION AND MANAGEMENTOFAN ESTABLISHED H OS P ITA L O UTPATI E IT $1,321.57 $1,321.57 MALE SUBSCRIBER RO1 PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY 3559 F COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR * * * ** * * * ** $0.00 $611.39 MALE MALE COORDINATION OF CARE WITH OTHER OSO ISO 5/22/2017 5/18/2017 5/19/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E871 SUBSCRIBER RO1 OSO 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED OUTPATIENT /HOSPITAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF $611.39 $611.39 MALE SUBSCRIBER R ISO MODERATE COMPLEXITY. COUNSELING AND /OR OTHER ASCITES PROFESSIONAL OFFICE $2.51 $10.00 MALE COORDINATION OF CARE WITH OTHER ISO 5/24/2017 5/12/2017 5/23/2017 5/25/2017 5/23/2017 5/24/2017 * * » ** 5/25/2017 5/23/2017 5/24/2017 5/26/2017 5/12/2017 5/25/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 1984 FRONTALAND LATERAL; 5/26/2017 5/18/2017 5/24/2017 - - 190 * * * ** * * * ** $215.20 $215.20 MALE SUBSCRIBER I OSO 3559 $107.60 $107.60 MALE SUBSCRIBER RO1 ISO 3559 HYPO- OSMOLALITYAND OTHER MEDICAL $313.41 $1,481.00 MALE SUBSCRIBER RO1 DID 3559 {U HYPONATREMIA O50 3559 $549.92 $1,677.00 MALE N ISO 3559 OTHER DISORDERS OF PROFESSIONAL $17.64 $42.00 MALE SUBSCRIBER R01 ISO 3559 LUNG OUTPATIENT /HOSPITAL Q! PLEURAL EFFUSION, NOT HOSP17A L OUTPATIENT $849.00 $849.00 MALE SUBSCRIBER R01 ISO 3559 ELSEWHERE CLASSIFIED OTHER ASCITES PROFESSIONAL $12342 $217.00 MALE SUBSCRIBER R01 ISO 3559 INPATIENT /HOSPITAL fl } fl s® CL CL Q OTHER ASCITES PROFESSIONAL $83.78 $148.00 MALE SUBSCRIBER R01 OSO 3559 v INPATIENT /HOSPITAL * * * ** * * * ** $305.72 $465.00 MALE SUBSCRIBER RO1 ISO 3559 $611.39 $611.39 MALE SUBSCRIBER R01 ISO 3559 $11.0] $70.00 MALE SUBSCRIBER R ISO 3559 F OTH ER ASCITES H OS P ITA L O UTPATI E IT $1,321.57 $1,321.57 MALE SUBSCRIBER RO1 DID 3559 F * * * ** * * * ** $0.00 $611.39 MALE MALE SUBSCRIBER RO1 SUBSCRIBER R01 OSO ISO 3559 3559 OTHER ASCITES PROFESSIONAL $186.00 $412.00 MALE SUBSCRIBER RO1 OSO 3559 OUTPATIENT /HOSPITAL $611.39 $611.39 MALE SUBSCRIBER R ISO 3559 OTHER ASCITES PROFESSIONAL OFFICE $2.51 $10.00 MALE SUBSCRIBER R01 ISO 3559 IL W O OTHER ASCITES PROFESSIONAL OFFICE $122.22 $215.00 MALE SUBSCRIBER R01 CEO 3559 HYPO- OSMOLALITYAND PROFESSIONAL OFFICE $122.22 $215.00 MALE SUBSCRIBER R01 ISO 3559 HYPONATREMIA $1,769.00 $1,769.00 MALE SUBSCRIBER R ISO 3559 * * * ** * * * ** $0.00 $4.30 MALE SUBSCRIBER R01 O50 3559 $549.92 $1,677.00 MALE SUBSCRIBER R01 ISO 3559 OTHER DISORDERS OF PROFESSIONAL $17.64 $42.00 MALE SUBSCRIBER R01 ISO 3559 LUNG OUTPATIENT /HOSPITAL PLEURAL EFFUSION, NOT HOSP17A L OUTPATIENT $849.00 $849.00 MALE SUBSCRIBER R01 ISO 3559 ELSEWHERE CLASSIFIED 5/30/2017 5/23/2017 5/29/2017 - - Z1211 ENCOUNTER FOR HOSPITAL OUTPATIENT $1,050.00 MALE SUBSCRIBER R01 RAO $2.34 $8.00 MALE SUBSCRIBER RO1 OSO SCREENING FOR $40.00 MALE SUBSCRIBER RO1 OSO $36.63 $91.00 MALE SUBSCRIBER RO1 OSO ($5, 278.A 2j MALIGNANT NEOPLASM SUBSCRIBER RO1 OSO $5,600.32 $15,136.00 MALE SUBSCRIBER RO1 RED $0.00 $15,136.00 MALE OFCOLON $1,378.00 6/1/2017 5/26/2017 5/31/2017 - - R188 OTHER ASCITES HOSPITAL OUTPATIENT 6/2/2017 5/23/2017 6/1/2017 88305 LEVELIV- SURGICAL PATHOLOGY, GROSS AND K3189 OTHER DISEASES OF PROFESSIONAL MICROSCOPIC EXAMINATION ABORTION- STOMACH AND OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE DUODENUM MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS, BREAST, REDUCTION 6/6/2017 5/2/2017 6/5/2017 - - R188 OTHER ASCITES HOSPITAL OUTPATIENT 6/6/2017 5/18/2017 6/5/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 190 PLEURAL EFFUSION, NOT PROFESSIONAL FRONTAL AND LATERAL; ELSEWHERE CLASSIFIED OUTPATIENT /HOSPITAL 6/7/2017 5/23/2017 6/6/2017 810 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC K3189 OTHER DISEASES OF PROFE55IONAL PROCEDURES, ENDOSCOPE INTRODUCED DISTAL TO STOMACH AND OUTPATIENT/HOSPITAL DUODENUM DUODENUM 6/7/2017 6/2/2017 6/6/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E871 HYPO- OSMOIALITY AND PROFESSIONAL OFFICE HYPONATREMIA 6/7/2017 6/2/2017 6/6/2017 99211 OFFICE DR OTHER OUTPATIENT VISIT FOR THE E871 HYPO- OSMOLALITY AND PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPONATREMIA PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN. USUALLY, THE PRESENTING PROBLEM(S) ARE MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING OR SUPERVISING THESE SERVICES. 6/13/2017 6/9/2017 6/12/2017 * * * ** * * * ** * * * ** * * * ** * * * ** 6/15/2017 6/9/2017 6/14/2017 - - R188 OTHER ASCITES HOSPITAL OUTPATIENT 6/16/2017 4/1/2017 4/12/2017 * " ** * * * ** + * * *+ * * * ** * * * ** 6/19/2017 5/12/2017 6/16/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFE55IONAL THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 6/26/2017 6/13/2017 6/23/2017 * * °:. ....* ..x ++ * *. *. ..... 6/28/2017 6/9/2017 6/27/2017 93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING R600 LOCALIZED EDEMA PROFESSIONAL RESPONSES TO COMPRESSION AND OTHER MANEUVERS; OUTPATIENT /HOSPITAL UNILATERAL OR LIMITED STUDY 6/29/2017 5/23/2017 5/29/2017 - - Z1211 ENCOUNTER FOR HOSPITAL OUTPATIENT SCREENING FOR MALIGNANT NEOPLASM OFCOLON 6/29/2017 5/23/2017 6/28/2017 - - Z1211 ENCOUNTER FOR HOSPITAL OUTPATIENT SCREENING FOR MALIGNANT NEOPLASM OFCOLON 6/29/2017 5/23/2017 6/28/2017 - - Z1211 ENCOUNTER FOR HOSPITAL OUTPATIENT SCREENING FOR MALIGNANT NEOPLASM OFCOLON 6/29/2017 6/23/2017 6128/2017 - - R188 OTHER ASCITES HOSPITAL OUTPATIENT 6/30/2017 5/26/2017 6/29/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 6/30/2017 6/9/2017 6/29/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R198 OTHER ASCITES PROFESSIONAL THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL $5,278.42 $14,266.00 MALE SUBSCRIBER RO1 050 $1,378.00 $1,378.00 MALE SUBSCRIBER RO1 RISE, $58.57 $140.00 MALE SUBSCRIBER RO1 OSO $2,035.70 $2,035.70 MALE SUBSCRIBER RO1 O50 $17.64 $42.00 MALE SUBSCRIBER RO1 OSO $577.61 $1,050.00 MALE SUBSCRIBER R01 RAO $2.34 $8.00 MALE SUBSCRIBER RO1 OSO $23.91 $40.00 MALE SUBSCRIBER RO1 OSO $122.22 $215.00 MALE SUBSCRIBER R01 OSO $3,082.00 $3,082.00 MALE SUBSCRIBER R01 CEO j<611.39 $611.39 MALE SUBSCRIBER RO1 EGO $186.00 $412.00 MALE SUBSCRIBER RO1 050 $309.53 $850.00 MALE SUBSCRIBER R01 OSO $36.63 $91.00 MALE SUBSCRIBER RO1 OSO ($5, 278.A 2j ($14, 2fifi.00J MALE SUBSCRIBER RO1 OSO $5,600.32 $15,136.00 MALE SUBSCRIBER RO1 RED $0.00 $15,136.00 MALE SUBSCRIBER R01 OSO $1,378.00 $1,378.00 MALE SUBSCRIBER RO1 O50 $186.00 $412.00 MALE SUBSCRIBER R01 OSO $186.00 $412.00 MALE SUBSCRIBER RO1 050 C.7.f 3559 3559 3559 3559 3559 3559 III III 3559 3559 3559 C.7.f 71312017 6/13/2017 71112017 ** * *" ' *' *" * * * ** * # # #p * *' ** $182.78 $507.00 MALE SUBSCRIBER R01 050 3559 7/7/2017 4/3/2017 7/6/2017 49083 ABDOMINAL PARACENTE515(DIAGN0STIC OR R188 OTHER ASCITES PROFESSIONAL $186.00 $412.00 MALE SUBSCRIBER RO1 OSO 3559 THERAPEUTIC(; WITH IMAGING GUIDANCE INPATIENT /HOSPITAL 7/10/2017 6/29/2017 7/7/2017 93320 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND /OR Z01810 ENCOUNTER FOR PROFESSIONAL $16.98 $58.00 MALE SUBSCRIBER R01 OSO 3559 N CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST PREPROCEDURAL OUTPATIENT /HOSPITAL SEPARATELY IN ADDITION TO CODES FOR CARDIOVASCULAR ECHOCARDIOGRAPHIC IMAGING); COMPLETE EXAMINATION 7/10/2017 6/29/2017 7/7/2017 93325 DOPPLER ECHOCARDIOGRAPHY COLOR FLOWVELOCITY Z01810 ENCOUNTER FOR PROFESSIONAL $3.63 $10.00 MALE SUBSCRIBER R01 OSO 3559 MAPPING (LIST SEPARATELY IN ADDITION TO CODES FOR PREPROCEDURAL OUTPATIENT /HOSPITAL } ECHOCARDIOGRAPHY) CARDIOVASCULAR "a EXAMINATION 7/10/2017 6/29/2017 7/7/2017 93351 ECHOCARDIOGRAPHY , TRANSTHORACIC, REAL -TIME WITH Z01810 ENCOUNTER FOR PROFESSIONAL $79.80 $271.00 MALE SUBSCRIBER R01 EGO 3559 IMAGE DOCUMENTATION(2D), INCLUDES M -MODE PREPROCEDURAL OUTPATIENT /HOSPITAL RECORDING, WHEN PERFORMED, DURING RESTAND CARDIOVASCULAR } CARDI0V45CUTAR STRESS TEST USING TREADMILL, EXAMINATION BICYCLE EXERCISE AND /OR PHARMACOLOGICALLY N. CL INDUCED STRESS, WITH INTERPRETATION AND REPORT; Q, INCLUDING PERFORMANCE 7/10/2017 6/29/2017 7/7/2017 ' * * ** * *x.. ****. : * *xx *xxx* $1,972.00 $6,042.80 MALE SUBSCRIBER RO1 OSO 3559 7/12/2017 6/29/2017 7/11/2017 99244 OFFICE CONSULTATION FOR ANEW OR ESTABLISHED ZO1810 ENCOUNTERFOR PROFESSIONAL $175.79 $405.00 MALE SUBSCRIBER RO1 OSO 3559 ® y PATIENT,WHICH REQUIRES THESE 3 KEY COMPONENTS: A PREPROCEDURAL OUTPATIENT /HOSPITAL COMPREHENSIVE HISTORY; ACDMPREHENSIVE CARDIOVASCULAR EXAMINATION; AND MEDICAL DECISION MAKING OF EXAMINATION h MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONS 7/17/2017 6/29/2017 7/13/2017 74160 COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST K7460 UNSPECIFIED CIRRHOSIS PROFESSIONAL $103.90 $241.00 MALE SUBSCRIBER R01 OSO 3559 MATERIALS) OF LIVER OUTPATIENT /HOSPITAL O 7/18/2017 5/2/2017 7/17/2017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT $0.00 $2,035.70 MALE SUBSCRIBER R01 O5O 3559 Q W 7/18/2017 7/7 /2017 7/17/2017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT $2,756.00 $2,756.00 MALE SUBSCRIBER R01 EGO 3559 712012017 6/29/2017 7/14/2017 + * * *` * * * ** * * *`+ * * * ** * * * ** $63.00 $150.00 MALE SUBSCRIBER RO1 050 3559 7121/2017 6/23/2017 7/20/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R198 OTHER ASCITES PROFESSIONAL $186.00 $412.00 MALE SUBSCRIBER RO1 OSO 3559 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL LLJ . * *'* * * * ** "' *' * * * ** * * * ** n °✓ 7/25/2017 6/13/2017 7/24/2017 $292.00 $292.00 MALE SUBSCRIBER R01 O5O 3559 7/25/2017 7/7/2017 7/24/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL $186.00 $412.00 MALE SUBSCRIBER RO1 OSO 3559 THERAPEUTIC(; WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL J 712812017 712112017 7/27/2017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT $1,378.00 $1,378.00 MALE SUBSCRIBER R01 OSO 3559 v 81812017 7/30/2017 8/7/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION K767 HEPATORENAL PROFESSIONAL $189.81 $893.00 MALE SUBSCRIBER R01 050 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES SYNDROME INPATIENT / HDSPITAL LLJ THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING (' AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 8/8/2017 7 /30/2017 8/7/2017 * * * ** * * * ** * * *`+ * * * ** * * * ** 7/30/2017 8/1/2017 $13,022.65 $26,740.06 MALE SUBSCRIBER RO1 OSO 3559 8/8/2017 7/31/2017 8/7/2017 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE K767 HEPATORENAL PROFESSIONAL $9718 $458.00 MALE SUBSCRIBER RO1 O5O 3559 N EVALUATION AND MANAGEMENTOFA PATIENT, WHICH SYNDROME INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A = DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVI 2 C.7.f 6/9/2017 7/30/2017 81812017 71010 RADIOLOGIC EXAM I NATION, CHEST; SINGLE VIEW, R0602 PROFESSIONAL $70.32 INPATIENT /HOSPITAL FRONTAL PROFESSIONAL 8/9/2017 7/30/2017 8/8/2017 76770 ULTRASOUND, RETROPERITONEAL(EG, RENAL, AORTA, R188 INPATIENT /HOSPITAL OTHER ASCITES HOSPITAL OUTPATIENT NODES), REAL TIME WITH IMAGE DOCUMENTATION; PROFESSIONAL ADIUSTMENTAND OUTPATIENT /HOSPITAL MANAGEMENT OF COMPLETE VASCULAR ACCESS DEVICE 8/9/2017 7/30/201] 8/8/201] * * " "* * * * ** * * * ** 8/9/2017 7/30/2017 8/8/2017 WY ° ** $0.00 $9.20 MALE 8/14/2017 8/1/2017 8/11/2017 76705 ULTRASOUND, ABDOMINAL, REALTIME WITH IMAGE Z944 $72.00 MALE SUBSCRIBER RO1 050 $103.51 DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, SUBSCRIBER R01 ISO $0.00 $10.40 MALE SUBSCRIBER RO1 050 QUADRANT, FOLLOW -UP) $2]6.00 MALE 8/14/2017 8/1/2017 8/11/2017 93975 DUPLEXSCAN OFARTERIAL INFLOW AND VENOUS Z944 $276.00 MALE SUBSCRIBER RO1 050 $103.51 OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS SUBSCRIBER RO1 050 $1,385.94 $1,385.94 MALE SUBSCRIBER R01 ISO AND /OR RETROPERITONEAL ORGANS; COMPLETE STUDY $966.60 MALE 8/14/2017 $0.00 $903.90 MALE SUBSCRIBER R01 ISO $0.00 8/14/20" 8/1/201] 611212017 $92.00 MALE SUBSCRIBER R ISO 8/14/2017 8/2/2017 8/11/2017 $122.22 $215.00 MALE 8/14/2017 8/2/2017 8/12/2017 SUBSCRIBER RO1 050 $148.53 8/14/2017 8/3/201] 8/11/2017 $399.00 MALE SUBSCRIBER ROT ISO 8/14/2017 8/3/2017 8/11/2017 $186.00 $412.00 MALE 8/14/2017 8/3/2017 8/11/2017 * * « ** * * * ** *« « ** 8/14/2017 1 8/11/201] $462.00 MALE SUBSCRIBER ROT 050 8/14/2017 8/3/2017 8/11/2017 $14.10 $5].00 MALE 8/14/2017 8/4/2017 8/11/2017 SUBSCRIBER R01 ISO $14.87 8/14/2017 8/4/2017 8/11/20" 8/14/2017 8/4/2017 8/12/2017 8/14/2017 8/5/2017 8/11/2017 8/14/2017 8/6/207 011 • « « »+ ..... * « » +» 8/15/2017 8/1/2017 : 8/14/201] - - R188 8/16/2017 8/1/2017 8/15/2017 8/16/2017 8/1/201] 8/15/201] * * * ** * * * ** * * *** 8/16/2017 8/2/201] 8/15/201] 8/16/2017 8/5/2017 8/15/2017 8/16/20" 8/6/201] 8/17/2017 8/14/2017 8/15/2017 8/21/2017 8/1 /2ov 8/18/2017 8/21/201] 8/2/20" 8/18/20" 8/21/2017 8/3/20; 8/18/20" 8/21/2017 8/4/2017 8/18/2017 8/22/2017 7/21/2017 8/21/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR Z452 THERAPEUTIC); WITH IMAGING GUIDANCE 8/24/2017 8/18/2017 8/23/2017 - - R188 8/25/2017 12/20/2016 8/24/201] * *+++ 8/25/20" 12/21/2016 8/24/201] 8/28/2017 8/22/2017 8/25/2017 8/31/2017 8/28/2017 8/30/2017 97110 THERAPEUTIC PR0CEDURE,I OR MORE AREAS, EACH 15 R262 MINUTES; THERAPEUTIC EXERCISESTO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 8/31/2017 8/28/2017 8/30/2017 97162 Physical therapy evaluation: moderate complexity, R262 requiring these -p A his Vofpresent problem with 1 -2 personal factors and /or comorbldities 8/31/2017 8128/2017 8/30/2017 97530 THERAPEUTIC ACTIVITIES, DIRECf(ONE- ON- ONE)PATIENT 8262 CONTACT BY THE PROVIDER )USE OF DYNAMIC ACTIVITIES TO IMPRDVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES SHORTNESS OF BREATH PROFESSIONAL SUBSCRIBER RO1 050 INPATIENT /HOSPITAL OTHER ASCITES PROFESSIONAL $70.32 INPATIENT /HOSPITAL LIVER TRANSPLANT PROFESSIONAL STATUS INPATIENT /HOSPITAL LIVER TRANSPLANT PROFESSIONAL STATUS INPATIENT /HOSPITAL OTHER ASCITES HOSPITAL OUTPATIENT ENCOUNTER FOR PROFESSIONAL ADIUSTMENTAND OUTPATIENT /HOSPITAL MANAGEMENT OF SUBSCRIBER RO1 050 VASCULAR ACCESS DEVICE $276.00 MALE MI: III:CF4111i� :P41J1FII9AIIIII DIFFICULTYINWALIKING, OTHERMEDICAL NOT ELSEWHERE CLASSIFIED DIFFICULTY IN WALKING, OTHERMEDICAL NOT ELSEWHERE CLASSIFIED DIFFICULTY IN WALKING, OTHERMEDICAL NOT ELSEWHERE CLASSIFIED $14.94 $36.00 MALE SUBSCRIBER RO1 050 $60.27 $142.00 MALE SUBSCRIBER RO1 ISO $70.32 $166.00 MALE SUBSCRIBER RO1 ISO $313.41 $1,481.00 MALE SUBSCRIBER R01 ISO $48.45 $112.00 MALE SUBSCRIBER R01 ISO $153.05 $218.00 MALE SUBSCRIBER R01 050 8/1/2017 8/6/2017 $15,268.95 $46,262.80 MALE SUBSCRIBER 1 OSO $0.00 $22.20 MALE SUBSCRIBER RO1 050 $103.51 $276.00 MALE SUBSCRIBER R01 050 $0.00 $10.40 MALE SUBSCRIBER RO1 050 $0.00 $4.30 MALE SUBSCRIBER RO1 1 $0.00 $9.20 MALE SUBSCRIBER R01 0 $0.00 $6.50 MALE SUBSCRIBER RO1 ISO $0.00 $72.00 MALE SUBSCRIBER RO1 050 $103.51 $276.00 MALE SUBSCRIBER R01 ISO $0.00 $10.40 MALE SUBSCRIBER RO1 050 $103.51 $2]6.00 MALE SUBSCRIBER RO1 150 $0.00 $81.60 MALE SUBSCRIBER R01 0 $103.51 $276.00 MALE SUBSCRIBER RO1 050 $103.51 $276.00 MALE SUBSCRIBER RO1 050 $1,385.94 $1,385.94 MALE SUBSCRIBER R01 ISO $0.00 $966.60 MALE SUBSCRIBER R 150 $0.00 $903.90 MALE SUBSCRIBER R01 ISO $0.00 $81.60 MALE SUBSCRIBER R01 OSO $0.00 $92.00 MALE SUBSCRIBER R ISO $0.00 $92.00 MALE SUBSCRIBER R ISO $122.22 $215.00 MALE SUBSCRIBER RUT OSO $320.58 $700.00 MALE SUBSCRIBER RO1 050 $148.53 $399.00 MALE SUBSCRIBER RO1 0 50 $148.53 $399.00 MALE SUBSCRIBER ROT ISO $148.53 $399.00 MALE SUBSCRIBER R01 OSO $186.00 $412.00 MALE SUBSCRIBER RO1 ISO $1,244.00 $1,244.00 MALE SUBSCRIBER RO1 ISO $0.00 $456.00 MALE SUBSCRIBER R ISO $0.00 $462.00 MALE SUBSCRIBER ROT 050 $122.22 $215.00 MALE SUBSCRIBER RO1 OSO $14.10 $5].00 MALE SUBSCRIBER R01 ISO $46.05 $153.00 MALE SUBSCRIBER R01 ISO $14.87 $59.00 MALE SUBSCRIBER RO1 050 it I :445: 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 1415: M K 9/1/2017 8/1/2017 811212017 A0431 AMBULANCE SERVICE , CONVENTIONALAIR SERVICES, K767 HEPATORENAL OTHER MEDICAL $63.97 MALE SUBSCRIBER R01 050 $14.61 TRANSPORT, ONE WAY (ROTARY WING) SUBSCRIBER R01 OSO SYNDROME $50.48 MALE 9/1/2017 8/1/2017 8/12/2017 A0436 ROTARY WING AIR MILEAGE, PER STATUTE MILE K767 HEPATORENAL OTHER MEDICAL $28.21 $114.00 MALE SUBSCRIBER R01 OSO $19.82 $59.00 MALE SYNDROME $186.00 9/1/2017 8/25/2017 8/31/2017 E0143 WALKER, FOLDING, WHEELED, ADJUSTABLE OR FIXED 14510 UNSPECIFIED RIGHT OTHER MEDICAL SUBSCRIBER R01 O5O $23.91 $40.00 MALE HEIGHT BUNDLE - BRANCH BLOCK 9/1/2017 8/25/2017 8/31/2017 E0156 SEAT ATTACHMENT, WALKER 14510 UNSPECIFIED RIGHT OTHER MEDICAL BUNDLE - BRANCH BLOCK 9/1/2017 8/25/2017 8/31/2017 E0163 COMMODE CHAIR, MOBILE OR STATIONARY, WITH FIXED 14510 UNSPECIFIED RIGHT OTHER MEDICAL ARMS BUNDLE - BRANCH BLOCK 9/1/2017 8/25/2017 8131/2017 E2601 GEN W/C CUSHION WIDTH 122 IN 14510 UNSPECIFIED RIGHT OTHER MEDICAL BUNDLE - BRANCH BLOCK 9/6/2017 817/2017 9/5/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR 8188 OTHER ASCITES PROFESSIONAL THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 9/8/2017 8/30/2017 9/7/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 9/8/2017 8/30/2017 9/7/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE - ON- ONE)PATIENT R293 ABNORMAL POSTURE OTHER MEDICAL CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 9/12/2017 8/18/2017 9/11/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL THERAPEUTIC(; WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 9/22/2017 9/1/2017 9/21/2017 49083 ABDOMIN4L PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 9/29/2017 9/27/2017 9/28/2017 36415 COLLECTIDN OF VENOUS BLOOD BY VENIPUNCTURE R945 ABNORMAL RESULTS OF PROFESSIONAL OFFICE LIVER FUNCTION STUDIES 9/29/2017 9/27/2017 9/28/2017 99211 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R945 ABNORMAL RESULTS OF PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED LIVER FUNCTION STUDIES PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN. USUALLY, THE PRESENTING PR0BLEM(5) ARE MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING OR SUPERVISING THESE SERVICES. 101 9/29/2017 101 - - R188 OTHER ASCITES HOSPITAL OUTPATIENT 101 9/22/2017 101 - - R188 OTHER ASCITES HOSPITAL OUTPATIENT 101 10/3/2017 101 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISESTO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 101 10/3/2017 10/6/2017 97116 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 101 10/3/2017 101 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE - ON- ONE)PATIENT R293 ABNORMAL POSTURE OTHER MEDICAL CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 101 10/5/2017 101 10/13/2017 9/1/2017 1011212017 - - 8188 OTHER ASCITES HOSPITAL OUTPATIENT 10/13/2017 10/6/2017 1011212017 $3,500.00 $12,000.00 MALE SUBSCRIBER R01 OSO $4,096.00 $12,800.00 MALE SUBSCRIBER RO1 OSO $63.96 $63.97 MALE SUBSCRIBER R01 050 $14.61 $14.61 MALE SUBSCRIBER R01 OSO $5048 $50.48 MALE SUBSCRIBER R01 OSO $39.76 $39.76 MALE SUBSCRIBER RO1 O5O $186.00 $412.00 MALE SUBSCRIBER RD1 050 $28.21 $114.00 MALE SUBSCRIBER R01 OSO $19.82 $59.00 MALE SUBSCRIBER R01 OSO $186.00 $412.00 MALE SUBSCRIBER R01 050 $186.00 $412.00 MALE SUBSCRIBER R01 OSO $2.34 $8.00 MALE SUBSCRIBER R01 O5O $23.91 $40.00 MALE SUBSCRIBER R01 OSO $1,244.00 $1,244.00 MALE SUBSCRIBER R01 OSO $1,378.00 $1,378.00 MALE SUBSCRIBER R01 050 $28.21 $114.00 MALE SUBSCRIBER RO1 OSO $11.58 $52.00 MALE SUBSCRIBER R01 OSO $19.82 $59.00 MALE SUBSCRIBER RD1 O5O $167.82 $310.00 MALE SUBSCRIBER R01 050 $1,378.00 $1,378.00 MALE SUBSCRIBER R01 O5O $2,321.12 $3,465.12 MALE SUBSCRIBER R01 OSO C.7.f 3559 w 3559 U N 3559 Q! 3559 3559 3559 } fl CL i® 3559 Q, Q 3559 n IS= 3559 3559 3559 3559 1 3559 3559 0 C.7.f 10/16/2017 9/22/2017 10/13/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL $186.00 $412.00 MALE SUBSCRIBER RO1 OSO 3559 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL Z 10/16/2017 9/29/2017 10/13/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR 8188 OTHER ASCITES PROFESSIONAL $186.00 $412.00 MALE SUBSCRIBER R01 RISC 3559 N THERAPEUTIC(; WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL Q! 10/26/2017 10/6/2017 10/25/2017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL $186.00 $412.00 MALE SUBSCRIBER R01 OSO 3559 THERAPEUTIC(; WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 10/30/2017 ]/30/201] 10/2]/201] 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 RO79 CHEST PAIN, UNSPECIFIED PROFESSIONAL $11.07 $70.00 MALE SUBSCRIBER R01 OSO 3559 "a LEADS; INTERPRETATION AND REPORT ONLY INPATIENT /HOSPITAL 10/30/2017 8/31/2017 10127/2017 * * * :. * * * ** *...* ** z * *.. * * * ** $328.45 $328.46 MALE SUBSCRIBER R01 OSO 3559 10/30/2017 10/26/2011 10/27/201] * *zzz * * * ** *zzzz * * + *. * * * ** $84.52 $155.00 MALE SUBSCRIBER R01 OSO 3559 > 10/31/2017 10/20/2017 10/3012017 74181 MAGNETIC RESONANCE (EC, PROTON) IMAGING, R188 OTHER ASCITES PROFESSIONAL $119.45 $566.00 MALE SUBSCRIBER R01 OSO 3559 ABDOMEN; WITHOUT CONTRAST MATERIALS) OUTPATIENT /HOSPITAL CL CL 11/3/2017 10/20/2017 11/2/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL $186.00 $412.00 MALE SUBSCRIBER R01 050 3559 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 11/6/2017 10/31/2017 11/3/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E291 TESTICULAR PROFESSIONAL OFFICE $1.80 $15.00 MALE SUBSCRIBER R01 050 3559 HYPOFUNCTION 11/6/2017 10/31/2017 11/3/2017 96372 Therapeutic, prophylactic, or diagnostic injection (specify E291 TESTICULAR PROFESSIONAL OFFICE $29.69 $74.00 MALE SUBSCRIBER RO1 OSO 3559 subst an ce or drug); subcutaneous or l ntamuscular HYPOFUNCTION LIJ h 11/6/2017 10/31/2017 11/3/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E291 TESTICULAR PROFESSIONAL OFFICE $86.79 $240.00 MALE SUBSCRIBER RO1 OSO 3559 EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPOFUNCTION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY _ COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED a. W 11/6/2017 10/31/2017 11/3/2017 J1071 INI TESTOSTERONE CYPIONATE E291 TESTICULAR PROFESSIONAL OFFICE $12.00 $40.00 MALE SUBSCRIBER RO1 OSO 3559 IT POFUNCTION U� 11/7/2017 10/20/2017 10/26/2017 - - R188 OTHER ASCITES HOSPITAL OUTPATIENT $7,826.00 $16,119.12 MALE SUBSCRIBER R01 050 3559 Q 11/8/2017 10/6/2017 10/12/2017 * " *zo- * *..x * ». ** x ».x . * *.. [$2,321.121 ($3,165.127 MALE SUBSCRIBER RO1 OSO 3559 J 11 /8 /2017 10/6/201] 11/]/2017 . **.+ * * * ** xxx.x x* * ** * * * ** $3,465.12 $3,465.12 MALE SUBSCRIBER RO1 OSO 3559 W 11/8/2017 10/6/2017 11/7/2017 * * °x' * * * ** `xx *' °k #k * * * ** $0.00 $3,465.12 MALE SUBSCRIBER RO1 050 3559 11/8/2017 10/12/2017 11/7/2017 - - K8689 OTHER SPECIFIED HOSPITAL OUTPATIENT $854.00 $2,000.14 MALE SUBSCRIBER RO1 O50 3559 DISEASES OF PANCREAS J 11/9/2017 11/3/2017 11/8/201]- - R188 OTHER ASCITES HOSPITAL OUTPATIENT $2,321.12 $3,465.12 MALE SUBSCRIBER R01 OSO 3559 V ~ 11/10/2017 9/5/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $28.21 $114.00 MALE SUBSCRIBER R01 EGO 3559 Z MINUTES; THERAPEUTIC EXERCISES TO DEVELOP uJ STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 9/5/2017 11 /8 /2017 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE - ON- ONE)PATIENT R293 ABNORMAL POSTURE OTHER MEDICAL $34.69 $118.00 MALE SUBSCRIBER R01 OSO 3559 CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES F TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 11/10/2017 9/28/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, I OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $14.10 $57.00 MALE SUBSCRIBER R01 OSO 3559 N MINUTES; THERAPEUTIC EXERCISES TO DEVELOP N STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY n 11/10/2017 9/28/2017 111812017 97112 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $52.00 MALE SUBSCRIBER R01 OSO MINUTES; NEURDMUSCULAR REEDUCATION OF $59.00 MALE SUBSCRIBER R01 050 $2811 MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SUBSCRIBER RD1 050 $19.82 $59.00 MALE SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING $11.58 $52.00 MALE SUBSCRIBER R01 OSO AND /OR STANDING ACTIVITIES $57.00 MALE 11/10/2017 9/28/2017 111812017 97116 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $34.69 $118.00 MALE MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) $28.21 11/10/2017 9/28/2017 11/8/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE- ON- ONE) PATIENT R293 ABNORMAL POSTURE OTHER MEDICAL SUBSCRIBER R01 O50 $11.58 CONTACT BV THE PROVIDER (USE OF DVNAMICACHVITIES SUBSCRIBER R01 RISC, $14.10 $57.00 MALE TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 $14.87 $59.00 MALE SUBSCRIBER R01 OSO MINUTES $52.00 MALE 11/10/2017 10/5/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11110/2017 10/5/2017 11/8/2017 97112 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING AND /OR STANDING ACTIVITIES 11/10/2017 10/5/2017 11/8/2017 97116 THERAPEUTIC PROCEDURE, 1 OR MOREAREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 11/10/2017 10/10/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 8293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISESTO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 10/10/2017 11/8/2017 97116 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 11/10/2017 10/10/2017 11/8/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE - ON- ONE)PATIENT R293 ABNORMAL POSTURE OTHER MEDICAL CONTACT BV THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 11110/2017 10/12/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 10/12/2017 111812017 97112 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 8293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING AND /OR STANDING ACTIVITIES 11/10/2017 10/12/2017 11/8/2017 97116 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 11/10/2017 1011712017 11/8 /2017 97110 THERAPEUTIC PROCEDURE, 1 OR MOREAREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 1011712017 11/8/2017 97112 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING AND /OR STANDING ACTIVITIES 11/10/2017 10/17/2017 11/8/2017 97116 THERAPEUTIC PROCEDURE, l OR MOREAREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) $14.87 $59.00 MALE SUBSCRIBER R01 OSO $11.58 $52.00 MALE SUBSCRIBER R01 OSO $19.82 $59.00 MALE SUBSCRIBER R01 050 $2811 $114.00 MALE SUBSCRIBER RD1 050 $19.82 $59.00 MALE SUBSCRIBER R01 OSO $11.58 $52.00 MALE SUBSCRIBER R01 OSO $14.10 $57.00 MALE SUBSCRIBER R01 OSO $11.58 $52.00 MALE SUBSCRIBER R01 OSO $34.69 $118.00 MALE SUBSCRIBER RD1 050 $28.21 $114.00 MALE SUBSCRIBER R01 O50 $19.82 $59.00 MALE SUBSCRIBER R01 O50 $11.58 $52.00 MALE SUBSCRIBER R01 RISC, $14.10 $57.00 MALE SUBSCRIBER R01 OSO $14.87 $59.00 MALE SUBSCRIBER R01 OSO $11.58 $52.00 MALE SUBSCRIBER R01 OSO C.7.f 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 C 11/10/2017 1011712017 111812017 97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT R293 ABNORMAL POSTURE OTHER MEDICAL $19.82 $59.00 MALE SUBSCRIBER R01 OSO CONTACT BY THE PROVIDER FUSE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 11/10/2017 10/24/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $42.31 $171.00 MALE SUBSCRIBER R01 050 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 10/24/2017 1118 12017 97112 THERAPEUTIC PROCEDURE, IOR MOREAREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $19.82 $59.00 MALE SUBSCRIBER R01 050 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING AND /OR STANDING ACTIVITIES 11/10/2017 10/31/2017 111812017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $28.21 $114.00 MALE SUBSCRIBER ROE 080 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 10/31/2017 11/8/2017 97112 THERAPEUTIC PROCEDURE, l OR MOREAREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $14.87 $59.00 MALE SUBSCRIBER RO1 OSO MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING AND /OR STANDING ACTIVITIES 11/10/2017 10/31/2017 11/8/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE- ON- ONE)PATIENT R293 ABNORMAL POSTURE OTHER MEDICAL $19.82 $59.00 MALE SUBSCRIBER R01 OSO CONTACT BY THE PROVIDER FUSE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 11/10/2017 11/2/2017 11/8/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $28.21 $114.00 MALE SUBSCRIBER R01 O50 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/10/2017 11/2/2017 11/8 /2017 97112 THERAPEUTIC PROCEDURE, IOR MOREAREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $14.87 $59.00 MALE SUBSCRIBER R01 OSO MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FOR SITTING AND /OR STANDING ACTIVITIES 11/10/2017 111212017 111812017 97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT 8293 ABNORMAL POSTURE OTHER MEDICAL $19.82 $59.00 MALE SUBSCRIBER R01 OSO CONTACT BY THE PROVIDER FUSE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 11/13/2017 10/20/2017 11/10/2017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT $700.00 $700.00 MALE SUBSCRIBER RO1 OSO 11/13/2017 11/7/2017 11/10/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $14.10 $57.00 MALE SUBSCRIBER R01 050 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/13/2017 11/7/2017 11/1012017 97112 THERAPEUTIC PROCEDURE, IOR MOREAREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $14.87 $59.00 MALE SUBSCRIBER R01 OSO MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND /OR PROPRIOCEPTION FORSITTING AND /OR STANDING ACTIVITIES 11/13/2017 11/7/2017 11/10/2017 97116 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $1138 $52.00 MALE SUBSCRIBER PUT 050 MINUTES; GAITTRAINING (INCLUDES STAIR CLIMBING) 11113/2017 11/7/2017 11/10/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE - ON- ONE)PATIENT R293 ABNORMAL POSTURE OTHER MEDICAL $19.82 $59.00 MALE SUBSCRIBER R01 050 CONTACT BY THE PROVIDER FUSE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 11/14/2017 11/9/2017 11/13/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $42.31 $171.00 MALE SUBSCRIBER R01 OSO MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/14/2017 11/9/2017 11/13/2017 97530 THERAPEUTIC ACTIVITIES, DIRECT(ONE- ON- ONE)PATIENT R293 ABNORMAL POSTURE OTHER MEDICAL $19.82 $59.00 MALE SUBSCRIBER R01 OSO CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 1112012017 11/14/2017 11/17/2017 97110 THERAPEUTIC PROCEDURE, l OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $47.01 $171.00 MALE SUBSCRIBER R01 050 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/21/2017 11/16/2017 11/20/2017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $42.31 $171.00 MALE SUBSCRIBER R01 OSO MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/21/2017 11/16/2017 1112012017 97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON- ONE)PATIENT R293 ABNORMAL POSTURE OTHER MEDICAL $19.82 $59.00 MALE SUBSCRIBER R01 0SO CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 11/21/2017 11/17/2017 11/20/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E291 TESTICULAR PROFESSIONAL OFFICE $1.80 $15.00 MALE SUBSCRIBER R01 OSO HYPOFUNCTION 11/21/2017 11/17/2017 1112012017 96372 Therapeutic, prophylactic, ordiagnostic injection (specify E291 TESTICULAR PROFESSIONAL OFFICE $29.69 $74.00 MALE SUBSCRIBER R01 OSO substance or drug); subcutaneous or Intramuscular HYPOFUNCTION 11/21/2017 11/17/2017 11/20/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E291 TESTICULAR PROFESSIONAL OFFICE $127.40 $350.00 MALE SUBSCRIBER R01 OSO EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPOFUNCTION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 11/21/2017 11/17/2017 11120/2017 11071 INI TESTOSTERONE CYPIONATE E291 TESTICULAR PROFESSIONAL OFFICE $12.00 $40.00 MALE SUBSCRIBER R01 OSO HYPOFUNCTION 1112712017 11/3/2017 1112212017 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL $186.00 $412.00 MALE SUBSCRIBER ROT OSO THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 11/27/2017 11/17/2017 11/22/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R198 OTHER ASCITES PROFESSIONAL $186.00 $515.00 MALE SUBSCRIBER R01 050 THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 1112712017 11/17 /2017 1112212017- - R198 OTHER ASCITES HOSPITAL OUTPATIENT $2,321.12 $2,321 -12 MALE SUBSCRIBER R01 0SO 1112812017 11/21/2017 1112712017 97110 THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 R293 ABNORMAL POSTURE OTHER MEDICAL $42.31 $171.00 MALE SUBSCRIBER R01 OSO MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY 11/28/2017 11/21/2017 11/27/2017 97530 THERAPEUTIC ACTIVITIES, DIRECF(ONE- ON- ONE) PATIENT R293 ABNORMAL POSTURE OTHER MEDICAL $19.82 $59.00 MALE SUBSCRIBER R01 OSO CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES 12/4/2017 11/28/2017 12/1/2017 96372 Therapeutic, prophylactic, or diagnostic injection (specify E291 TESTICULAR PROFESSIONAL OFFICE $29.69 $74.00 MALE SUBSCRIBER R01 050 substance Dr drug); s,bcutaneou s or'mtramuscular HYPOFUNCTION 12/4/2017 11/28/2017 12/1/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E291 TESTICULAR PROFE55IONAL OFFICE $86.79 $240.00 MALE SUBSCRIBER R01 OSO EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPOFUNCTION PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD C.7.f 12/4/2017 11/28/2017 12/1/2017 11071 INI TESTOSTERONE CYPIONATE E291 TESTICULAR PROFESSIONAL OFFICE $285.00 MALE SUBSCRIBER RO1 OSO W 3559 {U HYPOFUNCTION $4,181.12 MALE 12/4/2017 11/30/2017 12/2/2017 *Ytl "* * * "" ++'� ** • * * *« ...x. 12/8/2017 12/1/2017 12/6/2017 +x..+ ..... +«r ++ ..... ... ». 12/11/2017 11/27/2017 12/7/2017 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING L03115 CELLULITIS OF RIGHT OTHER MEDICAL $0.00 $154.00 MALE RESPONSESTO COMPRESSION AND OTHER MANEUVERS; OSO LOWER LIMB COMPLETE BIIATERALSTUDY i ' 12/11/2017 11/27/2017 12/7/2017 96372 Therapeutic, prophylactic, o,d,,gnostic injection (specify L03115 CELLULITIS OF RIGHT OTHER MEDICAL 050 3559 substance ordrug); subcutaneous orintramuscular LOWER LIMB 12/11/2017 11/27/2017 12/7/2017 97602 REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S); L03115 CELLULITIS OF RI6HT OTHER MEDICAL NON SELECTIVE DEBRIDEMENT, WITHDUTANESTHESIA LOWER LIMB (EG, W ET -TO -MOIST DRESSINGS, ENZYMATIC, ARRASION), fl i® NCLU DING TOPICAL APPLICATION(S), WOUND CL ASSESSMENT, AND INSTRUCTIONS) FOR ONGOING CARE, $300.00 MALE SUBSCRIBER RO1 OSO 3559 PER SESSION 12/11/2017 11/27/2017 12/7/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE L03115 CELLULITIS OF RIGHT OTHER MEDICAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED LOWER LIMB PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/11/2017 11/27/2017 12/7/2017 99354 PROLONGED SERVICE IN THE OFFICE OR OTHER L03115 CELLULITIS OF RIGHT OTHER MEDICAL OUTPATIENT SETTING REQUIRING DIRECT PATIENT LOWER LIMB CONTACT BEYOND THE USUAL SERVICE; FIRST HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR OFFICE OR OTHER OUTPATIENT EVALUATION AND MANAGEMENT SERVICE) 12/11/2017 11/27/2017 12/7/2017 J0696 INJECTION, CEFTRIAXONE SODIUM, PER 250 MG L03115 CELLULITIS OF RIGHT OTHER MEDICAL LOWER LIMB 12/11/2017 11/27/2017 12/7/2017 50077 INJECTION, CLINDAMYCIN PHOSPHATE, 300 MG L03115 CELLULITIS OF R16HT OTHER MEDICAL LOWER LIMB 12/11/2017 12/1/2017 12/8/2017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PR0FE55IONAL THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 12/11/2017 121712017 12/9/2017 * * °:. ..... ..x ++ ... *. ..... 12/12/2017 12/7/2017 12/11/2017 29580 STRAPPING; UNNA BOOT 183012 VARICOSE VEINS OF RIGHT PROFESSIONAL OFFICE LOWER EXTREMITY WITH ULCER OF CALF 1211212017 121712017 12/11/2017 99244 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED 183012 VARICOSE VEINS OF RIGHT PROFESSIONAL OFFICE PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A LOWER EXTREMITY WITH COMPREHENSIVE HISTORY; A COMPREHENSIVE ULCER OF CALF EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONS 12/13/2017 12/8/2017 1211212017 29580 STRAPPING; UNNA BOOT 183012 VARICOSE VEINS OF RIGHT PROFESSIONAL OFFICE LOWER EXTREMITY WITH ULCER OF CALF 12/14/2017 10/20/2017 10126/2017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT 12/14/2017 10120/2017 12/6/2017- - R188 OTHER ASCITES HOSPITAL OUTPATIENT 12/14/2017 1012012017 121612017- - R198 OTHER ASCITES HOSPITAL OUTPATIENT 12/14/2017 11/7/2017 12/13/2017 * * °x" " "" -- * *' *' "'•' $12.00 $40.00 MALE SUBSCRIBER R01 OSO 3559 $204.68 $285.00 MALE SUBSCRIBER RO1 OSO W 3559 {U $3,037.12 $4,181.12 MALE SUBSCRIBER RO1 OSO 3559 N $93.75 $822.00 MALE SUBSCRIBER RO1 OSO 3559 $138.52 $193.00 MALE SUBSCRIBER R01 OSO Q! $50.94 $230.00 MALE SUBSCRIBER RO1 OSO 3559 $0.00 $154.00 MALE SUBSCRIBER R01 OSO 3559 i ' $0.00 $130.00 MALE SUBSCRIBER RO1 050 3559 W } fl i® CL CL $225.00 $300.00 MALE SUBSCRIBER RO1 OSO 3559 $650.00 $650.00 MALE SUBSCRIBER RO1 EGO 3559 $0.00 $8.00 MALE SUBSCRIBER R01 OSO 3559 $0.00 $20.00 MALE SUBSCRIBER RO1 OSO 3559 $186.00 $515.00 MALE SUBSCRIBER R01 050 3559 $138.52 $193.00 MALE SUBSCRIBER R01 OSO 3559 $50.94 $230.00 MALE SUBSCRIBER RO1 OSO 3559 $130.81 $500.00 MALE SUBSCRIBER RO1 OSO 3559 $50.94 $230.00 MALE SUBSCRIBER R01 CSO 3559 ($7,826.00) ($16,11912) MALE SUBSCRIBER R01 OSO 3559 $7,826.00 $16,119.12 MALE SUBSCRIBER R01 O5O 3559 $0.00 $16,119.12 MALE SUBSCRIBER RO1 050 3559 $325.28 $440.00 MALE SUBSCRIBER R01 OSO 3559 C.7.f 12/14/2017 12/8/2017 1211212017 36415 COLLECTION OFVENOUS BLOOD BYVENIPUNCTURE M4716 OTHER SPONDYLOSIS PROFESSIONAL OFFICE $167.81 $300.00 MALE SUBSCRIBER RO1 OSO 41 WITH MYELOPATHY, $40.00 MALE SUBSCRIBER RO1 OSO 3559 N $2,321.12 LUMBAR REGION SUBSCRIBER R01 OSO 12/14/2017 12/8/2017 12/12/2017 99211 OFFICE OR OTHER OUTPATIENT VISIT FOR THE N14716 OTHER SPONDYLOSIS PROFESSIONAL OFFICE Q! $822.00 MALE EVALUATION AND MANAGEMENT OF AN ESTABLISHED $50.94 WITH MYELOPATHY, SUBSCRIBER R01 OSO $50.94 $230.00 MALE PATIENT,THAT MAY NOT REQUIRE THE PRESENCE OF A (53,.037.121 LUMBAR REGION SUBSCRIBER R01 OSO $4,181.12 $4,181.12 MALE PHYSICIAN. USUALLY, THE PRESENTING PROBLEM(S) ARE MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING OR SUPERVISING THESE SERVICES. $74.00 MALE SUBSCRIBER R01 0S0 12/18/2017 10/10/2017 12/14/2017 96372 Therapeutic, prophylactic, or diagnostic injection (specify E291 TESTICULAR PROFESSIONAL OFFICE $127.40 $350.00 MALE substance or drug); subcutaneous or rtramuscular OSO HYPOFUNCTION 12/18/2017 10/10/2017 12114/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E291 TESTICULAR PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED HYPOFUNCTION CL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY Q COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF $12.00 $40.00 MALE SUBSCRIBER R01 MODERATE COMPLEXITY. COUNSELING AND /OR 3559 COORDINATION OF CARE WITH OTHER $402.29 $553.00 MALE SUBSCRIBER R01 12/18/2017 10/10/2017 12/14/2017 11071 INI TESTOSTERONE CYPIONATE E291 TESTICULAR PROFESSIONAL OFFICE 3559 � h HYPOFUNCTION 12/18/2017 101 12/15/2017 * " ** ••••• * * * ** ..... ..... 1211812017 10/17/2017 12/15/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE K921 MELENA OTHER MEDICAL EVALUATION AND MANAGEMENTOFAN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 12/18/2017 10/26/2017 12/15/2017 ..... 12/18/2017 12/11/2017 12/15/2017 29580 STRAPPING; UNNA BOOT 183012 VARICOSE VEINS OF RIGHT PROFESSIONAL OFFICE LOWER EXTREMITY WITH ULCER OF CALF 12/18/2017 12/14/2017 12/15/2017 x.<.* ....* xx..s . + +.. ..... 12/20/2017 11/3/2017 1211212017 - - R188 OTHER ASCITES HOSPITA L OUTPATIENT 12/20/2017 12/15/2017 12/19/2017 29580 STRAPPING; UNNA BOOT 183022 VARICOSE VEINS OF LEFT PROFESSIONAL OFFICE LOWER EXTREMITY WITH ULCER OF CALF 12/20/2017 12/15/2017 12/19/2017 *...+ *...* .«. ++ ..... *.. ». 12/22/2017 12/15/2017 1212012017 49083 ABDOMINAL PARACENTESIS(DIAGNOSTIC OR R188 OTHER ASCITES PROFESSIONAL THERAPEUTIC); WITH IMAGING GUIDANCE OUTPATIENT /HOSPITAL 12/27/2017 11/9/2017 12/15/2017 ..... *•••* .«. ++ . *... *.. ». 12/27/2017 11/27/2017 12/22/2017 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING L03115 CELLULITIS OF RIGHT OTHER MEDICAL RESPONSESTO COMPRESSION AND OTHER MANEUVERS; LOWER LIMB COMPLETE BItATERALSTUDY 12/27/2017 12/19/2017 12/22/2017 29580 STRAPPING; UNNA BOOT 183022 VARICOSE VEINS OF LEFT PROFESSIONAL OFFICE LOWER EXTREMITY WITH ULCER OF CALF 12/28/2017 12/22/2017 12/27/2017 29580 STRAPPING; UNNA BOOT 183012 VARICOSE VEINS OF RIGHT PROFESSIONAL OFFICE LOWER EXTREMITY WITH ULCER OF CALF 12/29/2017 12/1/2017 120V2017 * * * ** 12/29/2017 121112017 1212812017 * "•' * " *w* >xx.. w.... ..... $2.34 $8.00 MALE SUBSCRIBER R01 OSO 3559 W SUBSCRIBER R01 EGO $167.81 $300.00 MALE SUBSCRIBER RO1 OSO 41 $23.91 $40.00 MALE SUBSCRIBER RO1 OSO 3559 N $2,321.12 $3,465.12 MALE SUBSCRIBER R01 OSO $186.00 m SUBSCRIBER R01 050 $612.00 $612.00 MALE SUBSCRIBER RO1 OSO Q! $822.00 MALE SUBSCRIBER RO1 0S0 $50.94 $230.00 MALE SUBSCRIBER R01 OSO $50.94 $230.00 MALE SUBSCRIBER R01 OSO (53,.037.121 (54,181.121 MALE SUBSCRIBER R01 OSO $4,181.12 $4,181.12 MALE SUBSCRIBER RO1 050 $29.69 $74.00 MALE SUBSCRIBER R01 0S0 3559 $127.40 $350.00 MALE SUBSCRIBER RO1 OSO 3559 } fl i® CL CL Q $12.00 $40.00 MALE SUBSCRIBER R01 OSO 3559 F $402.29 $553.00 MALE SUBSCRIBER R01 OSO 3559 uj $204.68 $285.00 MALE SUBSCRIBER RO1 OSO 3559 � h $204.68 $285.00 MALE SUBSCRIBER BUT 050 $50.94 $230.00 MALE SUBSCRIBER R01 EGO $167.81 $300.00 MALE SUBSCRIBER RO1 OSO $0.00 $3,465.12 MALE SUBSCRIBER RO1 OSO $50.94 $230.00 MALE SUBSCRIBER R01 OSO $2,321.12 $3,465.12 MALE SUBSCRIBER R01 OSO $186.00 $515.00 MALE SUBSCRIBER R01 050 $612.00 $612.00 MALE SUBSCRIBER RO1 OSO $125.00 $822.00 MALE SUBSCRIBER RO1 0S0 $50.94 $230.00 MALE SUBSCRIBER R01 OSO $50.94 $230.00 MALE SUBSCRIBER R01 OSO (53,.037.121 (54,181.121 MALE SUBSCRIBER R01 OSO $4,181.12 $4,181.12 MALE SUBSCRIBER RO1 050 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 3559 C.7.f 12/29/2017 121112017 12/2812017 "'• *" xx.xx ....* xxxx. xx.xx $0.00 $4,181.12 MALE SUBSCRIBER R01 OSO 3559 12/29/2017 12/26/2017 12128/2017 29580 STRAPPING; UNNA BOOT 183022 VARICOSE VEINS OF LEFT PROFESSIONAL OFFICE $33.96 $115.00 MALE SUBSCRIBER RO1 OSO 3559 LOWER EXTREMITY WITH ULCER OF CALF N Sub TOtal $165,099.58 $483,467.36 Q! 8.75E +10 3/8/2017 2/28/2017 3/3/2017 "' *" * * * ** * *' "* * * * ** * * * ** $286.63 $375.00 FEMALE SUBSCRIBER 1 BCC 3559 3/30/2017 3/28/2017 3/29/2017 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITHATLEAST12 R9431 ABNORMAL PROFESSIONAL OFFICE $0.00 $65.00 FEMALE SUBSCRIBER 1 BCC 3559 LEADS; WITH INTERPRETATION AND REPORT ELECTROCARDIOGRAM r [ECG] [EKG] 3/30/2017 3/28/2017 3/29/2017 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R9431 ABNORMAL PROFESSIONAL OFFICE $155.55 $638.00 FEMALE SUBSCRIBER 1 BCC 3559 EVALUATION AND MANAGEMENT OF A NEW PATIENT, ELECTROCARDIOGRAM WHICH REQUIRES THESE 3 KEY COMPONENTS:A [ECG] [EKG] COMPREHENSIVE HISTORY; A COMPREHENSIVE } EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR CL COORDINATION OF CARE WITH OTHER PROVIDERS OR Q, Q 4/11/2017 4/4/2017 4/1012017 93306 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL -TIME WITH R0683 SNORING PROFESSIONAL OFFICE $0.00 $841.00 FEMALE SUBSCRIBER 1 BCC 3559 v IMAGE DOCUMENTATION (2D), INCLUDES M -MODE RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY F W 4/11/2017 4/4/2017 4/10/2017 99211 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E669 OBESITY, UNSPECIFIED PROFESSIONAL OFFICE $0.00 $74.00 FEMALE SUBSCRIBER 1 BCC 3559 h EVALUATION AND MANAGEMENTOFAN ESTABLISHED PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN. USUALLY, THE PRESENTING PROBLEM(S) ARE _ MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING DR SUPERVISING THESE SERVICES. O 5/4/2017 4/28/2017 5/2/2017 78452 Myocardial perfusion imaging, tomographlc ( SPECT) R9431 ABNORMAL PROFESSIONAL OFFICE $137.44 $1,787.00 FEMALE SUBSCRIBER 1 BCC 3559 IL ( includingattenuationcorrection, qualitativeor ELECTROCARDIOGRAM ILLI quantitative wall motion, ejection fraction by first pass or [ECG] [EKG[ Rated technique, additional quantification, when U' performed); multiple studies, at rest and /or Q 5/4/2017 4/28/2017 5/2/2017 93015 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR 89431 ABNORMAL PROFESSIONAL OFFICE $49.89 $279.00 FEMALE SUBSCRIBER 1 BCC 3559 J SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, ELECTROCARDIOGRAM e LLJ CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, [ECG] [EKG] AND /OR PHARMACOLOGICAL STRESS; WITH PHYSICIAN �q SUPERVISION, WITH INTERPRETATION AND REPORT J 5/4/2017 4/28/2017 5/2/2017 A9500 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC R9431 ABNORMAL PROFESSIONAL OFFICE $176.77 $600.00 FEMALE SUBSCRIBER 1 BCC 3559 U IMAGING AGENT, TECHNETIUM TC 99M ELECTROCARDIOGRAM [ECG] [EKG] 5/4/2017 5/2/2017 5/3/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE $51.53 $276.00 FEMALE SUBSCRIBER 1BCC 3559 LLJ EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISEASE OF NATIVE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY CORONARY ARTERY COMPONENTS: AN EXPANDED PROBLEM FOCUSED WITHOUTANGINA U HISTORY; AN EXPANDED PROBLEM FOCUSED PECTORIS EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COLRD N 5/22/2017 5/15/2017 5/19/2017 93458 Catheter placement In coronary a rtery(s)for coronary R9439 ABNORMAL RESULT OF PROFESSIONAL $45139 $1,357.00 FEMALE SUBSCRIBER 1 BCC 3559 Cy angiography, including in[raprocedural injec[ion(s) for OTHER CARDIOVASCULAR OUTPATIENT /HOSPITAL coronary angiography, imaging supervision and FUNCTION STUDY C interpretation; with left heart catheterization including y intraproced ural injections) for left ventriculogmphy, when performed .G 5/22/2017 5/15/2017 5/19/2017 99152 Moderate sedation services provi ded by the same R9439 ABNORMAL RESULT OF PROFESSIONAL $21.84 $64.00 physician or other qualified health Care professional SUBSCRIBER OTHER CARDIOVASCULAR OUTPATIENT /HOSPITAL $7,371.73 $18,692.55 performing the diagnostic or therapeutic service that SUBSCRIBER FUNCTION STUDY 5/30/2017 5/16/2017 5/27/2017 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 R9431 ABNORMAL OTHER MEDICAL LEADS; INTERPRETATION AND REPORT ONLY ELECTROCARDIOGRAM [ECG] [EKG] 5/31/2017 5/15/2017 5/30/2017 - - 12510 ATHEROSCLEROTIC HEART HOSPITAL OUTPATIENT DISEASE OF NATIVE CORONARYARTERY W ITHOUT ANGI NA PECTORIS 6/8/2017 5/23/2017 6/6/2017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE E669 OBESITY, UNSPECIFIED PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 6/8/2017 6/5/2017 6/6/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISEASE OF NATIVE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY CORONARY ARTERY COMPONENTS: AN EXPANDED PROBLEM FOCUSED WITHOUTANGINA. HISTORY; AN EXPANDED PROBLEM FOCUSED PECTORIS EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 6/9/2017 5/24/2017 6/8/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E1165 TYPE 2 DIABETES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MELLITUS WITH PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY HYPERGLYCEMIA COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 6/19/2017 5/23/2017 6/16/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE R9431 ABNORMAL PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED ELECTROCARDIOGRAM PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY [ECG] [EKG] COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 7/5/2017 5/26/2017 7/4/2017 7/10/2017 7/5/2017 7/7/2117 ». ».. + + +ar ..... r + + +« + + + +• 7/10/201] ]/6/201] 7/7/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED DISEASE OF NATIVE PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY CORONARY ARTERY COMPONENTS: AN EXPANDED PROBLEM FOCUSED WITHOUTANGINA HISTORY; AN EXPANDED PROBLEM FOCUSED PECTORIS EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 7/17/2017 ]1111201] 7/13/2017 - - Z1211 ENCOUNTER FOR HOSPITAL OUTPATIENT SCREENING FOR MALIGNANT NEOPLASM OFCOLON 711712017 ]1111201] 7/14/2017 43239 ESOPHAGOGASTRODUODENOSCOPY ,FLEXIBLE, Z1211 ENCOUNTER FOR OTHER MEDICAL TRANSORAL; WITH BIOPSI, SINGLE OR MULTIPLE SCREENING FOR MALIGNANT NEOPLASM OFCOLON $15.05 $49.00 FEMALE SUBSCRIBER 1 BCC $21.84 $64.00 FEMALE SUBSCRIBER 1 BCC $7,371.73 $18,692.55 FEMALE SUBSCRIBER 1 BCC $0CD $276.00 FEMALE SUBSCRIBER 1 BCC $51.53 $276.00 FEMALE SUBSCRIBER 1 BCC $58.13 $148.00 FEMALE SUBSCRIBER 1 BCC $51.53 $276.00 FEMALE SUBSCRIBER 1 BCC $2]6.00 $800.00 FEMALE SUBSCRIBER 1 BCC $49.46 $90.00 FEMALE SUBSCRIBER 1 BCC $51.53 $276.00 FEMALE SUBSCRIBER 1 BCC $1,441.79 $11,600.00 FEMALE SUBSCRIBER 1 BCC $98.06 $1,100.00 FEMALE SUBSCRIBER 1 BCC C.7.f 7/17/2017 7/11/2017 7/14/2017 45378 COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, INCLUDING Z1211 ENCOUNTER FOR OTHER MEDICAL $352.20 $1,250.00 FEMALE SUBSCRIBER 1 BCC 3559 COLLECTION OF SPECIMENS) BY BRUSHING OR WASHING, SCREENING FOR WHEN PERFORMED )SEPARATE PROCEDURE) MALIGNANT NEOPLASM Z OFCOLON N 7/17/2017 7/11/2017 7/15/2017 740 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDDSCOPIC K219 GASTRO- ESOPHAGEAL PROFESSIONAL $312.00 $1,000.00 FEMALE SUBSCRIBER 1 BCC 3559 PROCEDURES, ENDOSCOPE INTRODUCED PROXIMALTO REFLUX DISEASE OUTPATIENT /HOSPITAL DUODENUM WITHOUT ESOPHAGITIS u 712012017 7/11/2017 7/19/2017 88305 LEVEL IV- SURGICAL PATHOLOGY, GROSS AND K2970 GASTRITIS, UNSPECIFIED, PROFESSIONAL $68.02 $528.00 FEMALE SUBSCRIBER 1 BCC 3559 7 MICROSCOPIC EXAM I NATION A DORTION- WITHOUT BLEEDING OUTPATIENT /HOSPITAL SPONTANEOUS /MISSED, ARTERY, BIOPSY, BONE MARROW, BIOPSY, BONE EXOSTOSIS, BRAIN /MENINGES, OTHER THAN FOR TUMOR RESECTION, BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF fl } SURGICAL MARGINS, BREAST, REDUCTION N. C ]1201201] ]1111201] 7/19/2017 883421MMUNOHISTO CHEMISTRY ORIMMUNOCYTOCHEMISTRV, K2970 GASTRITIS, UNSPECIFIED, PROFESSIONAL $105.54 $354.00 FEMALE SUBSCRIBER 1 BCC 3559 Q, PERSPECIMEN; INITIAL SINGLE ANTIBODY STAIN WITHOUT BLEEDING OUTPATIENT /HOSPITAL PROCEDURE 8/10/2017 8/3/2017 8/8/2017 - - 201810 ENCOUNTER FOR HOSPITAL OUTPATIENT $507.00 $676.00 FEMALE SUBSCRIBER 1 BCC 3559 PREPROCEDURAL CARDIOVASCULAR EXAMINATION 8/15/2017 8/8/2017 8/14/2017 88307 LEVELV - SURGICAL PATHOLOGY, GROSSAND E6601 MORBID (SEVERE) PROFESSIONAL $85.34 $762.00 FEMALE SUBSCRIBER 1 BCC 3559 LjU MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE OBESITY DUE TO EXCESS INPATIENT /HOSPITAL - BIOPSY /CURETTINGS BONE FRAGMENTS) , PATHOLOGIC CALORIES FRACTURE BRAIN, BIOPSY BRAIN /MENINGES, TUMOR RESECTION BREAST, EXCISION OF LESION, REQUIRING _ MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECT O 8/17/2017 8/8/2017 8/16/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R0602 SHORTNESS OF BREATH PROFESSIONAL $11.20 $36.00 FEMALE SUBSCRIBER 1 BCC 3559 Q FRONTAL OUTPATIENT /HOSPITAL LEI 8/21/2017 8/8/2017 8/15/2017 * * *ss + +.s* xx*sx s + + +. + +..s $1,651.84 $5,700.00 FEMALE SUBSCRIBER 1 BCC 3559 UJ 8/22/2017 8/12/2017 8/21/2017 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, R0602 SHORTNESS OF BREATH PROFESSIONAL $11.20 $36.00 FEMALE SUBSCRIBER 1 BCC 3559 FRONTAL OUTPATIENT /HOSPITAL 0 8/23/2017 8112/2017 812212017 * * * ** * * * ** * * * ** ' *' ** * * * ** $399.67 $1,870.00 FEMALE SUBSCRIBER 1 BCC 3559 LLJ 8/25/201] 8/8/201] 8/18/2017 * * * ** * * * ** * * * ** * * * ** * * * ** 8/8/2017 8/9/2017 $37,030.23 $145,149.07 FEMALE SUBSCRIBER 1 BCC 3559 8/25/2017 8/12/2017 8/21/2017 - - E1310 OTHER SPECIFIED HOSPITAL INPATIENT 8/12/2017 # # # # # # ## $12,549.55 $32,230.32 FEMALE SUBSCRIBER 1 BCC 3559 DIABETES MELLITUS WITH J KETOACIDOSIS WITHOUT COMA V 812812017 8/3/2017 8/25/2017 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, 201818 ENCOUNTER FOR OTHER PROFESSIONAL $17.64 $42.00 FEMALE SUBSCRIBER 1 BCC 3559 FRONTAL AND LATERAL; PREPROCEDURAL OUTPATIENT /HOSPITAL Z EXAMINATION LLJ 8/28/2017 8/12/2017 81 71275 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST R0602 SHORTNESS OF BREATH PROFESSIONAL $149.33 $376.00 FEMALE SUBSCRIBER 1 BCC 3559 (NONCORONARY), WITH CONTRAST MATERIAL(S), OUTPATIENT /HOSPITAL (' INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING 8/29/2017 8/8/2017 8/22/2017 797 ANESTHESIA FOR INTRAPERITONEAL PROCEDURES IN E6601 MORBID (SEVERE) OTHER MEDICAL $0.00 $3,096.00 FEMALE SUBSCRIBER 1 BCC 3559 „p UPPER ABDOMEN INCLUDING LAPAROSCOPY; GASTRIC OBESITY DUE TO EXCESS N RESTRICTIVE PROCEDURE FOR MORBID OBESITY CALORIES N 8/29/2017 8/9/2017 8/28/2017 74240 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, Z9884 BARIATRIC SURGERY PROFESSIONAL $57.02 $270.00 FEMALE SUBSCRIBER 1 BCC 3559 = UPPER; WITH OR WITHOUT DELAYED FILMS, WITHOUT STATUS INPATIENT /HOSPITAL Bj KVB 8/29/2017 8/14/2017 812812017 74240 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, 8110 NAUSEA PROFESSIONAL $57.02 $270.00 FEMALE SUBSCRIBER 1 DEC 3559 ._ UPPER; WITH OR WITHOUT DELAYED FILMS, WITHOUT I(U8 INPATIENT /HOSPITAL 03 8/30/2017 8/12/2017 8/29/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FORTH EVALUATION E1010 TYPE 1 DIABETES PROFESSIONAL $352.82 $370.00 FEMALE SUBSCRIBER 1 BCC AND MANAGEMENTOFA PATIENT, WHICH REQUIRES MELLITUS WITH INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; KETOACIDOSIS WITHOUT A COMPREHENSIVE EXAMINATION; AND MEDICAL COMA DECISION MAKING OF HIGH COMPLEXITY. COUNSELING SUBSCRIBER AND /OR COORDINATION OF CARE WITH OTHER 3559 PROVIDERS OR AGEN 9/8/2017 9/5/2017 9/6/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE $11430 $406.00 FEMALE SUBSCRIBER 1 BCC EVALUATION AND MANAGEMENTOFAN ESTABLISHED DISEASE OF NATIVE PATIENT,WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY CORONARY ARTERY COMPONENTS: A DETAILED HISTORY; A DETAILED WITHOUTANGINA EXAMINATION; MEDICAL DECISION MAKING OF PECTORIS MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER C.7.f 3559 Im 101212017 8/28/2017 9/28/2017- - E1310 OTHER SPECIFIED HOSPITAL OUTPATIENT $646.88 $1,442.50 FEMALE SUBSCRIBER 1BCC 3559 DIABETES MELLITUS WITH KETOACIDOSIS WITHOUT COMA 10/12/2017 10/6/2017 10/11/2017 80061 LIPID PANEL E119 TYPE DIABETES OTHER MEDICAL $0.00 $147.34 FEMALE SUBSCRIBER 1 BCC 3559 MELLITUS WITHOUT COMPLICATIONS 10/12/2017 10/6/2017 10/11/2017 82043 ALBUMIN; URINE, MICROALBUMIN, QUANTITATIVE E119 TYPE DIABETES OTHER MEDICAL $0.00 $73.11 FEMALE SUBSCRIBER 1 BCC 3559 MELLITUS WITHOUT COMPLICATIONS 10/12/2017 10/6/2017 10/11/2017 82570 CREATININE; OTHER SOURCE E119 TYPE DIABETES OTHER MEDICAL $0.00 $57.37 FEMALE SUBSCRIBER 1 BCC 3559 MELLITUS WITHOUT COMPLICATIONS 10/12/2017 10/6/2017 10111/2017 82947 GLUCOSE, QUANTITATIVE, BLOOD (EXCEPT REAGENT E119 TYPE 2 DIABETES OTHER MEDICAL $0.00 $34.87 FEMALE SUBSCRIBER 1 BCC 3559 STRIP) MELLITUS WITHOUT COMPLICATIONS 10/12/2017 10/6/2017 10/11/2017 83036 HEMOGLOBIN; GLYCOSYIATED(A1C) E119 TYPE DIABETES OTHER MEDICAL $0.00 $74.25 FEMALE SUBSCRIBER 1 BCC 3559 MELLITUS WITHOUT COMPLICATIONS 10/12/2017 10/6/2017 10/11/2017 84450 TRANSFERASE; ASPARTATE AMINO (AST)(SGOT) E119 TYPE DIABETES OTHER MEDICAL $0.00 $19.30 FEMALE SUBSCRIBER 1 BCC 3559 MELLITUS WITHOUT COMPLICATIONS 1011212017 10/6/2017 10/11/2017 84460 TRANSFERASE; ALANINE AMINO (ALT)(SGPT) E119 TYPE DIABETES OTHER MEDICAL $0.00 $19.75 FEMALE SUBSCRIBER 1 BCC 3559 MELLITUS WITHOUT COMPLICATIONS 10/18/2017 8/13/2017 10/17/2017 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION E872 ACIDOSIS PROFESSIONAL $0.00 $893.00 FEMALE SUBSCRIBER 1BCC 3559 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES INPATIENT /HOSPITAL THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; ACOMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGEN 10/18/2017 8/14/2017 10/17/2017 99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE E872 ACIDOSIS PROFESSIONAL $66.96 $315.00 FEMALE SUBSCRIBER 1BCC 3559 EVALUATION AND MANAGEMENT OF PATIENT, WHICH INPATIENT /HOSPITAL REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR 10/18/2017 8115/2017 10/17/2017 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE E872 ACIDOSIS PROFESSIONAL $99.29 $467.00 FEMALE SUBSCRIBER 1 BCC 3559 THAN 30 MINUTES INPATIENT /HOSPITAL 1012712017 1016/2017 10/26/2017 A4253 BLOOD GLUCOSETESTOR REAGENTSTRIPS FOR HOME E1165 TYPE 2 DIABETES OTHER MEDICAL $0.00 $180.80 FEMALE SUBSCRIBER 1BCC 3559 BLOOD GLUCOSE MONITOR, PER 50 STRIPS MELLITUS WITH HYPERGLYCEMIA 1012712017 10/11/2017 10/26/2017 A4259 LANCETS, PER BOX OF 100 E1165 TYPE 2 DIABETES OTHER MEDICAL $11.07 $70.00 FEMALE MELLITUS WITH 1 BCC $11.07 $70.00 FEMALE HYPERGLYCEMIA 1 BCC 10/30/2017 8/3/2017 10/27/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY OUTPATIENT /HOSPITAL 10/30/2017 8/12/2017 10/27/2017 93010 ELECTROCARDIOGRAM , ROUTINE ECG WITH AT LEAST 12 R079 CHEST PAIN, UNSPECIFIED PROFESSIONAL LEADS; INTERPRETATION AND REPORT ONLY INPATIENT / HDSPITAL 11/1/2017 10/11/2017 10/31/2017 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E1165 TYPE 2 DIABETES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MELLITUS WITH PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY HYPERGLYCEMIA COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 111212017 10/31/2017 11/1/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E119 TYPE 2 DIABETES PROFESSIONAL OFFICE MELLITUS WITHOUT COMPLICATIONS 11/3/2017 8/8/2017 10/9/2017 797 ANESTHESIA FOR INTRAPERITONEAL PROCEDURES IN E6601 MORBID (SEVERE) OTHER MEDICAL UPPER ABDOMEN INCLUDING LAPAROSCOPY; GASTRIC OBESITY DUE TO EXCESS RESTRICTIVE PROCEDURE FOR MORBID OBESITY CALORIES 11/10/2017 111712017 111912017 99213 OFFICE OR OTHER OUTPATIENTVISIT FOR THE 12510 ATHEROSCLEROTIC HEART PROFESSIONAL OFFICE EVALUATION AND MANAGEMENTOFAN ESTABLISHED DISEASE OF NATIVE PATIENT, WHICH REQUIRESAT LEAST2 OF THESE 3 KEY CORONARYARTERY COMPONENTS: AN EXPANDED PROBLEM FOCUSED WITHOUTANGINA HISTORY; AN EXPANDED PROBLEM FOCUSED PECTORIS EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORD 11/17/2017 8/28/2017 11/15/2017 81002 URINALYSIS, BY DIP STICK ORTABLET REAGENT FOR E119 TYPE 2 DIABETES PROFESSIONAL OFFICE BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, MELLITUS WITHOUT LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, COMPLICATIONS UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON - AUTOMATED, WITHOUT MICROSCOPY 11/17/2017 8/28/2017 11/15/2017 99214 OFFICE OR OTHER OUTPATIENTVISIT FOR THE E119 TYPE 20IABETES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MELLITUS WITHOUT PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPLICATIONS COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 11/17/2017 9/5/2017 11/15/2017 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E119 TYPE 20IABETES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MELLITUS WITHOUT PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPLICATIONS COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COOED 11/17/2017 9/27/2017 11/15/2017 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE E119 TYPE 2 DIABETES PROFESSIONAL OFFICE MELLITUS WITHOUT COMPLICATIONS 11/20/2017 11/10/2017 11/17/2017- - N6320 UNSPECIFIED LUMP IN HOSPITAL OUTPATIENT THE LEFT BREAST, UNSPECIFIED QUADRANT $0.00 $38.08 FEMALE SUBSCRIBER 1 BCC $11.07 $70.00 FEMALE SUBSCRIBER 1 BCC $11.07 $70.00 FEMALE SUBSCRIBER 1 BCC $83.13 $148.00 FEMALE SUBSCRIBER 1 BCC $1.80 $18.00 FEMALE SUBSCRIBER 1 BCC $658.35 $3,096.00 FEMALE SUBSCRIBER 1 BCC $76.53 $276.00 FEMALE SUBSCRIBER 1 BCC $2.85 $7.00 FEMALE SUBSCRIBER 1 BCC $95.18 $290.00 FEMALE SUBSCRIBER 1 BCC $63.86 $197.00 FEMALE SUBSCRIBER 1 BCC $2.34 $6.00 FEMALE SUBSCRIBER 1 BCC $988.50 $1,318,00 FEMALE SUBSCRIBER 1 BCC 1112812017 8/8/2017 11/27/2017 12/4/2017 8/8/2017 11/27/2017 12/6/2017 8/24/2017 12/4/2017 12/8/2017 11/10/2017 12/6/2017 12/8/2017 11/10/2017 12/6/2017 12/8/2017 11/10/2017 12/6/2017 12/13/2017 10/2/2017 12/11/2017 12/13/2017 10/2/2017 12/11/2017 12/13/2017 10/26/2017 12/11/2017 1211812017 8/21/2017 12/14/2017 12/18/2017 8/21/2017 12/14/2017 12/18/2017 8/21/2017 12/14/2017 13420 12/18/2017 12/14/2017 12/15/2017 2026F 797 ANESTHESIA FOR INTRAPERITONEAL PROCEDURESIN E6601 MORBID (SEVERE) OTHER MEDICAL UPPER ABDOMEN INCLUDING LAPAROSCOPY; GASTRIC $3,120.00 FEMALE OBESITY DUE TO EXCESS 1 BCC RESTRICTIVE PROCEDURE FOR MORBID OBESITY $6,568.60 FEMALE CALORIES 1 BCC 797 ANESTHESIA FOR INTRAPERITONEAL PROCEDURES IN E6601 MORBID (SEVERE) PROFESSIONAL UPPER ABDOMEN INCLUDING LAPAROSCOPY; GASTRIC $239.00 FEMALE OBESITY DUE TO EXCESS OUTPATIENT /HOSPITAL RESTRICTIVE PROCEDURE FOR MORBID OBESITY $213.00 FEMALE CALORIES 1 BCC - E860 DEHYDRATION HOSPITAL OUTPATIENT 76642 ULTRASOUND, BREAST, UNILATERAL, REALTIME WITH R922 INCONCLUSIVE PROFESSIONAL IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN MAMMOGRAM OUTPATIENT /HOSPITAL PERFORMED; LIMITED 77062 DIGITAL BREAST TOMOSYNTHESIS ;BILATERAL R922 INCONCLUSIVE PROFESSIONAL MAMMOGRAM OUTPATIENT /HOSPITAL 77066 Diagnostic mammography, including computer -aided R922 INCONCLUSIVE PROFESSIONAL detection (CAD) when performed; bilateral MAMMOGRAM OUTPATIENT /HOSPITAL 81002 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR E119 TYPE 2 DIABETES PROFESSIONAL OFFICE BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, MELLITUS WITHOUT LEUIKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, COMPLICATIONS UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON AUTOMATED, WITHOUT MICROSCOPY 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE E119 TYPE 2 DIABETES PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED MELLITUS WITHOUT PATIENT, WHICH REQUIRES AT LEAST 20F THESE 3 KEY COMPLICATIONS COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER 99396 PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE Z0000 ENCOUNTER FOR PROFESSIONAL OFFICE REEVALUATION AND MANAGEMENT OF AN INDIVIDUAL GENERAL ADULT MEDICAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION WITHOUT EXAMINATION ,COUNSELING /ANTICIPATORY ABNORMAL FINDINGS GUIDANCE /RISK FACTOR REDUCTION INTERVENTIONS, ANDTHE ORDERING OF LABORATORY /DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; 40 -64 YEARS 96372 Therapeutic, prophylactic, ordiagnostic injection (specify E538 DEFICIENCYOF OTHER PROFESSIONAL OFFICE substance or mug); subcut.ne— or l ntramuscular SPECIFIED B GROUP VITAMINS 99496 TRANSITNL CARE MGMT SVCS W/ FOLLOWING READ E538 DEFICIENCY OF OTHER PROFESSIONAL OFFICE ELEMENTS: COMMUNICATN(DIRECT CONTACT, SPECIFIED B GROUP TELEPHONE, ELECTRONIC) W /PTNT &/OR CAREGIVER VITAMINS W /IN 2 BUS DAYS OF DISCHARGE MEDICAL DECISION MAKING OF HIGH COMPLEXITY INJECTION, VITAMIN B -12 CYANOCOBALAMIN, UP TO E538 DEFICIENCY OF OTHER PROFESSIONAL OFFICE 1000 MCG SPECIFIED B GROUP VITAMINS EYE IMAGING VALIDATED TO MATCH DIAGNOSIS FROM H40053 OCULAR HYPERTENSION, PROFESSIONAL OFFICE SEVEN STANDARD FIELD STEREOSCOPIC PHOTOS RESULTS BILATERAL DOCUMENTED AND REVIEWED )DM) $0.00 $3,096.00 FEMALE SUBSCRIBER 1 BCC $658.35 $3,120.00 FEMALE SUBSCRIBER 1 BCC $4,357.21 $6,568.60 FEMALE SUBSCRIBER 1 BCC $121.76 $288.00 FEMALE SUBSCRIBER 1 BCC $0.00 $239.00 FEMALE SUBSCRIBER 1 BCC $86.86 $213.00 FEMALE SUBSCRIBER 1 BCC $2.85 $7.00 FEMALE SUBSCRIBER 1 BCC $95.18 $290.00 FEMALE SUBSCRIBER 1 BCC $9917 $283.00 FEMALE SUBSCRIBER 1 BCC $20.72 $67.00 FEMALE SUBSCRIBER 1 BCC $0.00 $620.00 FEMALE SUBSCRIBER 1 BCC $2.00 $2.00 FEMALE SUBSCRIBER 1 BCC $0.00 $0.00 FEMALE SUBSCRIBER 1 BCC C.7.f 3559 w U1 N 3559 Q! 3559 7 ° a 3559 3559 > } fl CL i® 3559 Q, Q 3559 n Iii ®' 3559 3559 3559 3559 12/18/2017 12/14/2017 12 /15/2017 12/18/2017 12/14/2017 12/15/2017 12/18/2017 12/14/2017 12/15/2017 12/18/2017 12/14/2017 12/15/2017 G8427 12/18/2017 12/14/2017 12/15/2017 G8785 Sub Total Total Notes: This report ontains Personal Health Information (PHI) data for Self Insured Account /Div HCC ID = Health Care Contract Identifier. -SSN= Social Security Numbe, 92083 VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, H40053 OCULAR HYPERTENSION, PROFESSIONAL OFFICE WITH INTERPRETATION AND REPORT; EXTENDED BILATERAL EXAMINATION (EG, GOLDMANN VISUAL FIELDS WITH AT LEAST 3 ISOPTERS PLOTTED AND STATIC DETERMINATION WITHIN THE CENTRAL 30 DEGREES, OR QUANTITATIVE, AUTOMATED THRESHOLD PERIMETRY, OCTOPUS PROGRAM G -1 92250 FUNDUS PHOTOGRAPHY WITH INTERPRETATION AND H40053 OCULAR HYPERTENSION, PROFESSIONAL OFFICE REPORT BILATERAL 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE H40053 OCULAR HYPERTENSION, PROFESSIONAL OFFICE EVALUATION AND MANAGEMENT OF AN ESTABLISHED BILATERAL PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND /OR COORDINATION OF CARE WITH OTHER ELIGIBLE PROFESSIONAL ATTESTS TO DOCUMENTING IN H40053 OCULAR HYPERTENSION, PROFESSIONAL OFFICE THE MEDICAL RECORD THEY OBTAINED, UPDATED, OR BILATERAL REVIEWED THE PATIENT'S CURRENT MEDICATIONS BLOOD PRESSURE SCREENING NOT PERFORMED AS H40053 OCULAR HYPERTENSION, PROFESSIONAL OFFICE RECOMMENDED BY SCREENING INTERVAL, REASON NOT BILATERAL OTHERWISE SPECIFIED C.7.f $46.05 $78.00 FEMALE SUBSCRIBER 1 BCC 3559 Q! A $46.73 $75.00 FEMALE SUBSCRIBER 1 BCC 3559 $6838 $110.00 FEMALE SUBSCRIBER 1 BCC 3559 m O fl } a C. Q. Q $0.00 $0.00 FEMALE SUBSCRIBER 1 BCC 3559 v $0.00 $0.00 FEMALE SUBSCRIBER 1 BCC $73,041.54 $258,675.91 $5,805,917.31 $19,854,577.06 mg Census Detail Comp—y: COUNTY BBCC Group: BOi, ; This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 P aCK$L Pg. t5bb'.. 12/12/1950 066 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** "0217 SUBSCRIBER BIG PINE KEY 80611 33043 BCC BLUEOPTIONS 08/01/2017 06/27/1968 049 FEMALE 44 3 FL ACIIVL 03559 EMPLOYEE & CHILDREN 001 MONROL 07/09/2016 ""'0296 SUBSCRIBER BIG PINE KEY B0611 33043 BOG BLUEOP I IONS 04128/2017 07/01/1993 024 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/09/2016 " "'0296 DEPENDENT BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 04/26/2017 12/18/1958 058 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/01/2014 * * ** "0303 SUBSCRIBER KEYLARGO 80611 33037 BCC BLUEOPTIONS 08/01/2017 06/21/1959 058 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/01/2013 " * ** *0319 SUBSCRIBER MARATHON 80611 33050 BCC BLUEOPTIONS 08/01/2017 02/12/1995 022 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 09/17/2016 " * ** "0323 SUBSCRIBER MIAMI B0611 33174 BCC BLUEOPTIONS 09/20/2016 08/16/1990 027 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/19/2015 * * ** *0337 SUBSCRIBER RAMROD KEY B0611 33042 OSO BLUEOPTIONS 08/19/2017 09/11/1935 082 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * ** "'0340 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 01/02/2017 08/27/1981 036 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' ** "0340 SUBSCRIBER ISLAMORADA B0611 33036 BCC BLUEOPTIONS 12/03/2013 02/07/2011 006 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2013 "" "0340 DEPENDENT ISLAMORADA B0611 33036 BCC BLUEOPTIONS 08/01/2017 11/27/1952 064 '.FEMALE 59 1 FL RETIREE 03559 EMPLOYEE ONLY R01 SEMINOLE 05/01/2015 " "'0342 '.SUBSCRIBER '.LAKE MARY B0611 32746 OSO BLUEOPTIONS 08/01/2017 09/16/1967 050 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "` *`0343 SUBSCRIBER KEYWEST B0611 33045 BCC BLUEOPTIONS 12/03/2013 07/18/1936 081 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 "* *'0352 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 03/02/2017 08/30/1963 054 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/05/2016 "' *'0353 SUBSCRIBER ISLAMORADA B0611 33036 BCC BLUEOPTIONS 08/24/2016 12/02/1946 070 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 "' *`0361 SUBSCRIBER MIAMI 80611 33126 OSO BLUEOPTIONS 12/03/2013 02/15/1966 051 'MALL 44 2 FL ACTIVE 03559 'EMPLOYEE &SPOUSE 001 MONROE 11/01/2011 * "' *0362 'SUBSCRIBER 'LITTLE TORCH KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 02/13/1971 046 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 "' "0362 SPOUSE LITTLE TORCH KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 05/06/1996 021 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * *** "0375 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 12/03/2013 11/08/1971 045 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " ** *0375 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 10/02/1985 032 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 05/01/2015 " ** "0383 SUBSCRIBER MIAMI B0611 33165 BCC BLUEOPTIONS 08/24/2016 07/03/1945 072 MALE 70 1 MI RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 11/01/2011 * * ** *0384 SUBSCRIBER GIBRALTAR B0611 48173 OSO BLUEOPTIONS 03/16/2017 ADDRESS 03/14/1982 035 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY GG1 MONROE 07/20/2014 * ** "'0389 SUBSCRIBER TAVERNIER B0611 33070 OCA BLUEOPTIONS 02/15/2017 07/14/1985 032 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 07/07/2017 * ** "'0396 SPOUSE KEY LARGO B0611 33037 BCC BLUEOPTIONS 08/01/2017 03/27/1985 032 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 09/13/2013 ' ** "'0396 SUBSCRIBER KEY LARGO B0611 33037 BCC BLUEOPTIONS 07/07/2017 12/16/1997 019 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/26/2017 " "'0397 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 04/28/2017 03/27/1970 047 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/06/2016 " "`0409 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 02/08/1989 028 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/02/2013 " "`0413 SUBSCRIBER VIRGINIA GARDENS B0611 33166 BCC BLUEOPTIONS 08/24/2016 04/06/1961 056 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 * * *' "0415 SUBSCRIBER BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 10/01/1961 056 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 01/01/2012 "' *`0415 SPOUSE BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 12/23/1964 052 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * "` *0422 SUBSCRIBER MARATHON B0611 33050 COG BLUEOPTIONS 02/15/2017 11/09/1931 085 FEMALE 12 1 FL RETIREE 03559 EMPLOYEE ONLY R01 COLUMBIA 11/01/2011 *`* "0426 SUBSCRIBER LAKE CITY B0611 32056 COO BLUEOPTIONS 10/17/2017 05/13/1980 037 FEMALE 35 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 LAKE 06/14/2016 "" *0439 SUBSCRIBER MINNEOLA 80611 34715 0 BLUEOPTIONS 10/30/2017 06/13/1950 067 FEMALE 70 1 NO RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 07/01/2012 ' * ** *0463 SUBSCRIBER GREENSBORO B0611 27407 OSO BLUEOPTIONS 11/30/2016 ADDRESS 11/25/2002 014 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 0465 DEPENDENT TAVERNIER 80611 33070 COO BLUEOPTIONS 12/08/2016 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 F 05/11/1969 048 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 05/20/1945 072 FEMALE 70 12/25/1991 025 FEMALE 44 11/15/1991 025 MALE 44 01/16/1956 061 FEMALE 44 01/06/1966 051 MALE 44 12/27/1966 050 FEMALE 44 11/09/2000 016 MALE 44 12/12/1993 023 FEMALE 13 02/07/1951 066 FEMALE O8 01/05/1944 073 MALE 42 06/10/1971 046 '.MALE 44 07/26/1938 079 MALE 44 05/28/1939 078 MALE 35 08/16/1947 070 MALE 70 11/23/1950 066 MALE 44 02/06/1972 045 MALE 13 10/15/1937 080 FEMALE 44 10/10/2003 014 MALE 13 06/23/2006 011 FEMALE 13 1 NO RETIREE 03559 EMPLOYEE ONLY 1 FL ACTIVE 03559 EMPLOYEE ONLY 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 1 FL ACTIVE 03559 EMPLOYEE ONLY 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 1 FL ACTIVE 03559 EMPLOYEE ONLY 1 FL RETIREE 03559 EMPLOYEE ONLY 1 FL RETIREE 03559 EMPLOYEE ONLY 1 '.. FL '.. ACTIVE '.. 03559 '.EMPLOYEE ONLY 1 FIL RETIREE 03559 EMPLOYEE ONLY 1 FIL RETIREE 03559 EMPLOYEE ONLY 1 SC RETIREE 03559 EMPLOYEE ONLY 1 FIL RETIREE 03559 EMPLOYEE ONLY 3 FIL ACTIVE 03559 EMPLOYEE & CHILDREN 1 FIL ACTIVE 03559 EMPLOYEE ONLY 3 FIL ACTIVE 03559 EMPLOYEE & CHILDREN 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 01/29/2015 002 MALE 44 4 FL ACTIVE 03559 FAMILY 04/23/1990 027 MALE 44 4 FL ACTIVE 03559 FAMILY 03/21/1991 026 FEMALE 44 4 FL ACTIVE 03559 FAMILY 07/03/1986 031 NIALE 44 4 FL ACTIVE 03559 FAMILY 10/24/2015 002 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ""'0465 SUBSCRIBER TAVERNIER B0611 33070 COG BLUEOPTIONS 12/08/2016 001 MIAMI -DADL 04/09/2016 ""'0557 SUBSCRIBER MIAMI R01 NON - FLORIDA 11/01/2011 " "'0562 SUBSCRIBER NEWLAND 05/01/2017 ADDRESS SPOUSE 001 MONROE 09/25/2016 001 MONROE 03/19/2017 ' * "" "0573 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 ' "'* "0580 DEPENDENT KEYWEST 001 MONROE 11/01/2011 * * ** "0580 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 * * ** "0589 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 ' * *" "0602 SUBSCRIBER KEYWEST 001 MONROE 02/01/2017 ' * *" "0602 DEPENDENT KEYWEST 001 MIAMI -DADE 08/13/2016 " *" "0604 SUBSCRIBER HOMESTEAD R01 CHARLOTTE 03/01/2013 " "'0606 SUBSCRIBER PUNTA GORDA R01 MARION 11/01/2011 " "" "0620 SUBSCRIBER BELLEVIEW 001 MONROE 11/01/2011 '.. ' " "" "0628 '.SUBSCRIBER (MARATHON R01 MONROE 04/01/2012 ` * ** "0638 SUBSCRIBER KEYWEST R01 LAKE 11/01/2011 * *" "0639 SUBSCRIBER CLERMONT R01 NON - FLORIDA 11/01/2011 .. "'0653 SUBSCRIBER MT PLEASANT B0611 ADDRESS OSO BLUEOPTIONS 08/01/2017 12/31/9999 R01 MONROE 11/01/2011 '" "`0660 SUBSCRIBER MARATHON 001 MIAMI -DADE 11/01/2011 " "' "0660 SUBSCRIBER MIAMI 001 MONROE 01/07/2012 ` .... I'll SUBSCRIBER CUDJOE KEY 001 MIAMI -DADE 01/01/2014 ' ° "* "0660 DEPENDENT MIAMI 001 MIAMI -DADE 01/01/2014 ' * *" "0660 DEPENDENT MIAMI 002 MONROE 05/01/2017 " "'0682 DEPENDENT 002 MONROE 05/01/2017 '" "`0682 SUBSCRIBEF 002 MONROE 05/01/2017 " *' "0682 SPOUSE 001 MONROE 09/25/2016 `` "" "0684 SUBSCRIBEF 001 MONROE 09/25/2016 '1614 DEPENDENT B0611 33040 BCC BLUEOPTIONS 09/30/2017 12/31/9999 v B0611 33040 BCC BLUEOPTIONS 09/30/2017 12/31/9999 D B0611 33040 BCC BLUEOPTIONS 09/30/2017 12/31/9999 B0611 33040 BCC BLUEOPTIONS 09/30/2017 12131/9999 w 0 B0611 33825 OSO BLUEOPTIONS 08/01/2017 12131/9999 N fi B0611 33036 BCC BLUEOPTIONS 11/30/2016 12131/9999 � B0611 33050 OSE BLUEOPTIONS 08/24/2016 12131/9999 B0611 33186 BCC BLUEOPTIONS 08/24/2016 12/31/9999 y B0611 28657 BCC BLUEOPTIONS 04/26/2017 12/31/9999 'U B0611 33040 OTC BLUEOPTIONS 03/22/2017 12/31/9999 80611 33040 COO BLUEOPTIONS 08/02/2016 12/31/9999 tO 7 80611 33040 COO BLUEOPTIONS 08/02/2016 12/31/9999 0 80611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 0 ' CL B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33030 OSO BLUEOPTIONS 08/24/2016 '.. 12/31/9999 B0611 33950 OPA BLUEOPTIONS 06/29/2016 12/31/9999 L!J B0611 34420 OSO BLUEOPTIONS 03/10/2015 12131/9999 F B0611 33050 OSO BLUEOPTIONS 08/01/2017 12131/9999 B0611 33040 BCC BLUEOPTIONS 04/26/2017 12131/9999 B0611 34711 OSO BLUEOPTIONS 04/20/2017 12/31/9999 �. Ua B0611 29464 BCC BLUEOPTIONS 08/28/2017 12/31/9999 B0611 33050 OSO SLUEOPTIONS 11/02/2015 12/31/9999 LIJ B0611 33176 BCC BLUEOPTIONS 09/30/2014 12/31/9999 U B0611 33042 DOC BLUEOPTIONS 11/30/2016 12/31/9999 B0611 33176 BCC BLUEOPTIONS 08/01/2017 12/31/9999 80611 33176 BCC BLUEOPTIONS 08/01/2017 12/31/9999 LLJ 80611 33040 OSO BLUEOPTIONS 08/24/2016 12/31/9999 80611 32348 OSO BLUEOPTIONS 09/22/2015 12/31/9999 V B0611 32348 OSO BLUEOPTIONS 09/22/2015 12/31/9999 h B0611 32348 OSO BLUEOPTIONS 08/01/2017 12/31/9999 F B0611 33040 BCC BLUEOPTIONS 12/03/2013 12131/9999 * M B0611 I 33040 OPA IBLUEOPTIONS '. 08/01/2017 I 12/31/9999 N B0611 I 33040 OSO '. BLUEOPTIONS '. 04/28/2017 . . I 12/31/9999 = B0611 33040 OTC BLUEOPTIONS 08/01/2017 12/31/9999 ay B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 S U B0611 33040 OSO SLUEOPTIONS 05/17/2017 12/31/9999 N B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 Q B0611 33040 OSO BLUEOPTIONS 10/06/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 10/06/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 07/04/1993 024 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 10/05/2017 " ** "0684 SPOUSE KEYWEST 80611 33040 OSO BLUEOPTIONS 10/06/2017 C 7 g 03/05/1948 069 MALE 08 1 FL RETIREE 03559 EMPLOYEE ONLY R01 CHARLOTTE 03/01/2013 " * ** *0687 SUBSCRIBER PUNTA GORDA 80611 33950 OPA BLUEOPTIONS 04/28/2017 06/09/1966 051 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 " * ** "0690 SUBSCRIBER MIAMI B0611 33156 OSO BLUEOPTIONS 06/24/2015 12/31/9999 09/07/1950 067 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 06/01/2015 * * *' *0694 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 06/29/2016 12/31/9999 07/25/1949 068 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 07/01/2016 * * *" *0699 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 07/02/2016 12/31/9999 11/13/1970 046 FEMALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 11/01/2011 ' ** "0702 SUBSCRIBER MIAMI B0611 33184 OSO BLUEOPTIONS 08/16/2017 12/31/9999 Qj 03/28/1995 022 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 01/01/2015 ' DEPENDENT MIAMI B0611 33184 OSO BLUEOPTIONS 08/17/2017 12/31/9999 D 04/24/1997 020 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 09/01/2015 "* *'0702 DEPENDENT MIAMI B0611 33184 OSO BLUEOPTIONS 08/01/2017 12/31/9999 12/30/1942 074 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 " "0707 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 03/16/2017 12131/9999 01/17/1986 031 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/09/2017 ' * *' *0722 SUBSCRIBER MARATHON B0611 33050 CCC BLUEOPTIONS 10/09/2017 12131/9999 N fi 09/15/1955 062 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 12/17/2016 ' * ** *0736 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12131/9999 11/25/1981 035 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/31/2015 " ** *0738 SUBSCRIBER ISLAMORADA 80611 33036 OTC BLUEOPTIONS 04/27/2017 12131/9999 06/02/1943 074 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * * ** *0748 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 7 06/07/1956 061 FEMALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 01/01/2013 . "'0768 SPOUSE HIALEAH 80611 33018 OSO BLUEOPTIONS 08/01/2017 12/31/9999 'U 09/21/1952 065 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * " ** "0768 SUBSCRIBER SUMMERLAND KEY 80611 33042 OPA BLUEOPTIONS 08/01/2017 12/31/9999 O 12/29/1958 058 NIALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 11/01/2011 " * ** *0768 SUBSCRIBER HIALEAH 80611 33018 OSO BLUEOPTIONS 08/01/2017 12/31/9999 fl 09/22/1990 027 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " * ** "0770 DEPENDENT KEYWEST B0611 33040 CCC BLUEOPTIONS 12/03/2013 12/31/9999 O 1 03/24/1996 021 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * ** *0770 DEPENDENT KEYWEST B0611 33040 CCC BLUEOPTIONS 12/03/2013 12/31/9999 CL CL 10/15/1970 047 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * *" *0770 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 12/03/2013 12/31/9999 v 09/11/1955 062 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 03/26/2016 ' ** "0805 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 08/02/2016 12/31/9999 09/06/1966 051 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/16/2015 * "* *0807 SUBSCRIBER CUDJOE KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 12/31/9999 Q 09/30/1944 073 '.MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/02/2015 ' ** *'0825 '.SUBSCRIBER '. SUMMERLAND KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 12/31/9999 08/26/1969 048 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * ** *0835 SUBSCRIBER KEYWEST B0611 33040 OTC BLUEOPTIONS 12/03/2013 12/31/9999 IJJ 12/04/1989 027 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/01/2017 ' * *' *0835 SUBSCRIBER KEYWEST B0611 33041 OSE BLUEOPTIONS 08/21/2017 12/31/9999 12/07/1928 088 FEMALE 51 1 FL RETIREE 03559 EMPLOYEE ONLY R01 PASCO 11/01/2011 ' * ** *0836 SUBSCRIBER HOLIDAY B0611 34691 OSO BLUEOPTIONS 08/01/2017 12131/9999 03/10/1984 033 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 07/17/2015 " ** *0846 SPOUSE MARATHON 80611 33050 OSO BLUEOPTIONS 08/29/2017 12/31/9999 08/14/1984 033 'MALE 44 4 FL ACTIVE 03559 'FAMILY 002 MONROE 07117/2015 * * ** *0846 'SUBSCRIBER 'MARATHON B0611 33050 OSO BLUEOPTIONS 02/13/2017 12/31/9999 01/18/2013 004 NIALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2014 .. "'0846 DEPENDENT MARATHON 80611 33050 OSO BLUEOPTIONS 08/27/2015 12/31/9999 01/24/2016 001 NIALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/24/2016 * "** "0846 DEPENDENT MARATHON 80611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 LU U 06/01/1996 021 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/01/2017 " * ** *0847 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 04/28/2017 12/31/9999 09/17/1955 062 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 11/01/2011 " * ** "0853 SPOUSE KEYWEST B0611 33041 BCC BLUEOPTIONS 11/30/2016 12/31/9999 10/19/1946 071 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 11/01/2011 * * ** *0853 SUBSCRIBER KEYWEST B0611 33041 BCC BLUEOPTIONS 11/30/2016 12/31/9999 07/02/1948 069 MALE 36 1 FL RETIREE 03559 EMPLOYEE ONLY R01 LEE 11/01/2011 * * *" *0873 SUBSCRIBER LEHIGH ACRES B0611 33974 BCC BLUEOPTIONS 04/26/2017 12/31/9999 05/20/1976 041 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/24/2014 ' ** "0874 SUBSCRIBER CUDJOE KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 12/31/9999 06/04/2008 009 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/24/2014 ' DEPENDENT CUDJOE KEY B0611 33042 BCC BLUEOPTIONS 10/11/2016 12/31/9999 ' ** *'0874 ~ 09/20/2010 007 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/24/2014 DEPENDENT CUDJOE KEY B0611 33042 BCC BLUEOPTIONS 10/11/2016 12/31/9999 h 11/23/1982 034 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 * ** *0881 SUBSCRIBER HOMESTEAD B0611 33035 OSO BLUEOPTIONS 12/27/2014 12131/9999 01/31/1947 070 MALE 05 1 FL RETIREE 03559 EMPLOYEE ONLY R01 BREVARD 11/01/2011 ' * *' *0882 SUBSCRIBER PALM BAY B0611 32908 OSO BLUEOPTIONS 08/01/2017 12131/9999 C4 05/27/1930 087 MALE 50 1 FL RETIREE 03559 EMPLOYEE ONLY R01 PALM BEACH 11/01/2011 ' * ** *0893 SUBSCRIBER BOCA RATON B0611 33428 OTC BLUEOPTIONS 03/02/2017 12131/9999 m= = 09/08/1972 045 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " ** *0901 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 iy 11/19/2008 008 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * *' *0928 DEPENDENT KEYWEST 80611 33040 CCC BLUEOPTIONS 12/03/2013 12/31/9999 08/04/1970 047 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 .. "'0928 SUBSCRIBER KEYWEST 80611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 S U 04/22/1996 021 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * " "* "0928 DEPENDENT KEYWEST 80611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 a+ *' 08/01/1961 056 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/25/2017 " * ** *0937 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/28/2017 12/31/9999 12/11/1978 038 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/29/2012 * * ** *0947 SUBSCRIBER SUMMERLAND KEY B0611 33042 BCC BLUEOPTIONS 01/20/2015 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 889 01/25/1987 030 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/17/2017 " * ** "0949 SUBSCRIBER BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 09/03/1977 040 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 02/26/2017 ' * "0968 SUBSCRIBER KEYWEST B0611 33041 BCC BLUEOPTIONS 10/10/2017 12/31/9999 Qj 09/30/1934 083 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * "" "0976 SUBSCRIBER KEYWEST B0611 33041 OSO BLUEOPTIONS 03/02/2017 12/31/9999 D 01/20/1952 065 FEMALE 70 1 VA RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 11/01/2011 ' * *" "0992 SUBSCRIBER VIRGILINA B0611 24598 BCC BLUEOPTIONS 01/02/2017 12/31/9999 4i ADDRESS +t= 12/16/1989 027 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 09/27/2015 ' *" "0992 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/24/2016 12/31/9999 g1 03/02/2016 001 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 03/02/2016. " * ** "0992 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 N fi 09/17/1957 060 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 08/30/2013 " * ** "0995 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/02/2016 12131/9999 w N 07/26/1953 004 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 10/01/2013 * * ** *0995 SPOUSE KEYWEST 80611 33040 BCC BLUEOPTIONS 08/01/2017 12131/9999 .® 12/16/1970 046 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " "'0997 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 0810112017 12/31/9999 y 09/02/1999 018 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 09/25/2015 " " "" "0997 DEPENDENT MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 fu 05/11/1968 049 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * "" "1006 SUBSCRIBER KEYWEST 80611 33040 OTC BLUEOPTIONS 12/03/2013 12/31/9999 01/26/2015 002 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 04/15/2017 ' *'" "1007 DEPENDENT CUTLER BAY 80611 33189 OSO BLUEOPTIONS 04/15/2017 12/31/9999 tO 7 12/12/1983 033 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 04/15/2017 " * ** "1007 SUBSCRIBER CUTLER BAY 80611 33189 OSO BLUEOPTIONS 08/01/2017 12/31/9999 O s 11/03/1999 017 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * ** *1010 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 C ' CL 05/27/1988 029 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' * *" "1010 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 08/12/1972 045 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' * *" "1010 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 01/16/1928 089 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ' * *" "1016 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 03/02/2017 12/31/9999 08/10/1974 043 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 11/01/2011 """ "1023 SUBSCRIBER HOMESTEAD B0611 33033 OSO BLUEOPTIONS 03/10/2017 12/31/9999 04/10/2009 008 FEMALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 11/01/2011 ' * "" "1023 DEPENDENT HOMESTEAD B0611 33033 OSO BLUEOPTIONS 03/10/2017 12131/9999 '.MALE '.EMPLOYEE " * ** "1023 '.DEPENDENT '.HOMESTEAD 06/10/2014 003 13 3 FL ACTIVE 03559 &CHILDREN 001 MIAMI -DADE 06/10/2014 B0611 33033 OSO BLUEOPTIONS 08/01/2017 12131/9999 09/22/1953 064 FEMALE 61 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 SUWANNEE 07/01/2016 " * ** "1026 SPOUSE BRANFORD B0611 32008 BCC BLUEOPTIONS 08/01/2017 12131/9999 06/08/1954 063 MALE 61 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 SUWANNEE 07/01/2016 * * *' *1026 SUBSCRIBER BRANFORD B0611 32008 BCC BLUEOPTIONS 03/10/2017 12/31/9999 �. 05/29/1940 077 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " * "* "1026 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 12/03/2013 12/31/9999 05/24/1969 048 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 ' * "" *1027 SUBSCRIBER HOMESTEAD B0611 33033 BCC BLUEOPTIONS 02/03/2016 12/31/9999 01/05/1950 067 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 01/01/2015 ' * "" "1032 SUBSCRIBER KEYWEST 80611 33040 CCC BLUEOPTIONS 11/30/2016 12/31/9999 LU U 01/31/1938 079 MALE O8 1 FL RETIREE 03559 EMPLOYEE ONLY R01 CHARLOTTE 11/01/2011 ' *'" "1034 SUBSCRIBER ROTONDA WEST 80611 33947 BCC BLUEOPTIONS 07/25/2015 12/31/9999 11/09/1951 065 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 02/17/2017 " * ** "1034 SPOUSE TAVERNIER 80611 33070 BCC BLUEOPTIONS 08/01/2017 12/31/9999 06/21/1954 063 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2015 ' * *' *1034 SUBSCRIBER TAVERNIER 80611 33070 BCC BLUEOPTIONS 02/27/2017 12131/9999 LLJ 09/16/1948 069 MALE 42 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MARION 11/01/2011 ' * *" "1038 SUBSCRIBER DUNNELLON B0611 34432 BCC BLUEOPTIONS 11/30/2016 12/31/9999 07/02/1959 058 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * *" "1040 SUBSCRIBER KEYWEST B0611 33040 OPA BLUEOPTIONS 12/03/2013 12/31/9999 U 06/05/1959 058 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ' * *" "1049 SUBSCRIBER TAVERNIER B0611 33070 OSO BLUEOPTIONS 12/03/2013 12/31/9999 h 06/16/1978 039 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 08/04/2014 """ "1053 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 12131/9999 F- 10/16/1977 040 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 08/04/2014 ' *" "1053 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 12131/9999 M 12/26/1956 060 '.MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " * ** "1060 SUBSCRIBER MARATHON B0611 '. 33050 OSO BLUEOPTIONS 11/12/2015 12131/9999 ' N 06/07/1961 056 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * ** "1063 SUBSCRIBER ISLAMORADA 80611 33036 BCC BLUEOPTIONS 08/01/2017 12131/9999 .w C 12/24/1992 024 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " "'1063 DEPENDENT ISLAMORADA B0611 33036 BCC BLUEOPTIONS 08/01/2017 12/31/9999 4! 01/08/1996 021 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " * "` "1063 DEPENDENT ISLAMORADA B0611 33036 BCC BLUEOPTIONS 08/01/2017 12/31/9999 06/25/1957 060 MALE 13 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MIAMI -DADE 06/01/2012 " "" "1069 SUBSCRIBER PALMETTO BAY B0611 33157 OSO BLUEOPTIONS 08/01/2017 12/31/9999 02/20/1960 057 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/22/2017 ' * "" "1070 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 10/23/2017 12/31/9999 09/14/1949 068 MALE 70 1 VA RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 11/01/2011 ' * *" "1074 SUBSCRIBER WILLIAMSBURG 80611 23188 OSO BLUEOPTIONS 08/01/2017 12/31/9999 ADDRESS 04/15/1969 048 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 02/20/2016 ' * °* "1085 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 890 12/14/1979 037 NIALE 06 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BROVN /ARD 11/01/2011 " " "" "1100 SUBSCRIBER PEMBROKE PINES B0611 33028 OSO BLUEOPTIONS 05/15/2017 11/30/2007 009 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' ** "1129 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 11/14/2016 12/31/9999 Qj 12/21/2006 010 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/15/2012 ' DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 D 12/30/1966 050 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " "" "1129 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 01/16/1971 046 MALE 50 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 PALM BEACH 05/24/2015. " SUBSCRIBER LAKE WORTH B0611 33467 OSO BLUEOPTIONS 08/24/2016 12131/9999 03/20/1974 043 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2016 —. 1150 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 01/19/2016 12131/9999 N fi 04/25/1979 038 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2016 ' * ** *1150 SPOUSE KEY LARGO B0611 33037 BCC BLUEOPTIONS 08/01/2017 12131/9999 � 12/08/2015 001 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2016 . - 1150 DEPENDENT KEYLARGO 80611 33037 BCC BLUEOPTIONS 08/01/2017 12131/9999 05/26/2006 011 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/05/2013 * * ** *1159 DEPENDENT SUGARLOAF KEY B0611 33042 OSO BLUEOPTIONS 04/20/2017 12/31/9999 7 01/14/1981 036 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/05/2013 " "'1159 SUBSCRIBER SUGARLOAF KEY 80611 33042 OSO BLUEOPTIONS 08/01/2017 12/31/9999 'U 02/11/1948 069 FEMALE O8 1 FL RETIREE 03559 EMPLOYEE ONLY R01 CHARLOTTE 11/01/2011 " "*" "1162 SUBSCRIBER PORT CHARLOTTE B0611 33981 CCC BLUEOPTIONS 10/17/2017 12/31/9999 O 12/07/1969 047 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** *1168 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 fl 06/12/1961 056 FEMALE 51 1 FL RETIREE 03559 EMPLOYEE ONLY R02 PASCO 01/22/2015 * * ** *1173 SUBSCRIBER HUDSON B0611 34667 OSO BLUEOPTIONS 05/02/2017 12/31/9999 O 1 06/04/1996 021 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * ** *1178 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 08/08/2014 12/31/9999 CL CL 05/23/2002 015 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * *" "1178 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 08/08/2014 12/31/9999 v 11/10/1966 050 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' ** "1178 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/08/2014 12/31/9999 03/30/1962 055 MALE 44 4 FL RETIREE 03559 FAMILY R01 MONROE 04/01/2017 * "" "1192 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 07/06/2017 12/31/9999 Q 07/04/1996 021 '.MALE 44 4 FL RETIREE 03559 '.FAMILY R01 MONROE 04/01/2017 ' * "" "1192 '.DEPENDENT '. KEYLARGO B0611 33037 BCC BLUEOPTIONS 08/01/2017 12/31/9999 05/29/1959 058 FEMALE 44 4 FL RETIREE 03559 FAMILY R01 MONROE 07/01/2017 ' * "" "1192 SPOUSE KEYLARGO B0611 33037 BCC BLUEOPTIONS 08/01/2017 12/31/9999 LLI 11/22/1964 052 FEMALE 13 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MIAMI -DADE 12/01/2012 "*"1214 SUBSCRIBER HOMESTEAD B0611 33035 OSO BLUEOPTIONS 08/01/2017 12/31/9999 04/01/1961 056 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * ** "1216 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 12/03/2013 12131/9999 04/08/1968 049 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "' *'1216 SUBSCRIBER KEYWEST 80611 33040 CCC BLUEOPTIONS 12/03/2013 12/31/9999 06/01/1979 038 'MALL 44 1 FL ACTIVE 03559 'EMPLOYLL ONLY 001 MONROL 11/01/2011 * * ** *1217 'SUBSCRIBER 'KLYWLST B0611 33040 OSO BLUEOPTIONS 04/27/2017 12/31/9999 09/30/1969 048 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 .. "'1227 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 10/08/2015 12/31/9999 08/03/1974 043 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " * "" "1232 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 LU U 04/12/1961 056 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/30/2017 * * ** *1237 SUBSCRIBER RAMROD KEY B0611 33042 BCC BLUEOPTIONS 04/30/2017 12/31/9999 11/12/1993 023 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2012 * * ** *1267 DEPENDENT BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/31/2017 12/31/9999 08/23/1959 058 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2012 * * ** *1267 SPOUSE BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 09/07/1964 053 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2012 * * *" "1267 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 12/23/1970 046 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' ** "1268 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/02/2016 12/31/9999 05/11/1980 037 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/24/2017 ' SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/07/2017 12/31/9999 ' * "" "1272 ~ 09/27/1953 064 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/30/2017 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 04/28/2017 12/31/9999 h 03/16/1959 058 MALE 70 1 AL RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 06/01/2012 ' * "" "1276 SUBSCRIBER MENTONE B0611 35984 OSO BLUEOPTIONS 08/01/2017 12131/9999 ADDRESS " M 06/01/1944 073 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 " " "" "1279 SUBSCRIBER KEYWEST B0611 '. 33040 CCC BLUEOPTIONS 04/20/2017 12131/9999 ' N 01/09/1952 065 FEMALE 52 1 FL RETIREE 03559 EMPLOYEE ONLY R01 PINELLAS 11/01/2011 * * ** "1283 SUBSCRIBER PINELLAS PARK B0611 33781 BCC BLUEOPTIONS 08/01/2017 12131/9999 .w C 04/17/2007 010 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 "' *'1284 DEPENDENT KEY LARGO B0611 33037 OSO BLUEOPTIONS 08/16/2017 12/31/9999 4! 11/19/1983 033 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * *` *1284 SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 08/19/2017 12/31/9999 03/06/1989 028 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 08/09/2012 * "" "1284 SPOUSE KEYLARGO B0611 33037 OSO BLUEOPTIONS 08/31/2017 12/31/9999 10/23/2013 004 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 10/23/2013 ' * "" "1284 DEPENDENT KEYLARGO 80611 33037 OSO BLUEOPTIONS 08/08/2017 12/31/9999 05/11/2015 002 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 05/11/2015 ' * *" "1284 DEPENDENT KEYLARGO 80611 33037 OSO BLUEOPTIONS 08/01/2017 12/31/9999 08/21/1952 065 MALE 44 4 FL RETIREE 03559 FAMILY R01 MONROE 02/01/2017 * * ** "1289 SPOUSE KEYLARGO B0611 33037 BCC BLUEOPTIONS 02/27/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 891_.. 12/04/1992 024 FEMALE 44 4 FL RETIREE 03559 FAMILY R01 MONROE 02/01/2017 * * ** "1289 DEPENDENT KEYLARGO B0611 33037 BCC BLUEOPTIONS 02/22/2017 03/31/1989 028 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 r .�. MONROE 01/04/2013 * * *" "1327 SUBSCRIBER BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 05/18/2017 12/31/9999 dg 02/16/1935 082 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * * *" "1331 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 11/30/2016 12/31/9999 = 04/02/1960 057 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 """ "1339 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 w w 02/19/1992 025 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/20/2015 "" "1351 SUBSCRIBER SUMMERLAND KEY B0611 33042 BCC BLUEOPTIONS 08/24/2016 12131/9999 g1 10/10/1975 042 FEMALE OS 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 BREVARD 10/27/2017. ' " "" "1359 SUBSCRIBER TITUSVILLE B0611 32796 BCC BLUEOPTIONS 10/30/2017 12131/9999 N fi 09/29/1995 022 FEMALE 05 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 BREVARD 10/27/2017 ` * ** "1359 DEPENDENT TITUSVILLE B0611 32796 BCC BLUEOPTIONS 10/30/2017 12131/9999 w N 06/01/1951 000 FEMALE 51 1 FL RETIREE 03559 EMPLOYEE ONLY R01 PASCO 11/01/2011 " ** *1367 SUBSCRIBER DADE CITY 60611 33525 CCC BLUEOPTIONS 11/30/2016 12131/9999 .® 1011911977 040 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'1371 SUBSCRIBER KEY LARGO B0611 33037 CCC BLUEOPTIONS 0810712017 12/31/9999 y 07/03/1953 064 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 02/06/2017 * * ** "1373 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 fu 01/06/2005 012 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 02/06/2017 ' * ** "1373 DEPENDENT MARATHON 80611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 03/05/1966 051 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 02/06/2017 ' *'* "1373 SPOUSE MARATHON 80611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 tO 7 09/09/1999 018 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 02/06/2017 * * ** "1373 DEPENDENT MARATHON 80611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 O s 02/24/1961 056 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * ** *1374 SUBSCRIBER SUMMERLAND KEY B0611 33042 MLA BLUEOPTIONS 05/10/2014 12/31/9999 C ' CL 11/25/1994 022 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * *" "1374 DEPENDENT SUMMERLAND KEY B0611 33042 DLA BLUEOPTIONS 05/10/2014 12/31/9999 09/26/1984 033 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/13/2016 * * *" "1375 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 10/06/1948 069 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * *" "1379 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 12/29/1956 060 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 10/01/2013 """ "1380 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 ULI 11/21/1990 026 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 10/17/2014 " "" "1384 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 '.MALE '.EMPLOYEE ' " "" "1384 '.DEPENDENT '.KEYWEST 12/21/2013 003 44 3 FL ACTIVE 03559 &CHILDREN 001 MONROE 02/01/2015 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 08/24/1963 054 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ` * ** "1391 SUBSCRIBER KEYWEST B0611 33041 CCC BLUEOPTIONS 08/01/2017 12131/9999 08/08/1958 059 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "" *1394 SUBSCRIBER KEYWEST B0611 33045 OSO BLUEOPTIONS 08/01/2017 12/31/9999 �. 11/23/1970 046 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/01/2015 '''* "1403 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 09/19/1985 032 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/24/2016 ` ** *'1407 SUBSCRIBER RAMROD KEY B0611 33042 OSO BLUEOPTIONS 08/21/2017 12/31/9999 05/23/1998 019 FEMALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 07/30/2013 ' * ** "1423 DEPENDENT MIAMI 80611 33176 BCC BLUEOPTIONS 08/01/2017 12/31/9999 LU U 05/27/1972 045 NIALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 11/01/2011 ' *'* "1423 SUBSCRIBER MIAMI 80611 33176 BCC BLUEOPTIONS 12/07/2015 12/31/9999 05/01/1973 044 FEMALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 07/30/2013 * * ** "1423 SPOUSE MIAMI 80611 33176 BCC BLUEOPTIONS 08/01/2017 12/31/9999 03/19/2002 015 MALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 07/30/2013 * * *" "1423 DEPENDENT MIAMI 80611 33176 BCC BLUEOPTIONS 08/01/2017 12131/9999 LLJ 01/11/1961 056 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/28/2013 * * *" "1426 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 04/26/2017 12/31/9999 03/05/1951 066 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * * *" "1427 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 U 01/09/1947 070 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 08/01/2013 * * *" "1433 SUBSCRIBER KEYWEST B0611 33040 OTC BLUEOPTIONS 06/29/2016 12/31/9999 h 05/07/1997 020 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/26/2016 """ "1435 DEPENDENT TAVERNIER B0611 33070 CCC BLUEOPTIONS 11/28/2016 12131/9999 F- 09/28/1963 054 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/26/2016 "" "1435 SUBSCRIBER TAVERNIER B0611 33070 CCC BLUEOPTIONS 11/28/2016 12131/9999 M 04/07/1954 063 '.MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/14/2016 ' " "" "1443 SUBSCRIBER KEY LARGO B0611 '. 33037 BCC BLUEOPTIONS 08/24/2016 12131/9999 ' N 08/17/1955 062 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/13/2013 * * *' "1456 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 10/17/2017 12131/9999 .w C 02/11/1955 062 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'1458 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 4! 05/18/1961 056 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/01/2017 " "'1459 SUBSCRIBER RAMROD KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 12/31/9999 10/08/1951 066 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/27/2012 ` ** *'1471 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 12/03/2013 12/31/9999 01/08/1962 055 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 02/01/2017 ' * ** "1477 SUBSCRIBER SUGARLOAF KEY 60611 33042 OSO BLUEOPTIONS 08/01/2017 12/31/9999 06/21/1986 031 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/23/2014 ' * ** "1478 SUBSCRIBER MARATHON 80611 33050 BCC BLUEOPTIONS 08/24/2016 12/31/9999 12/22/1983 033 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/09/2017 " * ** *1483 SUBSCRIBER KEY COLONY BEACH 80611 33051 BCC BLUEOPTIONS 09/09/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 892 10/08/1959 058 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/06/2013 ""'1485 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 02/09/1965 052 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 --i'll SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 07/27/2016 001 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2017 ' * "* "1553 DEPENDENT MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 10/03/1969 048 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 06/01/2016 ' "'* "1559 SUBSCRIBER BIG PINE KEY 80611 33043 BCC BLUEOPTIONS 08/01/2017 08/02/1955 062 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** "1559 SUBSCRIBER MARATHON 80611 33050 BCC BLUEOPTIONS 08/02/2016 01/31/2000 017 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 06/01/2016 * * ** *1559 DEPENDENT BIG PINE KEY 80611 33043 BCC BLUEOPTIONS 08/01/2017 03/23/2007 010 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 06/01/2016 ' ** "'1559 DEPENDENT BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 08/01/2017 07/04/1964 053 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 06/01/2016 ' ** "'1559 SPOUSE BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 08/01/2017 01/24/1996 021 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 06/01/2016 "* "'1559 DEPENDENT BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 08/01/2017 09/26/1967 050 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 09/18/2015 " "'1562 SPOUSE KEYWEST B0611 33040 OCA BLUEOPTIONS 08/01/2017 05/18/1975 042 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 " "" "1562 SUBSCRIBER KEYWEST B0611 33040 OCA BLUEOPTIONS 08/01/2017 09/17/2009 008 '.FEMALE 44 4 FL ACTIVE 03559 '.FAMILY 001 MONROE 09/18/2015 ' " "" "1562 '.DEPENDENT '. KEYWEST B0611 33040 OCA BLUEOPTIONS 08/01/2017 02/11/1957 060 FEMALE 44 1 FIL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ` * ** "1569 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/05/1964 052 FEMALE 44 1 FIL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "" *1571 SUBSCRIBER KEYWEST B0611 33045 BCC BLUEOPTIONS 08/01/2017 09/28/1956 061 MALE 13 2 FIL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 11/01/2011 '1117 SUBSCRIBER HOMESTEAD B0611 33033 BCC BLUEOPTIONS 02/03/2017 10/26/1954 063 FEMALE 13 2 FIL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 01/01/2017 ` "" "1587 SPOUSE HOMESTEAD B0611 33033 BCC BLUEOPTIONS 08/01/2017 04/24/1963 054 MALE 44 3 FIL RETIREE 03559 EMPLOYEE & CHILDREN R01 MONROE 11/01/2011 ' * "* "1588 SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 02/15/2017 09/22/2006 011 FEMALE 44 3 FL RETIREE 03559 EMPLOYEE & CHILDREN R01 MONROE 01/01/2014 ' "'* "1588 DEPENDENT KEYLARGO 80611 33037 OSO BLUEOPTIONS 08/01/2017 10/20/1992 025 MALE 44 3 FL RETIREE 03559 EMPLOYEE & CHILDREN R01 MONROE 01/01/2012 " * *" "1588 DEPENDENT KEYLARGO 80611 33037 OSO BLUEOPTIONS 08/11/2017 03/25/1999 018 MALE 44 3 FL RETIREE 03559 EMPLOYEE & CHILDREN R01 MONROE 01/01/2014 ' * *' *1588 DEPENDENT KEYLARGO 80611 33037 OSO BLUEOPTIONS 08/01/2017 05/21/1964 053 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 ' ** "'1593 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 09/18/1959 058 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 "* "'1593 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 11/12/1945 071 FEMALE 01 1 FL RETIREE 03559 EMPLOYEE ONLY R01 ALACHUA 11/01/2012 ' ** "'1606 SUBSCRIBER GAINESVILLE B0611 32607 BCC BLUEOPTIONS 11/30/2016 11/18/1988 028 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/03/2017 " "'1606 SUBSCRIBER BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 08/01/2017 11/11/1960 056 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/13/2016 "" "1611 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 10/27/1943 074 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 ' " "" "1622 SUBSCRIBER MIAMI B0611 33116 OSO BLUEOPTIONS 08/01/2017 09/06/1973 044 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 10/01/2017 * * *' "1624 SPOUSE SUGARLOAF KEY 80611 33042 BCC BLUEOPTIONS 10/13/2017 04/30/1974 043 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 10/01/2017 " "'1624 SUBSCRIBER SUGARLOAF KEY B0611 33042 BCC BLUEOPTIONS 10/13/2017 02/24/2003 014 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * ** "1629 DEPENDENT SUMMERLAND KEY B0611 33042 CCC BLUEOPTIONS 02/08/2016 11/24/1998 018 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ``" "1629 DEPENDENT SUMMERLAND KEY B0611 33042 CCC BLUEOPTIONS 02/08/2016 04/06/1967 050 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' * "* "1629 SUBSCRIBER SUMMERLAND KEY B0611 33042 CCC BLUEOPTIONS 02/08/2016 07/20/1965 052 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' * ** "1629 SPOUSE SUMMERLAND KEY 80611 33042 CCC BLUEOPTIONS 02/08/2016 04/22/1942 075 MALE 29 1 FL RETIREE 03559 EMPLOYEE ONLY R01 HILLSBOROUGH 11/01/2011 " * ** *1629 SUBSCRIBER VALRICO 80611 33594 ORA BLUEOPTIONS 04/20/2017 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 F 11/05/1992 024 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/10/2015 * *** *1633 SUBSCRIBER MARATHON 80611 33050 OSO BLUEOPTIONS 08/24/2016 01/28/1995 022 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/01/2017 ' "" "1662 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 07/01/2017 12/31/9999 Qj 03/16/1967 050 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' "" "1665 SPOUSE MARATHON B0611 33050 OSO BLUEOPTIONS 02/28/2017 12/31/9999 D 09/17/1990 027 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' ** "1665 DEPENDENT MARATHON B0611 33050 OSO BLUEOPTIONS 03/10/2017 12/31/9999 04/07/1965 052 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' ** *'1665 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 09/14/2017 12131/9999 11/05/1960 056 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * ** *1671 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 08/16/2017 12131/9999 N fi 12/04/1951 065 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 05/01/2014 ' *'* *1675 SUBSCRIBER CUDJOE KEY B0611 33042 CCC BLUEOPTIONS 01/02/2017 12131/9999 03/19/1987 030 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/08/2017 "' *'1691 SUBSCRIBER KEYWEST 80611 33040 CCC BLUEOPTIONS 04/28/2017 12131/9999 08/03/1962 055 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * *" *1694 SUBSCRIBER BIG PINE KEY B0611 33043 CCC BLUEOPTIONS 01/18/2017 12/31/9999 7 07/02/1965 052 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 . "'1698 SUBSCRIBER ISLAMORADA 80611 33036 OSO BLUEOPTIONS 08/01/2017 12/31/9999 'U 06/23/2000 017 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *1703 DEPENDENT KEYWEST 80611 33040 ORA BLUEOPTIONS 12/03/2013 12/31/9999 O 09/15/1995 022 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *1703 DEPENDENT KEYWEST 80611 33040 ORA BLUEOPTIONS 12/03/2013 12/31/9999 fl 11/29/1968 048 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *1703 SUBSCRIBER KEYWEST B0611 33040 ORA BLUEOPTIONS 12/03/2013 12/31/9999 O 1 12/14/1969 047 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *1703 SPOUSE KEYWEST B0611 33040 ORA BLUEOPTIONS 12/03/2013 12/31/9999 CL CL 08/20/2004 013 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * ** "'1703 DEPENDENT KEYWEST B0611 33040 ORA BLUEOPTIONS 12/03/2013 12/31/9999 v 06/17/1965 052 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' "" "1704 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 12/03/2013 12/31/9999 10/23/1951 066 FEMALE 37 1 FL RETIREE 03559 EMPLOYEE ONLY R01 LEON 11/01/2011 *" "1715 SUBSCRIBER TALLAHASSEE B0611 32311 ORA BLUEOPTIONS 06/12/2017 12/31/9999 Q 08/04/1986 031 '.FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' ** "1716 '.SUBSCRIBER '.KEYWEST B0611 33040 OSO BLUEOPTIONS 02/03/2016 12/31/9999 02/04/1982 035 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 10/05/2012 ' * ** *1728 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 11/12/2015 12/31/9999 LLI 02/11/2003 014 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 10/05/2012 * * *' *1728 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 04/20/2017 12/31/9999 09/12/2004 013 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 10/05/2012 ' *'* *1728 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 11/12/2015 12131/9999 10/28/1967 050 FEMALE 06 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BROVJARD 11/01/2011 "' *'1730 SUBSCRIBER PEMBROKE PINES 80611 33028 OSO BLUEOPTIONS 08/01/2017 12/31/9999 03/29/1946 071 'MALE 44 2 FL ACTIVE 03559 'EMPLOYEE &SPOUSE 001 MONROE 11/01/2011 * *" *1732 'SUBSCRIBER 'MARATHON B0611 33050 BCC BLUEOPTIONS 12/03/2013 12/31/9999 05/06/1958 059 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 .. "'1732 SPOUSE MARATHON 80611 33050 BCC BLUEOPTIONS 12/03/2013 12/31/9999 07/14/1990 027 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/26/2012 * *** *1737 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 LU U 02/07/1991 026 NIALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 04/21/2017 * * ** *1743 SUBSCRIBER MIAMI 80611 33185 BCC BLUEOPTIONS 04/28/2017 12/31/9999 09/20/1987 030 NIALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 01/01/2015 * * ** *1754 DEPENDENT AVENTUR4 B0611 33180 OSO BLUEOPTIONS 08/01/2017 12/31/9999 07/06/1959 058 FEMALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 11/01/2011 * * ** *1754 SUBSCRIBER AVENTUR4 B0611 33180 OSO BLUEOPTIONS 08/01/2017 12/31/9999 10/28/1960 057 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 11/01/2011 * ** "'1757 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 12/03/2013 12/31/9999 Llj ME 04/18/1957 060 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 11/01/2011 '* "'1757 SPOUSE MARATHON B0611 33050 BCC BLUEOPTIONS 12/03/2013 12/31/9999 12/11/1945 071 FEMALE 70 1 TN RETIREE 03559 EMPLOYEE ONLY R01 NON- FLORIDA 11/01/2011 "" "'1767 SUBSCRIBER MEMPHIS B0611 38114 DSO BLUEOPTIONS 03/10/2015 12/31/9999 ADDRESS f 06/01/1949 068 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 1787 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 07/27/2015 12131/9999 F- 09/01/1984 033 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/05/2012 ' *" "`1787 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 M 09/02/1951 066 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 02/01/2013 ' * ** *1790 SUBSCRIBER KEYWEST B0611 '. 33041 CCC BLUEOPTIONS 01/02/2017 12131/9999 ' N 09/26/1947 070 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** *1791 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 12/03/2013 12131/9999 .w C 01/21/1953 064 FEMALE 45 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 NASSAU 02/01/2013 "' *'1796 SPOUSE CALLAHAN B0611 32011 OSE BLUEOPTIONS 06/29/2016 12/31/9999 4! 05/29/1950 067 MALE 45 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 NASSAU 02/01/2013 * *" *1796 SUBSCRIBER CALLAHAN B0611 32011 OSE BLUEOPTIONS 04/26/2017 12/31/9999 09/03/1979 038 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/27/2017 ``* "1796 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 05/31/2017 12/31/9999 06/04/1959 058 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/13/2015 — 1815 SUBSCRIBER KEYWEST 80611 33040 ORA BLUEOPTIONS 11/30/2016 12/31/9999 08/08/1956 061 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * ** *1832 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 09/30/1936 081 FEMALE O8 1 FL RETIREE 03559 EMPLOYEE ONLY R01 CHARLOTTE 11/01/2011 * * ** *1834 SUBSCRIBER PUNTA GORDA 80611 33983 BCC BLUEOPTIONS 12/15/2016 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 894 04/23/2010 007 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ""'1837 DEPENDENT KEYWEST B0611 33041 BCC BLUEOPTIONS 12/03/2013 04/13/1981 035 :MALL 44 2 : FL : ACIIVL : 03559 :EMPLOYEE &SPOUSE : 001 MONROL 03/19/1984 033 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 04/10/1980 037 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/28/1947 070 FEMALE 70 1 GA RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORID EMPLOYEE & CHILD 11/01/2011 * * *" *1911 SUBSCRIBER MIRAMAR B0611 33027 OSO BLUEOPTIONS 07/06/2017 ADDRESS 01/23/1949 068 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/20/1975 042 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 07/28/1983 034 MALE 06 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 BROVJARD 12/30/1975 041 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/18/1999 017 MALE 44 4 FL ACTIVE 03559 : FAMILY 001 MONROE 07/06/2001 016 : FEMALE 44 4 FL ACTIVE 03559 : FAMILY 001 MONROE 02/10/2013 004 MALE 06 3 : FL ACTIVE 03559 : EMPLOYEE &CHILDREN 001 BROVN /ARD 03/12/2007 010 '.FEMALE 06 3 '.. FL '.. ACTIVE '.. 03559 ' &CHILDREN '.. 001 BROWARD 03/16/1997 020 : MALE 44 3 : FL : RETIREE : 03559 : EMPLOYEE & CHILDREN R01 MONROE 08/28/1955 062 FEMALE 44 3 FL RETIREE 03559 EMPLOYEE & CHILDREN R01 MONROE 11/03/2016 000 : FEMALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE & CHILDREN 001 MONROE 03/30/1984 033 : MALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE & CHILDREN : 001 MONROE 07/14/1991 026 : MALE 44 1 : FL : ACTIVE : 03559 : EMPLOYEE ONLY 001 MONROE 08/24/2004 013 MALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 11/25/1986 030 FEMALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 12/31/1971 045 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 06/14/1995 022 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 09/24/1999 018 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 10/25/2016 001 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 07/27/1988 029 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 01/01/2017 " "'1902 SPOUSE TAVERNIER 80611 33070 BCC BLUEOPTIONS 08/01/2017 01/27/2012 " " "" "1904 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 11/01/2011 * * ** *1907 SUBSCRIBER COVINGTON B0611 30014 OSO BLUEOPTIONS 08/01/2017 01/01/2013 " * *" "1908 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 08/01/2017 11/01/2011 * * ** *1911 SPOUSE SUMMERLAND KEY B0611 33042 BCC BLUEOPTIONS 12/03/2013 11/01/2011 * * *" *1911 SUBSCRIBER MIRAMAR B0611 33027 OSO BLUEOPTIONS 07/06/2017 11/01/2011 * * *" *1911 SUBSCRIBER SUMMERLAND KEY B0611 33042 BCC BLUEOPTIONS 12/03/2013 11/01/2011 * * *" *1911 DEPENDENT : SUMMERLAND KEY B0611 33042 BCC : BLUEOPTIONS : 04/19/2017 11/01/2011 * *1911 DEPENDENT SUMMERLAND KEY B0611 33042 BCC BLUEOPTIONS 12/03/2013 01/01/2015 : " "" "1911 DEPENDENT MIRAMAR B0611 33027 OSO : BLUEOPTIONS : 08/01/2017 01/01/2015 ' " "" "1911 '.DEPENDENT '. MIRAMAR B0611 33027 OSO BLUEOPTIONS 08/01/2017 07/14/2015 : 1925 : DEPENDENT : KEYWEST B0611 : 33040 CCC : BLUEOPTIONS : 08/01/2017 07/14/2015 * *" *1925 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 11/03/2016 '1121 :DEPENDENT : KEYWEST B0611 : 33040 OSO :BLUEOPTIONS : 08/01/2017 11/02/2013 : *` *' *1925 :SUBSCRIBER : KEYWEST B0611 : 33040 OSO :BLUEOPTIONS : 04/26/2017 12/31/2016 : ' " "' "1933 : SUBSCRIBER TAVERNIER 80611 : 33070 BCC : BLUEOPTIONS : 12/31/2016 10/23/2015 " 1934 DEPENDENT HOMESTEAD 80611 33033 OSO BLUEOPTIONS 08/31/2017 01/01/2016 " * *" "1934 SPOUSE HOMESTEAD B0611 33033 OSO BLUEOPTIONS 09/15/2017 001 MONROE 11/01/2011 '. —i'll SUBSCRIBEF 001 MONROE 11/01/2011 *`* "1990 DEPENDENT 001 MONROE 11/01/2011 ' " "' "1990 DEPENDENT 001 MONROE 10/25/2016 ' * *" "1990 DEPENDENT 001 MONROE 12/06/2013 " * ** *1990 SUBSCRIBEF B0611 33041 OSE BLUEOPTIONS 04/27/2017 B0611 33041 OSE BLUEOPTIONS 03/08/2016 80611 33041 OSE BLUEOPTIONS 03/08/2016 80611 33050 OSO BLUEOPTIONS 08/01/2017 B0611 33050 OSO BLUEOPTIONS 01/02/2017 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 03/11/1984 033 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/07/2015 ''" "1994 SUBSCRIBER LITTLE TORCH KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 05/02/2014 003 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 04/01/2017 " "'2027 DEPENDENT BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 02/26/1981 036 MALE 06 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BROVN /ARD 02/05/2012 ''" "2029 SUBSCRIBER MIRAMAR 80611 33023 OSO BLUEOPTIONS 08/01/2017 10/31/2007 010 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " * ** *2038 DEPENDENT SUMMERLAND KEY 80611 33042 OSO BLUEOPTIONS 08/01/2017 09/02/2009 008 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " * ** "2038 DEPENDENT SUMMERLAND KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 04/20/1971 046 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * ** *2038 SUBSCRIBER SUMMERLAND KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 03/31/1955 062 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 04/01/2017 * * *" *2040 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 01/02/1957 060 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 '* "'2053 SUBSCRIBER BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 12/03/2013 08/07/1979 038 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 08/05/2016 "" "2060 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 08/22/2017 09/30/2015 002 '.FEMALE 44 4 FL ACTIVE 03559 '.FAMILY 001 MONROE 04/29/2016 * "' *2060 '.DEPENDENT '.KEYWEST B0611 33040 BCC BLUEOPTIONS 10/30/2017 09/24/1975 042 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 02/13/2015 '2060 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 10/24/2017 02/23/1969 048 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " — '2070 SUBSCRIBER KEYWEST B0611 33045 BCC BLUEOPTIONS 01/02/2017 06/26/1958 059 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "' *'2070 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/17/1947 069 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 01/01/2012 "' *'2077 SUBSCRIBER ISLAMORADA 80611 33036 BCC BLUEOPTIONS 04/20/2017 02/21/1965 052 'FEMALE 44 1 FL ACTIVE 03559 'EMPLOYEE ONLY 001 MONROE 11/01/2011 * *" *2090 'SUBSCRIBER 'KLYWLST B0611 33040 OSO 'BLUEOPTIONS 08/01/2017 03/12/2008 009 NIALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 06/02/2013 " "'2091 DEPENDENT HOMESTEAD B0611 33030 BCC BLUEOPTIONS 12/03/2013 06/04/2009 008 NIALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 06/02/2013 ' * "' "2091 DEPENDENT HOMESTEAD 80611 33030 BCC BLUEOPTIONS 12/03/2013 01/30/1952 065 F FEMALE 4 44 1 F FL ACTIVE 0 03559 EMPLOYEE ONLY ` 03/28/1949 068 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/15/2013 ""'2181 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 09/10/2016 08/01/2009 008 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 12/04/2015 " "* "2188 DEPENDENT ISLAMORADA B0611 33036 BCC BLUEOPTIONS 08/24/2016 12/31/9999 Qj 02/06/1963 054 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 01/01/2012 ' SPOUSE BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 08/01/2017 12/31/9999 D 05/13/1961 056 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 05/01/2017 " *'* "2191 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 05/02/2017 12/31/9999 05/01/1950 067 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 05/01/2017. 2111 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 05/02/2017 12131/9999 05/04/1987 030 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 04/19/2015 " ** *'2193 SUBSCRIBER MIAMI B0611 33187 BCC BLUEOPTIONS 08/01/2017 12131/9999 N fi 01/25/1990 027 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 12/27/2014 ' ** *'2201 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 01/18/2017 12131/9999 12/21/2016 000 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2017 ' * ** *2215 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 01/09/2017 12131/9999 01/11/1986 031 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 10/02/2015 * * *" *2215 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 01/09/2017 12/31/9999 7 05/11/1980 037 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2016 . "`2215 SPOUSE KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 'U 08/11/1950 067 MALE 70 2 TN RETIREE 03559 EMPLOYEE & SPOUSE R01 NON - FLORIDA 11/01/2011 " "2230 SUBSCRIBER LAWRENCEBURG 80611 38464 BCC BLUEOPTIONS 03/20/2017 12/31/9999 O ADDRESS 06/10/1958 059 FEMALE 70 2 TN RETIREE 03559 EMPLOYEE & SPOUSE R01 NON - FLORIDA 01/01/2014 ' *'" "2230 SPOUSE LAWRENCEBURG 80611 38464 BCC BLUEOPTIONS 08/01/2017 12/31/9999 tO ADDRESS O 03/18/1961 056 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/16/2017 ^ °' "2251 SUBSCRIBER KEYLARGO 80611 33037 OTC BLUEOPTIONS 09/16/2017 12/31/9999 L 10/15/1988 029 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/25/2014 ' * ** "2252 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 04/28/2017 12/31/9999 CL Q, 04/30/1966 051 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE D2/01/2016 " * *" *2287 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 04/17/1977 040 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/19/2017 " * *" "2321 SUBSCRIBER MARATHON 80611 33050 BCC BLUEOPTIONS 03/20/2017 12/31/9999 01/27/1941 076 FEMALE 56 1 FL RETIREE 03559 EMPLOYEE ONLY R01 SAINT LUCIE 11/01/2011 " " "" "2330 SUBSCRIBER PORT SAINT LUCIE B0611 34983 BCC BLUEOPTIONS 03/10/2015 12/31/9999 02/20/1967 050 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'" "2341 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 LIJ 07/12/1930 087 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 " *" "2347 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 12/03/2013 12131/9999 09/18/1975 042 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "" "2352 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 12131/9999 05/07/1944 073 MALE 52 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 PINELLAS 11/01/2011 '* "`2358 SUBSCRIBER DUNEDIN B0611 34698 BCC BLUEOPTIONS 03/16/2017 12/31/9999 12/18/1942 074 '.FEMALE 52 2 FL RETIREE 03559 '.EMPLOYEE &SPOUSE R01 PINELLAS 11/01/ 2011 ' * ** *2358 '.SPOUSE '.DUNEDIN B0611 34698 BCC BLUEOPTIONS 08/24/2016 12/31/9999 06/13/1949 068 FEMALE 53 1 FL RETIREE 03559 EMPLOYEE ONLY R01 POLK 08/01/2013 " ** *'2368 SUBSCRIBER LAKE WALES B0611 33898 BCC SLUEOPTIONS 11/30/2016 12131/9999 06/01/1988 029 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/16/2014 '2370 SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 08/24/2016 12/31/9999 LIJ 06/03/1965 052 MALE 52 1 FL RETIREE 03559 EMPLOYEE ONLY R01 PINELLAS 11/01/2011 "'" "2374 SUBSCRIBER CLEARWATER B0611 33756 OSO BLUEOPTIONS 08/01/2017 12/31/9999 U 09/08/1979 038 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 " "" "'2386 SPOUSE RAMROD KEY B0611 33042 BCC BLUEOPTIONS 04/18/2017 12/31/9999 11/16/1970 046 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' ° "* "2386 SUBSCRIBER RAMROD KEY 80611 33042 BCC BLUEOPTIONS 03/10/2017 12/31/9999 09/17/1993 024 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' * *" "2386 DEPENDENT RAMROD KEY 80611 33042 BCC BLUEOPTIONS 02/22/2017 12/31/9999 LLJ 07/07/2009 008 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 " * *" *2386 DEPENDENT RAMROD KEY 80611 33042 BCC BLUEOPTIONS 02/16/2017 12/31/9999 03/05/1996 021 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 " * *" "2386 DEPENDENT RAMROD KEY 80611 33042 BCC BLUEOPTIONS 03/15/2017 12/31/9999 V 10/06/1957 060 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " " "" "2386 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 h 07/20/2016 001 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2017 " * *" "2386 DEPENDENT RAMROD KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 12/31/9999 h 12/16/2013 003 .FEMALE 44 4 FL ACTIVE 03559 .FAMILY 001 MONROE 12/16/2013. "* "`2386 DEPENDENT RAMROD KEY B0611 33042 BCC BLUEOPTIONS 08/14/2017 12131/9999 . M 05/31/1966 051 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY `. 001 MONROE 11/01/2011 "" "`2391 SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 08/01/2017 12/31/9999 N 03/02/1991 026 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -0ADE 07/09/2017 " "`2393 SUBSCRIBER HOMESTEAD B0611 33034 OSO BLUEOPTIONS 08/01/2017 12/31/9999 . . = 08/04/1943 074 FEMALE 48 1 FL RETIREE 03559 EMPLOYEE ONLY R01 ORANGE 11/01/2011 ' * ** *2394 SUBSCRIBER APOPKA B0611 32712 OTC BLUEOPTIONS 03/16/2017 12/31/9999 ay 01/20/2015 002 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/20/2015 *' *'2399 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 S U 03/13/1987 030 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/05/2015 2399 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 12/31/9999 N 06/02/1943 074 MALE 70 1 TN RETIREE 03559 EMPLOYEE ONLY RO1 NON - FLORIDA 11/01/2011 " " "* "2413 SUBSCRIBER FRANKEWING B0611 38459 BCC BLUEOPTIONS 03/16/2017 12/31/9999 ADDRESS 10/14/1961 056 MALE O6 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BROYJARD 10/07/2017 " "" *'2426 SUBSCRIBER OAKLAND PARK B0611 33309 OSO BLUEOPTIONS 10/07/2017 12/31/9999 08/20/2017 000 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 08/20/2017 " "" "'2439 DEPENDENT HOMESTEAD B0611 33032 BCC BLUEOPTIONS 09/22/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 897 11/01/1988 028 NIALE 13 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 001 MIAMI -DADE 05/23/2014 ""'2439 SUBSCRIBER HOMESTEAD 80611 33032 BCC BLUEOPTIONS 09/22/2017 03/05/1992 025 MALE 06 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BROVN /ARD 11/26/2016 ' ** "2466 SUBSCRIBER PEMBROKE PINES B0611 33029 BCC BLUEOPTIONS 12/31/2016 12/31/9999 Qj 10/27/2008 009 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2012 ' DEPENDENT TAVERNIER B0611 33070 OSO BLUEOPTIONS 08/01/2017 12/31/9999 D 05/05/1967 050 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2012 "* *'2468 SUBSCRIBER TAVERNIER B0611 33070 OSO BLUEOPTIONS 08/01/2017 12/31/9999 04/05/1973 044 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2012. " "2468 SPOUSE TAVERNIER B0611 33070 OSO BLUEOPTIONS 08/01/2017 12131/9999 07/05/2016 001 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/05/2016 " "2481 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 N fi 07/27/2012 005 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/23/2012 ' * ** *2481 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 10/30/2017 12131/9999 11/11/1993 023 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/23/2012 "' *'2481 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/22/2017 12131/9999 06/07/1983 034 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/18/2014 * * ** *2487 SUBSCRIBER BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 03/09/2017 12/31/9999 7 08/17/2009 008 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/18/2014 . "'2487 DEPENDENT BIG PINE KEY 80611 33043 BCC BLUEOPTIONS 03/09/2017 12/31/9999 'U 09/21/2011 006 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/18/2014 ""'2487 DEPENDENT BIG PINE KEY 80611 33043 BCC BLUEOPTIONS 03/09/2017 12/31/9999 O 03/26/1979 038 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/24/2016 * * ** *2487 SUBSCRIBER BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 04/28/2017 12/31/9999 fl 09/30/1968 049 FEMALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 11/01/2011 * * ** *2489 SUBSCRIBER MIAMI SHORES B0611 33150 OSO BLUEOPTIONS 12/03/2013 12/31/9999 O 1 10/21/1966 051 MALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 11/01/2011 * * ** *2489 SPOUSE MIAMI SHORES B0611 33150 OSO BLUEOPTIONS 12/03/2013 12/31/9999 CL CL 02/04/1966 051 FEMALE 06 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BROWARD 11/01/2011 * * *" *2494 SUBSCRIBER PLANTATION B0611 33324 OSO BLUEOPTIONS 08/01/2017 12/31/9999 v 08/01/1986 031 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/24/2013 ' ** "2496 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 05/21/2015 12/31/9999 09/22/1978 039 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/12/2016 * "* *2509 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 08/01/2017 12/31/9999 Q 10/29/1996 021 '.FEMALE 44 3 FL ACTIVE 03559 '.EMPLOYEE &CHILDREN 001 MONROE 11/01/2011 ' *' *'2512 '.DEPENDENT '.SUGARLOAF KEY B0611 33042 OSO BLUEOPTIONS 05/31/2016 12/31/9999 07/15/1959 058 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 "2512 SUBSCRIBER SUGARLOAF KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 12/31/9999 LLI 10/02/1955 062 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/23/2017 " — '2523 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 04/26/2017 12/31/9999 03/19/1984 033 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 03/27/2015 ' ** *'2523 SUBSCRIBER HOMESTEAD B0611 33033 OSO BLUEOPTIONS 10/05/2017 12131/9999 03/27/1927 090 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 "' *'2527 SUBSCRIBER KEYWEST 80611 33041 BCC BLUEOPTIONS 12/03/2013 12/31/9999 12/20/1959 057 'FEMALE 59 1 FL RETIREE 03559 'EMPLOYEE ONLY R01 SEMINOLE 11/01/2011 * * ** *2543 'SUBSCRIBER '.OVIEDO B0611 32765 OPA BLUEOPTIONS 12/03/2013 12/31/9999 02/11/1990 027 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/10/2013 .. "'2543 SUBSCRIBER KEYWEST 80611 33040 OPA BLUEOPTIONS 02/03/2017 12/31/9999 07/28/1977 040 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/27/2015 " " "' "2546 SUBSCRIBER MARATHON 80611 33050 OSO BLUEOPTIONS 04/27/2017 12/31/9999 LIJ U 01/04/1994 023 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/03/2017 * * ** *2548 SUBSCRIBER CUDJOE KEY 80611 33042 CCC BLUEOPTIONS 08/01/2017 12/31/9999 09/13/1984 033 NIALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 08/22/2014 * * ** *2555 SUBSCRIBER HIALEAH B0611 33010 BCC BLUEOPTIONS 08/24/2016 12/31/9999 06/07/1951 066 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** *2557 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 08/01/2017 12/31/9999 05/03/1930 087 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * * *" *2561 SUBSCRIBER KEYWEST B0611 33040 OPA BLUEOPTIONS 03/10/2015 12/31/9999 03/17/1992 025 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 09/04/2015 ' ** "2564 SUBSCRIBER MIAMI B0611 33165 BCC BLUEOPTIONS 08/24/2016 12/31/9999 10/24/1999 018 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' DEPENDENT MARATHON B0611 33050 DSO BLUEOPTIONS 12/03/2013 12/31/9999 ' *' *'2575 ~ 09/15/1960 057 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 SPOUSE MARATHON B0611 33050 OSO BLUEOPTIONS 12/03/2013 12/31/9999 h 05/16/1961 056 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 '* "'2575 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 12131/9999 01/27/1963 054 FEMALE 28 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 HIGHLANDS 01/01/2014 " — '2583 SPOUSE SEBRING B0611 33870 OSO BLUEOPTIONS 08/01/2017 12131/9999 C4 11/18/1961 055 MALE 28 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 HIGHLANDS 02/01/2012 ' ** *'2583 SUBSCRIBER SEBRING B0611 33870 OSO BLUEOPTIONS 08/19/2017 12131/9999 m= _ 07/29/1938 079 MALE 09 1 FL RETIREE 03559 EMPLOYEE ONLY R01 CITRUS 11/01/2011 „ », 2594 SUBSCRIBER BEVERLY HILLS B0611 34464 BCC BLUEOPTIONS 01/02/2017 12/31/9999 iy 03/11/1995 022 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/27/2011 * * *' *2610 DEPENDENT TAVERNIER 80611 33070 BCC BLUEOPTIONS 03/08/2016 12/31/9999 08/07/1984 033 NIALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 03/04/2012 .. "'2610 SUBSCRIBER PALMETTO BAY 80611 33157 BCC BLUEOPTIONS 08/01/2017 12/31/9999 S U 04/02/1974 043 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/27/2011 * " "' "2610 SPOUSE TAVERNIER 80611 33070 BCC BLUEOPTIONS 03/08/2016 12/31/9999 a+ *' 03/25/1978 039 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/27/2011 " * ** *2610 SUBSCRIBER TAVERNIER 80611 33070 BCC BLUEOPTIONS 03/08/2016 12/31/9999 11/07/1958 058 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * ** *2611 SUBSCRIBER BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 08/01/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 898 03/09/2007 010 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 07/12/1970 047 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/25/1970 047 FEMALE 44 4 FL ACTIVE 03559 FAMILY 08/04/1961 056 MALE 44 4 FL ACTIVE 03559 FAMILY 12/19/2000 016 NIALE 44 4 FL ACTIVE 03559 FAMILY 10/24/1942 075 MALE 12 1 FL RETIREE 03559 EMPLOYEE ONLY 02/10/1988 029 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 07/17/1964 053 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 01/20/1931 086 MALE 51 1 FL RETIREE 03559 EMPLOYEE ONLY 01/27/1992 025 MALE 44 2 '.. FL '.. ACTIVE '.. 03559 ' &SPOUSE 10/12/1986 031 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 01/04/1954 063 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 08/29/1993 024 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 11/09/1966 050 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 06/28/1954 063 (FEMALE 70 1 MI '.. RETIREE 03559 (EMPLOYEE ONLY 08/17/1948 069 FEMALE 11 1 FL RETIREE 03559 EMPLOYEE ONLY 05/14/1946 071 NIALE 70 1 TN RETIREE 03559 EMPLOYEE ONLY 12/06/1947 069 NIALE 53 2 FL RETIREE 03559 EMPLOYEE & SPOUSE 10/05/1960 057 FEMALE 53 2 FL RETIREE 03559 EMPLOYEE & SPOUSE 12/26/1997 019 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 12/04/1958 058 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 01/22/1951 066 MALE 55 1 FL RETIREE 03559 EMPLOYEE ONLY 02/02/1944 073 MALE 13 1 FL RETIREE 03559 EMPLOYEE ONLY 07/21/1956 061 FEMALE 44 2 FL COBRA 03559 EMPLOYEE & SPOUSE 08/23/1958 059 MALE 44 2 FL COBRA 03559 EMPLOYEE & SPOUSE COLUMBIA This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 OSO 1:19 PM Page 1 of 1 001 MONROE 11/01/2011 ""'2611 DEPENDENT BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 08/01/2017 001 MONROE 11/01/2011 " "'2681 SUBSCRIBER KEYWEST 80611 33041 OCA BLUEOPTIONS 12/03/2013 001 MONROE 05/02/2017 ""'2686 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 001 MONROE 05/02/2017 * * ** *2686 SPOUSE KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 001 MONROE 05/02/2017 * * ** *2686 DEPENDENT KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 R01 COLUMBIA 11/01/2011 * * ** "2690 SUBSCRIBER LAKE CITY B0611 32024 OSO BLUEOPTIONS 08/01/2017 001 MONROE 11/01/2011 * * *" *2691 SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 08/01/2017 001 MIAMI -DADE 11/01/2011 ' ** "2706 SUBSCRIBER MIAMI B0611 33183 OSO BLUEOPTIONS 08/01/2017 R01 PASCO 11/01/2011 "" "2710 SUBSCRIBER WESLEY CHAPEL B0611 33543 OSO BLUEOPTIONS 12/28/2016 001 MONROE 01/01/2017 "" *2716 '.SPOUSE IKEYWEST B0611 '.. 33040 CCC IBLUEOPTIONS '.. 08/01/2017 001 MONROE 08/30/2013 '2716 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 R01 MONROE 08/01/2017 " — '2722 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 001 MONROE 12/21/2015 "' *'2726 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 001 MONROE 11/01/2011 "' *'2728 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 04/26/2017 R01 NON - FLORIDA 11/01/2011 * *" *2755 'SUBSCRIBER 'CLAY B0611 48001 OSO 'BLUEOPTIONS 05/05/2017 ADDRESS R01 COLLIER 11/01/2011 — 2760 SUBSCRIBER NAPLES B0611 34104 CCC BLUEOPTIONS 04/26/2017 R01 NON - FLORIDA 11/01/2011 — 2760 SUBSCRIBER DYER 80611 38330 OSO BLUEOPTIONS 08/01/2017 ADDRESS R01 POLK 11/01/2011 *" "'2766 SUBSCRIBER FORT MEADE B0611 33841 OSO BLUEOPTIONS 08/01/2017 R01 POLK 07/01/2016 ' ° "* "2766 SPOUSE FORT MEADE 80611 33841 OSO BLUEOPTIONS 08/01/2017 001 MONROE 05/08/2015 ' * *" "2768 DEPENDENT MARATHON 80611 33050 BCC BLUEOPTIONS 02/14/2017 R01 SAINT JOHNS 11/01/2011 2121 SUBSCRIBER SAINT AUGUSTINE B0611 32084 OSO SLUEOPTIONS 04/28/2017 12131/9999 R01 MIAMI -DADE 11/01/2011 ` *'" "2824 SUBSCRIBER FLORIDA CITY B0611 33034 BCC BLUEOPTIONS 08/01/2017 12/31/9999 C01 MONROE 07/14/2017 ` "" "2827 SPOUSE SUMMERLAND KEY B0611 33042 BCC BLUEOPTIONS 08/08/2017 12/31/9999 C01 MONROE 07/14/2017 2827 SUBSCRIBER SUMMERLAND KEY 80611 33042 BCC BLUEOPTIONS 08/08/2017 12/31/9999 12/27/1962 054 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ""'2836 SUBSCRIBER TAVERNIER 80611 33070 OSO BLUEOPTIONS 08/01/2017 10/09/1952 065 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 09/23/2014 2846 SPOUSE RAMROD KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 12/31/9999 Qj 04/11/2002 015 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2017 ' DEPENDENT MARATHON B0611 33050 BCC BLUEOPTIONS 01/02/2017 12/31/9999 D 03/14/1970 047 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 09/14/2012 "* *'2852 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 09/19/1954 063 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 " "2855 SUBSCRIBER HOMESTEAD B0611 33030 BCC BLUEOPTIONS 11/12/2015 12131/9999 09/30/1933 084 MALE 60 1 FL RETIREE 03559 EMPLOYEE ONLY R01 SUMTER 11/01/2011 " "2855 SUBSCRIBER THE VILLAGES B0611 32162 OPA BLUEOPTIONS 03/02/2017 12131/9999 N fi 11/08/1967 049 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/01/2017 ' * ** *2862 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 01/02/2017 12131/9999 02/07/1971 046 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "' *'2864 SUBSCRIBER KEYLARGO 80611 33037 CCC BLUEOPTIONS 12/03/2013 12131/9999 10/14/1942 075 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * * ** *2869 SUBSCRIBER KEYWEST B0611 33040 OPA BLUEOPTIONS 03/16/2017 12/31/9999 7 12/05/1948 068 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 02/01/2013 " "'2871 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 11/30/2016 12/31/9999 'U 01/17/1978 039 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/04/2016 ""'2872 SUBSCRIBER KEYWEST 80611 33040 OCA BLUEOPTIONS 04/26/2017 12/31/9999 O 09/27/1959 058 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/01/2017 * * ** *2892 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 fl 05/29/1955 062 FEMALE 38 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 LEVY 11/01/2011 * * ** *2894 SPOUSE WILLISTON B0611 32696 OSO BLUEOPTIONS 11/30/2016 12/31/9999 O 1 01/07/1948 069 MALE 38 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 LEVY 11/01/2011 * * ** *2894 SUBSCRIBER WILLISTON B0611 32696 OSO BLUEOPTIONS 08/01/2017 12/31/9999 CL CL 07/17/2017 000 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 07/17/2017 * * *" *2906 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 08/07/2017 12/31/9999 v 05/27/1986 031 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 04/19/2017 ' ** "2906 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 04/20/2017 12/31/9999 08/20/1989 028 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 04/19/2017 * "' *2906 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 08/21/2017 12/31/9999 Q 07/04/2015 002 '.FEMALE 44 4 FL ACTIVE 03559 '.FAMILY 002 MONROE 04/19/2017 ' ** *'2906 '.DEPENDENT '. KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 08/23/1987 030 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 08/31/2016 "2909 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 LLI 06/23/2007 010 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 08/31/2016 " "2909 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 09/10/2016 12/31/9999 08/27/1981 036 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 08/31/2016 ' * ** *2909 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 09/10/2016 12131/9999 10/15/1989 028 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 04/01/2017 "' *'2913 SPOUSE MARATHON 80611 33050 OSO BLUEOPTIONS 04/03/2017 12/31/9999 03/04/1989 028 'MALE 44 4 FIL ACTIVE 03559 'FAMILY 001 MONROE 04101/2017 * * ** *2913 'SUBSCRIBER 'MARATHON B0611 33050 OSO BLUEOPTIONS 04/28/2017 12/31/9999 10/24/2013 004 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 04/01/2017 .. "'2913 DEPENDENT MARATHON 80611 33050 OSO BLUEOPTIONS 04/03/2017 12/31/9999 01/25/1973 044 NIALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 04/23/2016 " " "* "2914 SUBSCRIBER HOMESTEAD 80611 33031 BCC BLUEOPTIONS 08/01/2017 12/31/9999 LU U 10/19/1950 067 NIALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * * ** *2929 SUBSCRIBER CUDJOE KEY 80611 33042 BCC BLUEOPTIONS 01/02/2017 12/31/9999 08/13/1949 068 NIALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 07/01/2015 * * ** *2934 SUBSCRIBER KEYWEST B0611 33041 OSO BLUEOPTIONS 08/01/2017 12/31/9999 03/07/1968 049 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/01/2016 * * ** *2939 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 02/21/1989 028 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/10/2017 * * *" *2956 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 ME 01/31/1977 040 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/22/2015 ' ** "2957 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 02/06/1956 061 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ' SUBSCRIBER KEYWEST B0611 33045 BCC BLUEOPTIONS 12/28/2016 12/31/9999 ' ** *'2963 ~ 08/09/1947 070 MALE 70 2 TN RETIREE 03559 EMPLOYEE & SPOUSE R01 NON - FLORIDA 11/01/2014 SUBSCRIBER NEW MARKET B0611 37820 BCC BLUEOPTIONS 05/21/2015 12/31/9999 01/17/1990 027 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 ADDRESS MIAMI -DADE 02/12/2016 ' *" *2963 SUBSCRIBER HOMESTEAD B0611 33032 BCC BLUEOPTIONS 03/02/2017 12131/9999 vi 09/21/1955 062 FEMALE 70 2 TN RETIREE 03559 EMPLOYEE & SPOUSE R01 NON - FLORIDA 05/20/2015 ' * ** *2963 SPOUSE NEW MARKET B0611 37820 BCC BLUEOPTIONS 08/01/2017 12131/9999 ' N ADDRESS . . 09/17/1964 053 FEMALE 07 2 FL RETIREE 03559 EMPLOYEE R01 CALHOUN 11/01/2011 "'* "2978 SPOUSE ALTHA B0611 32421 OSO BLUEOPTIONS 12/03/2013 12/31/9999 = 07/27/1944 073 MALE 07 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 CALHOUN 11/01/2011 " ** *2978 SUBSCRIBER ALTHA B0611 32421 OSO BLUEOPTIONS 08/01/2017 12/31/9999 ay 06/01/1965 052 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 ' *' *'2980 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 S U 03/16/1962 055 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 03/08/2013 2111 SPOUSE KEYWEST B0611 33040 BCC SLUEOPTIONS 08/01/2017 12/31/9999 N 02/15/1984 033 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/13/2013 `' *' *2982 SUBSCRIBER KEYWEST B0611 33040 0SO BLUEOPTIONS 05/27/2015 12/31/9999 06/18/1958 059 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 09/12/2014 `' *" *2995 SUBSCRIBER SUMMERLAND KEY B0611 33042 OSO BLUEOPTIONS 09/10/2016 12/31/9999 11/22/2003 013 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 09/12/2014 '2111 DEPENDENT SUMMERLAND KEY 80611 33042 OSO BLUEOPTIONS 09/10/2016 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 900 02/09/2014 003 NIALE 44 4 FL ACTIVE 03559 FAMILY 08/18/1961 056 : FEMALE 44 4 : FL : ACTIVE : 03559 : FAMILY 10/24/1988 029 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 11/06/1958 058 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 07/16/1964 053 FEMALE 31 2 FL RETIREE 03559 EMPLOYEE & SPOUSE 10/29/1961 056 FEMALE 31 2 FL RETIREE 03559 EMPLOYEE & SPOUSE 02/03/1947 070 MALE 05 1 FL RETIREE 03559 EMPLOYEE ONLY 10/09/2017 000 : FEMALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE &CHILDREN 03/11/1987 030 : FEMALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE &CHILDREN 03/11/1987 030 '.FEMALE 44 1 '.. FL '.. ACTIVE '.. 03559 EMPLOYEE ONLY 08/22/1994 023 : MALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE & CHILDREN 09/03/1963 054 : FEMALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE & CHILDREN 07/01/1940 077 : MALE 50 1 : FL : RETIREE : 03559 : EMPLOYEE ONLY 10/01/1948 069 : MALE 70 1 : VA : RETIREE : 03559 : EMPLOYEE ONLY 03/19/1954 063 : FEMALE 44 1 : FL : ACTIVE : 03559 : EMPLOYEE ONLY 07/27/1969 048 : FEMALE 44 1 : FL : ACTIVE : 03559 : EMPLOYEE ONLY 08/18/1981 036 : FEMALE 13 1 : FL : ACTIVE : 03559 : EMPLOYEE ONLY 01/11/1956 061 : FEMALE 13 1 : FL : ACTIVE : 03559 : EMPLOYEE ONLY 03/08/1961 056 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 02/15/1945 072 MALE 53 1 : FL : RETIREE : 03559 : EMPLOYEE ONLY 03/13/1948 069 NIALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 05/09/1935 082 NIALE 48 1 FL RETIREE 03559 EMPLOYEE ONLY 09/21/1934 083 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 02/03/2011 006 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 001 MONROE 09/12/2014 " " "" "2995 DEPENDENT SUMMERLAND KEY 80611 33042 OSO BLUEOPTIONS 09/10/2016 001 MONROE 08/12/2017 : " "'3015 : SPOUSE : ISLAMORADA B0611 : 33036 BCC : BLUEOPTIONS : 08/12/2017 001 MONROE 11/01/2011 ""'3017 DEPENDENT KEYWEST 80611 33040 BCC BLUEOPTIONS 12/03/2013 001 MONROE 11/01/2011 * " ** *3017 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 12/03/2013 R01 INDIAN RIVER 11/01/2011 " 3018 SUBSCRIBER SEBASTIAN B0611 32958 OSO BLUEOPTIONS 08/01/2017 R01 INDIAN RIVER 01/01/2012 * * ** *3018 SPOUSE SEBASTIAN B0611 32958 0SO BLUEOPTIONS 08/01/2017 R01 BREVARD 11/01/2011 * * *" *3025 SUBSCRIBER PALM BAY B0611 32907 OSO BLUEOPTIONS 08/01/2017 002 MONROE 10/09/2017 : '* "'3026 : DEPENDENT : SUMMERLAND KEY B0611 : 33042 CCC : BLUEOPTIONS : 10/24/2017 002 MONROE 10/09/2017 "" "3026 SUBSCRIBER SUMMERLAND KEY B0611 33042 CCC BLUEOPTIONS 10/24/2017 001 MONROE 10/09/2017 * ... *3026 '.SUBSCRIBER ISUMMERLAND KEY B0611 '.. 33042 CCC IBLUEOPTIONS '.. 10/24/2017 001 MONROE 11/01/2011 "3030 DEPENDENT TAVERNIER B0611 33070 OSO BLUEOPTIONS 09/30/2016 001 MONROE 11/01/2011 : "" *'3030 : SUBSCRIBER TAVERNIER B0611 : 33070 OSO : BLUEOPTIONS : 08/01/2017 R01 PALM BEACH 11/01/2011 "' *'3032 SUBSCRIBER BOYNTON BEACH B0611 33436 BCC BLUEOPTIONS 08/01/2017 R01 NON - FLORIDA 11/01/2011 : "' *`3047 : SUBSCRIBER : PALMYRA 80611 : 22963 080 : BLUEOPTIONS : 11/30/2016 ADDRESS 001 MONROE 11/01/2011 * *" *3060 :SUBSCRIBER :MARATHON B0611 : 33050 CCC :BLUEOPTIONS : 04/27/2017 001 MONROE 04/01/2017 *` "' *3069 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 04/26/2017 001 MIAMI -DADE 12/10/2016 : ' " "' "3070 : SUBSCRIBER :CUTLER BAY 80611 : 33190 OSO : BLUEOPTIONS : 08/01/2017 001 MIAMI -DADE 11/01/2011 " 3073 SUBSCRIBER HIALEAH 80611 33012 OSO BLUEOPTIONS 08/01/2017 001 MONROE 11/01/2011 " " *" "3074 SUBSCRIBER BIG PINE KEY 80611 33043 BCC BLUEOPTIONS 07/09/2016 R01 POLK 11/01/2011 " "3136 : SUBSCRIBER : FROSTPROOF B0611 : 33843 BCC : BLUEOPTIONS : 01/05/2017 R01 MONROE 11/01/2011 — 3148 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 12/03/2013 R01 ORANGE 11/01/2011 ' " "' "3158 SUBSCRIBER ORLANDO 80611 32837 OSO BLUEOPTIONS 12/03/2013 R01 MONROE 11/01/2011 ' " *" "3166 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 001 MONROE 10/05/2012 * " "* *3173 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 10/02/2014 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 02/09/1990 027 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 001 MONROE 10/05/2012 ""'3173 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 10/02/2014 09/18/1959 058 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 '* "'3211 SUBSCRIBER KEYLARGO B0611 33037 ORA BLUEOPTIONS 12/03/2013 07/07/1996 021 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ` "" "3212 DEPENDENT KEYWEST B0611 33040 OSO SLUEOPTIONS 02/22/2017 04/02/1962 055 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ` * ** "3212 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/22/2017 09/10/1971 046 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/28/2014 ` * ** "3220 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/24/2016 04/05/1969 048 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 " * *" "3223 SUBSCRIBER MIAMI 80611 33175 OSO BLUEOPTIONS 08/01/2017 11/23/1986 030 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE D8/07/2015 * * *" "3225 SUBSCRIBER MIAMI 80611 33194 BCC BLUEOPTIONS 08/01/2017 01/26/1956 061 FEMALE 44 2 FL COBRA 03559 EMPLOYEE & SPOUSE C01 MONROE D7/07/2017 ` " "" "3232 SPOUSE CUDJOE KEY 80611 33042 BCC BLUEOPTIONS 10/05/2017 08/23/1955 062 MALE 44 2 FL COBRA 03559 EMPLOYEE & SPOUSE C01 MONROE 07107/2017 " "" "3232 SUBSCRIBER CUDJOE KEY 80611 33042 BCC BLUEOPTIONS 10/05/2017 10/03/1984 033 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 "" "3240 SUBSCRIBER KEYWEST B0611 33040 OTC BLUEOPTIONS 09/30/2017 05/16/2013 004 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2015 " "`3240 DEPENDENT KEYWEST B0611 33040 OTC BLUEOPTIONS 09/30/2017 12/09/1980 036 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/01/2015 " "`3244 SUBSCRIBER KEYWEST B0611 33040 OCA BLUEOPTIONS 08/24/2016 05/19/1972 045 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/25/2015 " "`3253 SUBSCRIBER KEYWEST B0611 33041 BCC BLUEOPTIONS 08/24/2016 04/23/2015 002 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 04/23/2015 " "'3255 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 0810112017 03/20/1977 040 'MALE 44 3 FL ACTIVE 03559 'EMPLOYEE &CHILDREN 001 MONROE 11/ 01/ 2011 " "'3255 'SUBSCRIBER 'KEYWEST B0611 33040 BCC 'BLUEOPTIONS 01/14/2016 10/20/1975 042 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 3261 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/10/2017 02/07/1948 069 FEMALE 70 1 MA RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 04/01/2014 `` "* "3285 SUBSCRIBER CHICOPEE B0611 01022 OSO BLUEOPTIONS 11/30/2016 ADDRESS 12/07/1970 046 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 "'" "3293 SUBSCRIBER HOMESTEAD B0611 33033 OSO BLUEOPTIONS 08/01/2017 10/01/1971 046 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/29/2016 ` — "3295 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 02/23/1945 072 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/21/2015 * * "" "3300 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 08/24/2016 10/13/1994 023 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE D2/04/2017 * * "* *3304 SUBSCRIBER HIALEAH B0611 33018 BCC BLUEOPTIONS 02/04/2017 11/28/1987 029 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE D4129/2017 * * *" "3315 SUBSCRIBER MIAMI 80611 33165 BCC BLUEOPTIONS 04/30/2017 12/27/2006 010 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 10101/2015 ` * *" "3316 DEPENDENT MARATHON 80611 33050 BCC BLUEOPTIONS 05/17/2017 10/27/2009 008 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 10101/2015 "" "3316 DEPENDENT MARATHON 80611 33050 BCC BLUEOPTIONS 05/17/2017 01/08/1973 044 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " "`3316 SUBSCRIBER MARATHON 80611 33050 BCC BLUEOPTIONS 08/01/2017 03/07/1944 073 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 " "`3321 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 03/10/2015 01/02/1955 062 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * "*" "3324 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 09/30/1965 052 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2015 " " "" "3335 SPOUSE MARATHON B0611 33050 OSO BLUEOPTIONS 08/10/2017 11/21/2006 010 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 10/01/2015 " "'3335 DEPENDENT MARATHON B0611 33050 OSO BLUEOPTIONS 10/09/2015 05/23/1993 024 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2015 ' "'" "3335 DEPENDENT MARATHON B0611 33050 OSO BLUEOPTIONS 0212212017 02/19/1970 047 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2015 ' "'" "3335 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 08/10/2017 07/31/2017 000 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE& CHILDREN 001 MONROE 07/31/2017 " "" "3338 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/22/2017 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 F 10/05/1982 035 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 001 MONROE 11/01/2011 ""'3338 SUBSCRIBER 02/24/1949 068 FEMALE O5 1 FL RETIREE 03559 EMPLOYEE ONLY R01 BREVARD 11/01/2011 " "'3378 SUBSCRIBER 05/28/1949 068 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ' " "' "3384 SUBSCRIBER 10/17/1954 063 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 " 3387 SPOUSE 09/08/1955 062 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 " " "" "3387 SUBSCRIBER 05/22/2013 004 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 05/22/2013 ' " "* *3406 DEPENDENT 12/16/2009 007 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' "" "'3406 DEPENDENT 12/25/2005 011 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * "* "'3406 DEPENDENT 09/16/1974 043 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 "' "'3406 SUBSCRIBER 01/16/1997 020 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 06/01/2014 — 3406 DEPENDENT 03/31/1999 018 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 06/01/2014 " "`3406 DEPENDENT 01/06/1988 029 '.MALE 06 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BROWARD 11/01/2011 "' ""3416 '.SUBSCRIBER 12/28/2006 010 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/23/2015 "" "3420 DEPENDENT 02/08/2010 007 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/23/2015 "" *3420 DEPENDENT 10/15/1990 027 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/23/2015 ' - 3420 SUBSCRIBER 08/24/1951 066 NIALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 `" "3422 SPOUSE 09/05/1958 059 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 " ' SUBSCRIBER 05/21/1939 078 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 " .. 3424 SUBSCRIBER 11/08/1957 059 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ` "'3426 SUBSCRIBER 05/11/1946 071 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 " SUBSCRIBER 057 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY `.. 001 MONROE 01/01/2016 ""'3488 SUBSCRIBEF 047 MALE 44 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 001 MONROE 11/01/2011 ` "" "3491 SUBSCRIBEF 018 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 001 MONROE 11/01/2011 ` "'3491 DEPENDENT This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 BLUEOPTIONS 03/16/2017 12131/9999 w U B0611 33040 OSO BLUEOPTIONS 08/01/2017 WEST B0611 33040 OSO BLUEOPTIONS 11/30/2016 12/31/9999 v WEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 D MERLAND KEY B0611 33042 OTC BLUEOPTIONS 02/17/2017 12/31/9999 MERLAND KEY B0611 33042 OTC BLUEOPTIONS 03/16/2017 12131/9999 w U ATHON B0611 33050 BCC BLUEOPTIONS 06/05/2017 12131/9999 N fi 11 B0611 33177 BCC BLUEOPTIONS 11/21/2016 12131/9999 � LARGO 80611 33037 BCC BLUEOPTIONS 08/01/2017 12131/9999 'INE KEY B0611 33043 OTC BLUEOPTIONS 06/05/2017 12/31/9999 7 HARBOUR BCH B0611 32937 BCC BLUEOPTIONS 11/30/2016 12/31/9999 'U JOE KEY 80611 33042 BCC BLUEOPTIONS 11/30/2016 12/31/9999 SINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 tO 7 SINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 0 WEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 C ' CL WEST B0611 33040 OSO BLUEOPTIONS 01/02/2017 12/31/9999 WEST B0611 33040 OSO BLUEOPTIONS 01/02/2017 12/31/9999 WEST B0611 33040 OSO BLUEOPTIONS '.. 08/01/2017 12/31/9999 WEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 UJI WEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 F ,MAR B0611 33023 OSO BLUEOPTIONS 08/01/2017 12131/9999 WEST B0611 33040 CCC BLUEOPTIONS 08/24/2016 12131/9999 WEST B0611 33040 CCC BLUEOPTIONS 08/24/2016 12/31/9999 �. Ua WEST B0611 33040 CCC BLUEOPTIONS 08/24/2016 12/31/9999 COLONY BEACH B0611 33051 BCC BLUEOPTIONS 02/06/2016 12/31/9999 LU COLONY BEACH B0611 33051 BCC BLUEOPTIONS 02/06/2016 12/31/9999 U WEST B0611 33040 BCC BLUEOPTIONS 11/30/2016 12/31/9999 ATHON B0611 33050 BCC BLUEOPTIONS 10/14/2015 12/31/9999 :RNIER B0611 33070 BCC BLUEOPTIONS 11/22/2014 12/31/9999 LLj WEST 80611 33040 CCC BLUEOPTIONS 12/03/2013 12/31/9999 LARGO 80611 33037 OSO BLUEOPTIONS 07/18/2017 12/31/9999 () 11 B0611 33155 BCC BLUEOPTIONS 08/24/2016 12/31/9999 h ~ LARGO 80611 33037 OSO BLUEOPTIONS 07/18/2017 12/31/9999 Q LARGO B0611 33037 OSO BLUEOPTIONS 07/18/2017 12/31/9999 ESTEAD B0611 33032 BCC BLUEOPTIONS 08/24/2016 12/31/9999 N MERLAND KEY B0611 33042 OLA BLUEOPTIONS 10/05/2017 12/31/9999 C Q) 4 COAST B0611 32164 BCC BLUEOPTIONS 04/26/2017 12/31/9999 VILLAGES B0611 32162 OTC BLUEOPTIONS 03/03/2017 12/31/9999 U ESTEAD B0611 33031 OSO BLUEOPTIONS 08/01/2017 12131/9999 N Q WEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 WEST B0611 33040 BCC BLUEOPTIONS 07/17/2017 12/31/9999 WEST B0611 33040 BCC BLUEOPTIONS 07/17/2017 12/31/9999 05/06/1990 027 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 001 MONROE 11/01/2011 " """ "3491 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 07/17/2017 10/15/1968 049 FEMALE 44 2 FL ACIIVL 03559 EMPLOYEE & SPOUSE 001 MONROL 11/01/2011 ""'3528 SPOUSE KLYLARGO B0611 33037 050 BLULOP I IONS 12103/2013 12/02/1932 084 MALE 26 1 FL RETIREE 03559 EMPLOYEE ONLY R01 HERNANDO 11/01/2011 " "'3534 SUBSCRIBER BROOKSVILLE 80611 34601 BCC BLUEOPTIONS 07/18/2017 08/31/1967 050 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 10/07/2014 " """ "3537 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 04/27/2017 03/24/1967 050 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 10/07/2014 — 3537 SPOUSE KEYWEST 80611 33040 BCC BLUEOPTIONS 08/24/2016 12/24/1969 047 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/03/2014 " 3539 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 03/12/1953 064 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " " "* "3543 SUBSCRIBER CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 11/22/1994 022 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/24/2016 " "" "'3546 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 10/23/1972 045 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/05/2016 " "" "3559 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 10/25/1979 038 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 07/16/2017 "" "3561 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/30/1998 018 '.FEMALE 44 4 FL ACTIVE 03559 '.FAMILY 001 MONROE 07/16/2017 ' "" "'3561 '.DEPENDENT '.KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 11/30/1977 039 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 07/16/2017 - - 3561 SPOUSE KEYWEST B0611 33040 OSO BLUEOPTIONS 07/17/2017 07/15/1980 037 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/08/2014 ` "" "'3566 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/24/2016 08/02/1973 044 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 - - 3569 SUBSCRIBER ISLAMORADA B0611 33036 080 BLUEOPTIONS 08/01/2017 07/19/1946 071 FEMALE 56 1 FL RETIREE 03559 EMPLOYEE ONLY R01 SAINT LUCIE 11/01/2011 - - 3576 SUBSCRIBER PORT SAINT LUCIE 80611 34986 BCC BLUEOPTIONS 03/16/2017 10/10/1987 030 'MALE 44 1 FL ACTIVE 03559 'EMPLOYEE ONLY 001 MONROE 02101/2013 - - 3576 'SUBSCRIBER 'KEYWEST B0611 33040 OSO 'BLUEOPTIONS 01/14/2016 07/21/2014 003 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 09/04/2016 " "'3590 DEPENDENT KEYLARGO 80611 33037 BCC BLUEOPTIONS 11/21/2016 03/30/1978 039 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 09/04/2016 " " "" "3590 SUBSCRIBER KEYLARGO 80611 33037 BCC BLUEOPTIONS 11/21/2016 11/25/1991 025 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/02/2013 " " "" "3591 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 03/27/2017 000 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 03/27/2017 " " "" "3591 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 03/27/2017 000 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 03/27/2017 " " "* "3591 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 01/30/1990 027 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2017 " "" "'3591 SPOUSE KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 02/09/2017 000 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 02/09/2017 - - 3600 DEPENDENT TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/10/2017 07/13/1964 053 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 04/28/2015 "" "'3600 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 03/30/2017 05/29/1972 045 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 04/28/2015 " "" "'3600 SPOUSE TAVERNIER B0611 33070 BCC BLUEOPTIONS 10/20/2017 09/03/1994 023 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 04/28/2015 - - 3600 DEPENDENT TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/28/2017 10/11/2002 015 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 04/28/2015 ""3600 DEPENDENT TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/21/2017 05/23/2005 012 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 04/28/2015 ' " "" "3600 DEPENDENT TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/10/2017 02/22/2013 004 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 02/22/2013 ' " "" "3602 DEPENDENT BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 03/26/1968 049 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 "" "3602 SUBSCRIBER BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 06/15/1995 022 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 " "'3602 DEPENDENT BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 07/23/1998 019 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 " """ "3602 DEPENDENT BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 12/06/2001 015 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 " " "" "3602 DEPENDENT BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 08/17/1975 042 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2016 " " "* "3602 SPOUSE BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 10/30/2017 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 F 02/05/1959 058 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 11/08/1952 064 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 02/11/1956 061 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 05/16/1944 073 FEMALE 38 1 FL RETIREE 03559 EMPLOYEE ONLY 10/11/1943 074 FEMALE 50 1 FL RETIREE 03559 EMPLOYEE ONLY 12/05/1966 050 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/17/1957 060 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE 12/03/1955 061 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE 10/19/1956 061 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 05/03/1979 038 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 11/28/1961 055 FEMALE 70 1 MT RETIREE 03559 EMPLOYEE ONLY 12/12/1946 070 MALE 70 1 GA RETIREE 03559 EMPLOYEE ONLY 01/07/2016 001 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 02/09/1986 031 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 07/29/1962 055 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 03/07/1941 076 (MALE 44 1 FL RETIREE 03559 (EMPLOYEE ONLY 09/30/1950 067 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 08/17/1961 056 MALE 70 1 AR RETIREE 03559 EMPLOYEE ONLY 07/24/1938 079 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 12/03/2010 006 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/24/2012 ""'3604 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 08/01/2017 001 MONROE 11/01/2011 ' "" "3629 SUBSCRIBER KEYWEST B0611 33040 OCA BLUEOPTIONS 08/01/2017 12/31/9999 v 001 MONROE 02/18/2014 " "" *3630 DEPENDENT MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 D 001 MONROE 02/18/2014 ' "" "'3630 SPOUSE MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 001 MONROE 02/18/2014. "3630 DEPENDENT MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 12131/9999 001 MONROE 02/18/2014 "*' *3630 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 12131/9999 N fi 001 MONROE 11/01/2011 ' * ** *3632 SUBSCRIBER TAVERNIER 30611 33070 OTC BLUEOPTIONS 08/01/2017 12131/9999 � R01 MONROE 04/01/2014 "' *'3638 SUBSCRIBER KEYWEST 80611 33040 CCC BLUEOPTIONS 11/30/2016 12131/9999 R01 MONROE 11/01/2011 * * ** *3648 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 01/02/2017 12/31/9999 7 001 MONROE 11/01/2011 " "`3656 SUBSCRIBER KEYLARGO 80611 33037 OPA BLUEOPTIONS 03/02/2016 12/31/9999 'U 001 MONROE 03/08/2013 ""'3656 SPOUSE KEYLARGO 80611 33037 OPA BLUEOPTIONS 08/01/2017 12/31/9999 O R01 LEVY 11/01/2011 * * ** *3661 SUBSCRIBER MCRRISTON 80611 32668 BCC BLUEOPTIONS 12/03/2013 12/31/9999 fl R01 PALM BEACH 11/01/2011 * * ** *3661 SUBSCRIBER DELRAY BEACH B0611 33484 OSO BLUEOPTIONS 08/01/2017 12/31/9999 O 001 MONROE 04/01/2016 * * ** *3662 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 CL CL R01 MONROE 02/01/2015 * * *" *3667 SUBSCRIBER KEYWEST B0611 33040 OTC BLUEOPTIONS 03/30/2016 12/31/9999 U R01 MONROE 02/01/2015 ' "" "3667 SPOUSE KEYWEST B0611 33040 OTC BLUEOPTIONS 03/30/2016 12/31/9999 001 MONROE 11/16/2012 " "" *3669 SUBSCRIBER MARATHON SHORES B0611 33052 BCC BLUEOPTIONS 08/01/2017 12/31/9999 Q 001 MIAMI -DADE 11/01/2011 3671 SUBSCRIBER HOMESTEAD B0611 33032 BCC BLUEOPTIONS 08/01/2017 12/31/9999 ILLI R01 NON- FLORIDA 11/01/2014 ' * "" "3680 SUBSCRIBER LIVINGSTON B0611 59047 OSO BLUEOPTIONS 08/01/2017 12131/9999 ADDRESS R01 NON- FLORIDA 11/01/2011 " "`3683 SUBSCRIBER HIAWASSEE B0611 30546 BCC BLUEOPTIONS 04/20/2017 12131/9999 ADDRESS " "`3686 001 MONROE 01/07/2016 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 001 MONROE 12/22/2015 *" "3686 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/24/2016 12/31/9999 "' *'3687 001 MIAMI -DADE 10/24/2014 SUBSCRIBER MIAMI B0611 33175 OSO BLUEOPTIONS 0810112017 12/31/9999 Cal R01 MONROE 01/21/2017 "'* *3687 (SUBSCRIBER (TAVERNIER B0611 33070 BCC IBLUEOPTIONS 08/01/2017 12131/9999 LU R01 MONROE 11/01/2011 " - 3689 SUBSCRIBER BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 11/02/2015 12/31/9999 Ca R01 NON - FLORIDA ADDRESS 02/01/2017 ` " "" "3691 SUBSCRIBER MENA B0611 71953 OSO BLUEOPTIONS 08/01/2017 12/31/9999 R01 MONROE 11/01/2011 "'" "3692 SUBSCRIBER MARATHON B0611 33050 OPA BLUEOPTIONS 03/10/2015 12/31/9999 001 MONROE 05/01/2016 ""3703 DEPENDENT KEYLARGO B0611 33037 OSO BLUEOPTIONS 08/09/2017 12/31/9999 LLJ 001 MONROE 05/01/2016 " *" *'3703 SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 08/09/2017 12/31/9999 R01 NON - FLORIDA D9/01/2014 * " "* *3705 SUBSCRIBER SHAWANO B0611 54166 OSO BLUEOPTIONS 08/01/2017 12/31/9999 V ADDRESS h 001 MONROE 11/01/2011 ' " "* *3706 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 h 001 MONROE 12/31/2016 * * ** *3708 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 R01 LEE 11/01/2011 * ** "3719 SUBSCRIBER CAPE CORAL 80611 33909 BCC BLUEOPTIONS 11/30/2016 12/31/9999 C4 R01 MONROE 11/01/2011 ' *`* "3719 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 m= 001 MONROE 01/14/2017 " "`3722 SUBSCRIBER BIG PINE KEY 30611 33043 OTC BLUEOPTIONS 01/16/2017 12/31/9999 = Q) 001 MONROE 11/01/2011 ""'3726 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 04/26/2017 12/31/9999 001 MONROE 11/07/2015 " * ** *3729 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 04/27/2017 12/31/9999 U 001 MIAMI DADE 07/25/2015 " * ** *3734 SUBSCRIBER HOMESTEAD 30611 33033 BCC BLUEOPTIONS 04/28/2017 a+ 12131/9999 +' This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 03/21/1939 078 FEMALE 70 1 TN RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 11/01/2011 * * ** "3754 SUBSCRIBER BLAINE B0611 37709 OLA BLUEOPTIONS 03/10/2015 �* *7 ADDRESS 07/01/1992 025 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 12/11/2016 "'" "3763 SUBSCRIBER ISLAMORADA 80611 33036 BCC BLUEOPTIONS 12/31/2016 12/31/9999 03/25/1987 030 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 * *** "3764 SUBSCRIBER HOMESTEAD 80611 33035 0SO BLUEOPTIONS 01/14/2014 12/31/9999 A FEMALE 70 1 PA 10/31/1966 051 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *3855 SUBSCRIBER KEY LARGO B0611 33037 12/15/1956 060 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/30/2013 * ** *'3855 SPOUSE MARATHON B0611 33050 08/29/2011 006 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 0111712015 "' *'3855 DEPENDENT KEYLARGO B0611 33037 12/23/1943 073 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 05/01/2015 *'* "3857 SUBSCRIBER TAVERNIER B0611 33070 10/13/1966 051 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' "" "3867 SUBSCRIBER KEYWEST 80611 33040 02/18/2008 009 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 04/01/2016 "'* "3879 DEPENDENT KEYWEST 80611 33040 08/01/1975 042 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 04/01/2016 * * "* "3879 SUBSCRIBER KEYWEST 80611 33040 06/13/1975 042 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 04/01/2016 * * ** *3879 SPOUSE KEYWEST B0611 33040 05/26/1959 058 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 * * *" "3881 SUBSCRIBER KEYWEST B0611 33040 0SO BLUEOPTIONS 08/01/2017 BCC BLUEOPTIONS 04/28/2017 BCC BLUEOPTIONS 12/03/2013 CCC BLUEOPTIONS 04/01/2016 CCC BLUEOPTIONS 08/01/2017 CCC BLUEOPTIONS 04/19/2016 0SO BLUEOPTIONS 08/01/2017 12/31/9999 Qj 12/31/9999 _ 12/31/9999 ++-® 4i 12131/9999 a) V1 12131/9999 m 12131/9999 w _N 12/31/9999 12/31/9999 ' 12/31/9999 t0 O 12131/9999 - fl 12/31/9999 O 1 12/31/9999 CL CL 12/31/9999 12/31/9999 12/31/9999 12/31/9999 (— W 12/31/9999 12/31/9999 12/31/9999 12/31/9999 12/31/9999 N 12/31/9999 12/31/9999 LIJ U 12/31/9999 12/31/9999 H 12/31/9999 Z 12/31/9999 12/31/9999 V 12/31/9999 F 12/31/9999 Q, 12/31/9999 12/31/9999 {y 12/31/9999 = 12/31/9999 12/31/9999 S U 12/31/9999 12/31/9999 Q This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 01/14/1988 029 NIALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 01/02/2015 ""'3913 SUBSCRIBER MIAMI B0611 33185 BCC BLUEOPTIONS 08/24/2016 09/25/1956 061 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 3925 SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 08/01/2017 12/31/9999 Qj 07/26/1969 048 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' SUBSCRIBER CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 12/03/2013 12/31/9999 D 10/08/1977 040 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/30/2012 "* *'3937 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 11/04/1974 042 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 09/05/2016. " "3944 SUBSCRIBER FLORIDA CITY B0611 33034 BCC BLUEOPTIONS 08/01/2017 12131/9999 04/13/1965 052 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/16/2014 '` *' *3951 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/24/2016 12131/9999 N fi 07/15/1959 058 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * ** *3959 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 12131/9999 07/26/1957 060 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 "' *'3960 SUBSCRIBER KEYWEST 80611 33040 ORA BLUEOPTIONS 04/20/2017 12131/9999 05/01/1952 055 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 08/01/2016 * * ** *3960 SPOUSE KEYWEST B0611 33040 ORA BLUEOPTIONS 08/01/2017 12/31/9999 7 11/04/1965 051 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 . "`3972 SUBSCRIBER KEYWEST 80611 33040 CCC BLUEOPTIONS 01/18/2017 12/31/9999 'U 02/18/2003 014 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/11/2014 " " "" *3972 DEPENDENT KEYWEST 80611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 O 08/24/1962 055 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *3977 SUBSCRIBER BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 fl 01/28/1988 029 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *3977 DEPENDENT BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 12/03/2013 12/31/9999 O 1 02/04/1959 058 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *3977 SPOUSE BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 12/03/2013 12/31/9999 CL CL 07/20/2002 015 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 10/08/2015 * * *" *3981 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 v 03/26/1975 042 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' ** "3981 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 10/09/2015 12/31/9999 11/11/1993 023 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/24/2017 * "* *3986 SUBSCRIBER T.TAVERNIER B0611 33070 CCC BLUEOPTIONS 08/01/2017 12/31/9999 Q 10/28/1956 061 '.MALE 48 2 FL RETIREE 03559 '.EMPLOYEE &SPOUSE R01 ORANGE 10/01/2015 ' ** *'4007 '.SPOUSE '.ORLANDO B0611 32836 OLA BLUEOPTIONS 08/01/2017 12/31/9999 08/23/1958 059 FEMALE 48 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 ORANGE 10/01/2015 "4007 SUBSCRIBER ORLANDO B0611 32836 OLA BLUEOPTIONS 08/01/2017 12/31/9999 L!J 09/24/1994 023 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2015 '` *' *4019 DEPENDENT LITTLE TORCH KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 12/31/9999 09/03/1971 046 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' * ** *4019 SUBSCRIBER LITTLE TORCH KEY B0611 33042 080 BLUEOPTIONS 01/15/2015 12131/9999 04/21/1948 069 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 "' *'4024 SUBSCRIBER BIG PINE KEY 80611 33043 BCC BLUEOPTIONS 11/30/2016 12/31/9999 01/17/1983 034 'FEMALE 44 3 FL ACTIVE 03559 'EMPLOYEE &CHILDREN 001 MONROE 11127/2015 * * ** *4025 'SUBSCRIBER 'KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 12/31/9999 06/20/2001 016 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/27/2015 .. "'4025 DEPENDENT KEYWEST 80611 33040 BCC BLUEOPTIONS 08/24/2016 12/31/9999 10/08/1961 056 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " """ *4030 SUBSCRIBER KEYLARGO 80611 33037 OSO BLUEOPTIONS 08/01/2017 12/31/9999 LU U 02/10/2009 008 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 02/10/2017 * * ** *4035 DEPENDENT KEYWEST 80611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 01/08/1986 031 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 08/28/2013 * * ** *4035 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 02/15/2017 12/31/9999 08/20/1950 067 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 12/01/2016 * * ** *4036 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 04/20/2017 12/31/9999 06/01/1973 044 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/01/2012 * * *" *4043 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 ME 08/26/1945 072 MALE 70 1 OH RETIREE 03559 EMPLOYEE ONLY R01 NON- FLORIDA 11/01/2011 ' ** "4045 SUBSCRIBER KENT B0611 44240 OSO BLUEOPTIONS 08/21/2017 12/31/9999 ADDRESS U 06/04/1982 035 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/23/2015 ' * *" *4054 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 10/20/2017 12/31/9999 h 03/18/1938 079 MALE 70 1 OK RETIREE 03559 EMPLOYEE ONLY R01 NON- FLORIDA 11/01/2011 ' *"`4062 SUBSCRIBER LONE WOLF B0611 73655 OSO BLUEOPTIONS 08/01/2017 12131/9999 F— ADDRESS_ 07/20/1937 080 MALE 09 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 CITRUS 11/01/2011 '* "`4071 SUBSCRIBER CITRUS SPRINGS B0611 34434 OSO BLUEOPTIONS 03/02/2017 12131/9999 M 08/17/1949 068 FEMALE 09 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 CITRUS 11/01/2011 " "`4071 SPOUSE CITRUS SPRINGS B0611 34434 OSO BLUEOPTIONS 03/10/2015 12/31/9999 N 02/11/1990 027 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/30/2016 " "`4081 SUBSCRIBER KEYLARGO LARGO B0611 33037 OSO BLUEOPTIONS 10/31/2016 12/31/9999 . . = 02/22/1966 051 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 " ** *4084 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 07/21/2017 12/31/9999 iy 07/26/1956 061 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 01/01/2017 *' *'4084 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 S U 01/04/1930 087 MALE 37 1 FL RETIREE 03559 EMPLOYEE ONLY R01 LEON 11/01/2011 4111 SUBSCRIBER TALLAHASSEE B0611 32309 ORA SLUEOPTIONS 01/02/2017 12/31/9999 N 07/11/1990 027 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 07/23/2016 ` * ** *4109 SUBSCRIBER MIAMI B0611 33185 BCC BLUEOPTIONS 08/24/2016 12/31/9999 09/08/1941 076 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ` ** *`4117 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 03/16/2017 12/31/9999 10/07/1953 064 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' ° °* *4122 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 03/09/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 907 12/07/1946 070 NIALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 06/21/1962 055 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 01/04/1967 050 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 07/29/1989 028 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 12/13/1964 052 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 03/10/1958 059 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 06/11/2004 013 MALE 44 4 FL ACTIVE 03559 FAMILY 01/23/2014 003 MALE 44 4 FL ACTIVE 03559 FAMILY 01/23/2007 010 FEMALE 44 4 FL ACTIVE 03559 FAMILY 03/05/1948 069 '.MALE 18 1 '.. FL '.. RETIREE '.. 03559 EMPLOYEE ONLY 03/23/1983 034 FEMALE 44 4 FL ACTIVE 03559 FAMILY 07/28/1979 038 MALE 44 4 FL ACTIVE 03559 FAMILY 12/22/1993 023 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 02/08/1959 058 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 04/03/1971 046 (FEMALE 44 1 FL ACTIVE 03559 (EMPLOYEE ONLY 03/07/1929 088 FEMALE 70 1 AR RETIREE 03559 EMPLOYEE ONLY 12/14/1988 028 MALE O6 1 FL ACTIVE 03559 EMPLOYEE ONLY 03/21/1963 054 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 06/17/1988 029 MALE 06 1 FL ACTIVE 03559 EMPLOYEE ONLY 04/12/1959 058 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 09/21/1963 054 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 07/07/2010 007 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 07/07/2010 007 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 04/23/2000 017 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD R01 MONROE 11/01/2011 ""'4128 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 11/30/2016 001 MONROE 11/01/2011 " "'4208 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 001 MONROE 06/27/2015 " " "" *4229 SUBSCRIBER KEYWEST 80611 33045 OSO BLUEOPTIONS 08/01/2017 001 MIAMI -DADE 10/14/2017 * * ** *4232 SUBSCRIBER MIAMI 80611 33176 BCC BLUEOPTIONS 10/14/2017 001 MONROE 11/01/2011 * * ** *4238 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 001 MONROE 11/01/2011 * * ** *4239 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 001 MONROE 11/03/2016 * * *" *4242 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 001 MONROE 11/03/2016 '* "'4242 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 001 MONROE 11/03/2016 "" "4242 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 R01 FLAGLER 11/01/2011 "" *4242 SUBSCRIBER '.PALM COAST B0611 '.. 32137 ORA BLUEOPTIONS '.. 04/28/2017 001 MONROE 11/03/2016 '4242 SPOUSE KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 001 MONROE 11/01/2011 " — '4242 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 11/09/2016 001 MONROE 11/01/2011 "' *'4246 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 03/10/2017 001 MONROE 11/01/2011 "' *'4246 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 02/14/2017 001 MONROE 10128/2017 * *" *4248 'SUBSCRIBER 'BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 10/30/2017 R01 NON - FLORIDA 11/01/2011 " "'4263 SUBSCRIBER LEAD HILL B0611 72644 BCC BLUEOPTIONS 03/02/2017 ADDRESS 001 BROVN /ARD 12/31/2016 — 4263 SUBSCRIBER MIRAMAR 80611 33027 BCC BLUEOPTIONS 12/31/2016 001 MONROE 11/01/2011 " 4268 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 12/03/2013 001 BROVJARD 08/21/2015 4276 SUBSCRIBER PEMBROKE PINES 80611 33029 BCC BLUEOPTIONS 08/24/2016 001 MONROE 11/01/2011 4352 SUBSCRIBEF 001 MONROE 11/01/2011 — 4354 SUBSCRIBEF 001 MONROE 01/11/2014 ' "" "4356 DEPENDENT 001 MONROE 01/11/2014 ' * *" "4356 DEPENDENT 001 MONROE 01/11/2014 * * ** *4356 DEPENDENT B0611 33045 BCC BLUEOPTIONS 12/03/2013 B0611 33040 ORA BLUEOPTIONS 04/26/2017 80611 33040 OSO BLUEOPTIONS 08/15/2017 80611 33040 OSO BLUEOPTIONS 10/31/2017 80611 33040 OSO BLUEOPTIONS 09/20/2017 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 12/03/1968 048 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 001 MONROE 01/11/2014 ""'4356 SUBSCRIBER 07/17/1981 036 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2017 " "'4394 SPOUSE 05/12/2000 017 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2017 ""'4394 DEPENDENT 10/25/1981 036 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2017 " " "" "4394 SUBSCRIBER 07/16/2006 011 NIALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2017 " 4394 DEPENDENT 03/09/1986 031 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/28/2017 ' " "* "4396 SUBSCRIBER 09/28/1945 072 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 11/01/2011 ' "" "'4398 SPOUSE 10/06/1944 073 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 11/01/2011 ' "" "4398 SUBSCRIBER 07/06/1982 035 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 "" "4399 SUBSCRIBER 05/30/2011 006 '.FEMALE 44 3 FL ACTIVE 03559 '.EMPLOYEE &CHILDREN 001 MONROE 01/01/2014 ' "" "'4399 '.DEPENDENT 04/29/2014 003 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 04/29/2014 ' - 4399 DEPENDENT 10/15/1968 049 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "' "'4404 SUBSCRIBER 12/21/1986 030 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'4412 SUBSCRIBER 04/29/1919 098 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 " "'4414 SUBSCRIBER 11/03/1956 060 (MALE 44 1 FL ACTIVE 03559 (EMPLOYEE ONLY 001 MONROE 11/01/2011 ""'4416 (SUBSCRIBER 12/31/1960 056 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'4431 SUBSCRIBER 05/15/1938 079 NIALE 28 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 HIGHLANDS 11/01/2011 " """ "4436 SPOUSE 02/12/1982 035 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 04/26/2013 "" "4496 SPOUSE 08/17/1978 039 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 04/26/2013 " "'4496 SUBSCRIBEF 05/17/2011 006 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 04/26/2013 " """ "4496 DEPENDENT 06/05/1961 056 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/27/2014 " " "" "4501 SUBSCRIBEF 05/02/2012 005 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2016 ' " "* "4502 DEPENDENT This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 80611 33040 OSO BLUEOPTIONS 08/01/2017 80611 33040 OSO BLUEOPTIONS 08/31/2017 B0611 33178 OSO BLUEOPTIONS 08/01/2017 12/31/9999 v B0611 33178 OSO BLUEOPTIONS 08/01/2017 12/31/9999 D EST B0611 33040 OTC BLUEOPTIONS 03/10/2015 12/31/9999 HON B0611 33050 OSO BLUEOPTIONS 08/01/2017 12131/9999 w =RLAND KEY B0611 33042 OSO BLUEOPTIONS 03/08/2016 12131/9999 N fi iTEAD B0611 33031 BCC BLUEOPTIONS 12/03/2013 12131/9999 � STEAD 80611 33031 BCC BLUEOPTIONS 08/01/2017 12131/9999 )RADA B0611 33036 CCC BLUEOPTIONS 08/01/2017 12/31/9999 7 EST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 "1a EST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 O EST 80611 33040 OSO BLUEOPTIONS 04/20/2017 12/31/9999 EST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 > 0 1 EST B0611 33040 BCC BLUEOPTIONS 08/28/2017 12/31/9999 CL CL EST B0611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 U EST B0611 33040 OSO BLUEOPTIONS '.. 08/01/2017 12/31/9999 EST B0611 33040 OSO BLUEOPTIONS 01/02/2017 12/31/9999 EST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 EST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 L!J EST B0611 33040 OCA BLUEOPTIONS 08/01/2017 12/31/9999 EST B0611 33045 OSO BLUEOPTIONS 02/18/2015 12131/9999 EST 80611 33040 BCC BLUEOPTIONS 03/10/2015 12/31/9999 ""' EST B0611 33040 OSO BLUEOPTIONS 05/16/2016 12/31/9999 EST 80611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 JG 80611 33875 CCC BLUEOPTIONS 11/30/2016 12/31/9999 LU JG 80611 33875 CCC BLUEOPTIONS 03/16/2017 12/31/9999 U 'HON B0611 33050 OSO BLUEOPTIONS 11/12/2015 12/31/9999 ,RGO B0611 33037 OSO BLUEOPTIONS 07/18/2017 12/31/9999 , URNS B0611 32935 BCC BLUEOPTIONS 12/03/2013 12/31/9999 W EST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 y 1E KEY B0611 33043 BCC BLUEOPTIONS 01/02/2017 12/31/9999 ~ 1E KEY B0611 33043 BCC BLUEOPTIONS 01/02/2017 12/31/9999 h EST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12131/9999 RHAVEN B0611 33881 CCC BLUEOPTIONS 04/20/2017 12131/9999 C4 1E KEY B0611 33043 CCC BLUEOPTIONS 08/24/2016 12131/9999 m= .r+ = 1E KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 Q) E KEY B0611 33042 OSO BLUEOPTIONS 11/12/2015 12/31/9999 E KEY 80611 33042 OSO BLUEOPTIONS 11/12/2015 S 12/31/9999 U E KEY 80611 33042 OSO BLUEOPTIONS 11/12/2015 12/31/9999 TORCH KEY 80611 33042 BCC BLUEOPTIONS 02/18/2015 12/31/9999 EST B0611 33040 BCC BLUEOPTIONS 08/16/2017 12/31/9999 07/03/1976 041 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2016 " * ** "4502 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 08/29/2017 08/20/1941 076 MALE 35 1 FL RETIREE 03559 EMPLOYEE ONLY R01 LAKE 11/07/1940 076 MALE 70 2 PA RETIREE 03559 EMPLOYEE & SPOUSE R01 NON -FLO 80611 18229 CCC BLUEOPTIONS 12/03/2013 11/01/2011 ' *'" "4543 SUBSCRIBER JIM THORPE 80611 ADORES; 03/11/1942 075 FEMALE 70 2 PA RETIREE 03559 EMPLOYEE & SPOUSE R01 NON -FLO 01/04/2017 11/01/2011 ' * ** "4546 SPOUSE KEYWEST 80611 33040 OTC BLUEOPTIONS 01/04/2017 ADORES; 05/27/1944 073 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 02/05/1941 076 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 05/12/1943 074 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 12/19/1957 059 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 02/27/1967 050 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/10/1995 022 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 0111012002 015 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 12/17/1974 042 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 03/13/1951 066 FEMALE 35 1 FL RETIREE 03559 EMPLOYEE ONLY R01 LAKE 04/19/1937 080 '.FEMALE 44 1 '.. FL '.. RETIREE '.. 03559 EMPLOYEE ONLY R01 MONROE 06/04/1987 030 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/03/1971 046 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/20/1952 065 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 10/30/1947 070 NIALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 12/22/1957 059 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/1965 051 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/20/1950 066 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/24/1948 069 MALE 06 1 FL RETIREE 03559 EMPLOYEE ONLY R01 BROVJAR 08/21/1959 058 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 09/08/1955 062 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/08/1976 040 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/06/1963 054 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 09/26/1962 055 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 07/24/1977 040 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 12/22/1997 019 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 02/09/1978 039 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 08/23/1994 023 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -0A 05/31/1991 026 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/27/1970 047 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 04/02/2016 4535 SUBSCRIBER KLYWLSI 80611 33040 BCG BLULOP I IONS 08124/2016 11/01/2011 " "`4541 SUBSCRIBER MOUNTDORA B0611 32757 OSO BLUEOPTIONS 08/01/2017 11/01/2011 " * ** "4543 SPOUSE JIM THORPE 80611 18229 CCC BLUEOPTIONS 12/03/2013 11/01/2011 ' *'" "4543 SUBSCRIBER JIM THORPE 80611 18229 CCC BLUEOPTIONS 12/03/2013 11/01/2011 ^ °" "4546 SUBSCRIBER KEYWEST 80611 33040 OTC BLUEOPTIONS 01/04/2017 11/01/2011 ' * ** "4546 SPOUSE KEYWEST 80611 33040 OTC BLUEOPTIONS 01/04/2017 11/01/2011 " * *" *4547 SUBSCRIBER KEYWEST 80611 33040 OPA BLUEOPTIONS 04/28/2017 11/01/2011 " * *" "4548 SUBSCRIBER KEYWEST 80611 33041 BCC BLUEOPTIONS 12/03/2013 11/01/2011 " " *" "4555 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 01114/2017 " "'" "4573 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 01/17/2017 01/14/2017 " "" "4573 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 01/17/2017 01/14/2017 "" "4573 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 01/17/2017 11/01/2011 "`" "4574 SUBSCRIBER MOUNTDORA B0611 32757 BCC BLUEOPTIONS 04/20/2017 11/01/2011 '.. * * ** *4582 '.SUBSCRIBER IKEYWEST B0611 '.. 33040 OPA BLUEOPTIONS '.. 04/20/2017 11/01/2011 * * ** *4588 SUBSCRIBER KEYLARGO B0611 33037 BCC SLUEOPTIONS 01/14/2016 11/01/2011 '4111 SUBSCRIBER BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 08/01/2017 12/01/2012 "'" "4596 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 11/30/2016 12/01/2012 " "'" "4596 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 04/20/2017 02/01/2017 '4615 SUBSCRIBER SUGARLOAF KEY 80611 33042 OSO BLUEOPTIONS 08/01/2017 11/01/2011 ' * ** "4617 SUBSCRIBER MARATHON 80611 33050 OSO BLUEOPTIONS 12/03/2013 01/01/2015 " "'4642 DEPENDENT KEYWEST B0611 33040 OSO 01/01/2015 "" "'4642 SUBSCRIBER KEYWEST B0611 33040 OSO 04/15/2017 " "'" "4643 SUBSCRIBER MIAMI B0611 33176 BCC 11/01/2011 " "'" "4652 DEPENDENT KEYWEST B0611 33040 OSO 11/01/2011 4652 SUBSCRIBER KEYWEST 80611 33040 OSO 08/01/2017 12/31/9999 12/18/1956 060 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " " "" "4653 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 05/17/2016 07/31/1947 070 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 10/23/1972 045 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 05/29/1970 047 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 07/12/1968 049 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 08/22/1957 060 FEMALE 44 4 FL ACTIVE 03559 FAMILY 07/26/1961 056 MALE 44 4 FL ACTIVE 03559 FAMILY 08/08/2008 009 FEMALE 44 4 FL ACTIVE 03559 FAMILY 09/03/1992 025 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 08/26/1985 032 '.MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 05/29/1953 064 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 06/07/1987 030 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 07/12/1960 057 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 07/22/1991 026 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 05/02/1960 057 (FEMALE 44 4 FL ACTIVE 03559 (FAMILY 09/16/1997 020 MALE 44 4 FL ACTIVE 03559 FAMILY 01/20/1991 026 FEMALE 44 4 FL ACTIVE 03559 FAMILY 12/27/1994 022 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 06/09/1960 057 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 05/08/1928 089 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 06/29/1975 042 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/23/1950 067 FEMALE 70 1 TN RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 " "'4686 SUBSCRIBER KEYWEST 001 MONROE 10/05/2012 ""'4698 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 * * ** *4704 SUBSCRIBER KEYLARGO 001 MONROE 06/02/2017 " * ** *4704 SPOUSE KEYLARGO 002 MONROE 11/01/2011 * * ** *4712 SUBSCRIBER KEYWEST 002 MONROE 11/01/2011 * * *" *4712 SPOUSE .KEYWEST 002 MONROE 0110112012 ' ** "4712 DEPENDENT KEYWEST 001 MIAMI -DADE 12/12/2015 "" "4713 SUBSCRIBER HOMESTEAD 001 MONROE 10/25/2014 ' * ** *4714 '.SUBSCRIBER '.BIG PINE KEY R01 MONROE 11/01/2011 "4715 SUBSCRIBER KEYWEST 001 MIAMI -DADE 11/30/2012 ' *' *'4719 SUBSCRIBER CUTLER BAY 001 MONROE 11/01/2011 "' *'4719 SUBSCRIBER KEY LARGO 001 MONROE 11/02/2013 "' *'4724 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 * *" *4728 (SPOUSE IKEYLARGO 001 MONROE 11/01/2011 " "'4728 DEPENDENT KEYLARGO 001 MONROE 11/01/2011 " *"" "4728 DEPENDENT KEYLARGO 001 MONROE 03/12/2016 *'" *4789 001 MONROE 11/01/2011 ''" *4791 R01 MONROE 11/01/2011 12/31/9999 D 001 MIAMI -DADE 08/07/2015 " * ** *4805 R01 NON - FLORIDA 11/01/2012 * * ** *4817 B0611 33196 BCC BLUEOPTIONS 08/01/2017 12/31/9999 v B0611 33196 BCC BLUEOPTIONS 08/01/2017 12/31/9999 D B0611 33196 BCC BLUEOPTIONS 08/16/2017 12/31/9999 B0611 33196 BCC BLUEOPTIONS 08/16/2017 12131/9999 w B0611 33196 BCC BLUEOPTIONS 08/16/2017 12131/9999 N fi B0611 33196 BCC BLUEOPTIONS 10/10/2016 12131/9999 � 80611 33196 BCC BLUEOPTIONS 10/10/2016 12131/9999 B0611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 7 80611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 'U 80611 33040 OSO BLUEOPTIONS 01/02/2017 12/31/9999 O 80611 33037 OSE BLUEOPTIONS 07/06/2017 12/31/9999 B0611 33037 OSE BLUEOPTIONS 08/01/2017 12/31/9999 > 0 1 B0611 33040 BCC BLUEOPTIONS 04/21/2017 12/31/9999 CL CL B0611 33040 BCC BLUEOPTIONS 02/13/2017 12/31/9999 U B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33032 BCC BLUEOPTIONS 08/24/2016 12/31/9999 B0611 33043 BCC BLUEOPTIONS 04/28/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 LLI B0611 33189 BCC BLUEOPTIONS 02/18/2015 12/31/9999 B0611 33037 BCC BLUEOPTIONS 08/01/2017 12131/9999 80611 33040 OSO BLUEOPTIONS 07/18/2017 12/31/9999 ""' B0611 33037 BCC BLUEOPTIONS 11/10/2016 12/31/9999 80611 33037 BCC BLUEOPTIONS 11/10/2016 12/31/9999 80611 33037 BCC BLUEOPTIONS 11/10/2016 12/31/9999 LIJ 80611 33037 BCC BLUEOPTIONS 11/10/2016 12/31/9999 U B0611 33324 BCC BLUEOPTIONS 12/03/2013 12/31/9999 B0611 33155 BCC BLUEOPTIONS 01/02/2017 12/31/9999 B0611 33041 BCC BLUEOPTIONS 12/03/2013 12/31/9999 W B0611 33050 OSO BLUEOPTIONS 09/18/2017 12/31/9999 X B0611 33040 OCA BLUEOPTIONS 11/30/2016 12/31/9999 ~ B0611 33042 OCA BLUEOPTIONS 04/28/2017 12/31/9999 h B0611 33133 OSO BLUEOPTIONS 08/01/2017 12131/9999 B0611 33070 BCC BLUEOPTIONS 08/01/2017 12131/9999 C4 B0611 33040 OSO BLUEOPTIONS 11/13/2014 12131/9999 m= .r+ = B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 Q) 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 80611 33036 OCA BLUEOPTIONS 02/18/2016 S 12/31/9999 U N 80611 33070 OTC BLUEOPTIONS 12/03/2013 12/31/9999 80611 33177 BCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 37865 BCC BLUEOPTIONS 07/02/2016 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 09/16/2014 003 MALE 13 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 001 MIAMI -DADE 06/26/2015 ""'4821 DEPENDENT MIAMI 80611 33175 OSO BLUEOPTIONS 08/01/2017 10/19/1948 069 FEMALE 13 1 FL RETIREE 03559 EMPLOYEE ONLY 07/23/1956 061 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 03/23/1968 049 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 01/11/1971 046 FEMALE 52 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 10/31/1998 019 MALE 52 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 04/07/2000 017 FEMALE 52 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 05/23/1957 060 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 12/27/2003 013 FEMALE 29 4 FL ACTIVE 03559 FAMILY 06/26/1971 046 '.MALE 29 4 FL ACTIVE 03559 '.FAMILY 04/21/1970 047 FEMALE 29 4 FL ACTIVE 03559 FAMILY 11/26/1992 024 FEMALE 29 4 FL ACTIVE 03559 FAMILY 12/27/2003 013 MALE 29 4 FL ACTIVE 03559 FAMILY 10/25/2010 007 FEMALE 29 4 FL ACTIVE 03559 FAMILY 08/26/1995 022 (MALE 44 3 FL ACTIVE 03559 (EMPLOYEE &CHILDREN 12/16/1992 024 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 06/07/1966 051 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 02/17/1960 057 MALE 44 2 FL ACIIVE 03559 EMPLOYEE &SPOU1 09/13/1954 063 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 09/17/1999 018 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 01/16/1972 045 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 10/05/1959 058 MALE 26 1 FL RETIREE 03559 EMPLOYEE ONLY 09/20/1985 032 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD R01 MWMI -DADE 11/01/2011 " "'4863 SUBSCRIBER MIAMI 001 MONROE 11/01/2011 ""'4865 SUBSCRIBER KEYLARGO 001 MONROE 11/01/2011 " " "" "4866 SUBSCRIBER CUDJOE KEY 001 PINELLAS 01/01/2017 " 4870 SUBSCRIBER LARGO 001 PINELLAS 01/01/2017 " " "* "4870 DEPENDENT LARGO 001 PINELLAS 01/01/2017 " "" "'4870 DEPENDENT .LARGO R01 MONROE 11/01/2011 " "" "4876 SUBSCRIBER KEYWEST 001 HILLSBOROUGH 11/01/2011 "" "4900 DEPENDENT LUTZ 001 HILLSBOROUGH 11/01/2011 ..".1100 '.SUBSCRIBER '.LUTZ 001 HILLSBOROUGH 11/01/2011 ' " "" "4900 SPOUSE LUTZ 001 HILLSBOROUGH 11/01/2011 " DEPENDENT LUTZ 001 HILLSBOROUGH 11/01/2011 - - 4900 DEPENDENT LUTZ 001 HILLSBOROUGH 11/01/2011 - - 4900 DEPENDENT LUTZ 001 MONROE 11/01/2011 - - 4902 (DEPENDENT IKEYWEST 001 MONROE 11/01/2011 " "'4902 DEPENDENT KEYWEST 001 MONROE 11/01/2011 " " "' "4902 SUBSCRIBER BIG PINE KEY 001 MONROE 11/01/2011 .... I'll SUBSCRIBER KEYLARGO 001 MONROE 06/18/2017 " "'4947 DEPENDENT KEYWEST 001 MONROE 06/18/2017 " """ "4947 SUBSCRIBER KEYWEST R01 HERNANDO 11/01/2011 " " "" "4952 SUBSCRIBER SPRING HILI 001 MONROE 06/28/2013 " " "* "4966 SUBSCRIBER KEYWEST B0611 33036 BCC BLUEOPTIONS 04/27/2017 12/31/9999 v B0611 33019 BCC BLUEOPTIONS 08/24/2016 12/31/9999 D B0611 32162 OPA BLUEOPTIONS 03/10/2015 12/31/9999 B0611 33050 BCC BLUEOPTIONS 08/01/2017 12131/9999 w B0611 33050 BCC BLUEOPTIONS 11/28/2016 12131/9999 N fi B0611 33043 BCC BLUEOPTIONS 08/01/2017 12131/9999 � 80611 33043 BCC BLUEOPTIONS 08/01/2017 12131/9999 B0611 33043 BCC BLUEOPTIONS 08/01/2017 12/31/9999 7 80611 33192 BCC BLUEOPTIONS 12/21/2015 12/31/9999 80611 33037 CCC BLUEOPTIONS 12/03/2013 12/31/9999 O 80611 33042 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33778 CCC BLUEOPTIONS 08/01/2017 12/31/9999 > O 1 B0611 33778 CCC BLUEOPTIONS 01/02/2017 12/31/9999 CL CL B0611 33778 CCC BLUEOPTIONS 01/02/2017 12/31/9999 U B0611 33040 BCC IBLUEOPTIONS '.. 12/03/2013 '.. 12/31/9999 B0611 33558 OTC BLUEOPTIONS 02/03/2017 12/31/9999 B0611 33558 OTC BLUEOPTIONS 02/03/2017 12/31/9999 B0611 33558 OTC BLUEOPTIONS 02/03/2017 12/31/9999 UJ B0611 33558 OTC BLUEOPTIONS 02/03/2017 12/31/9999 B0611 33558 OTC BLUEOPTIONS 02/03/2017 12131/9999 80611 33558 OTC BLUEOPTIONS 02/03/2017 12/31/9999 ""' B0611 33040 OSO BLUEOPTIONS 06/16/2016 12/31/9999 80611 33040 OSO BLUEOPTIONS 06/16/2016 12/31/9999 80611 33043 OSO BLUEOPTIONS 06/29/2016 12/31/9999 LU 80611 33040 OSO BLUEOPTIONS 10/16/2017 12/31/9999 U B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 04/28/2017 12/31/9999 W B0611 33050 OPA BLUEOPTIONS 07/16/2015 12/31/9999 y B0611 33050 OPA BLUEOPTIONS 07/16/2015 12/31/9999 ~ B0611 33050 OPA BLUEOPTIONS 07/16/2015 12/31/9999 h B0611 33050 OPA BLUEOPTIONS 07/16/2015 12131/9999 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 C4 B0611 33050 BCC BLUEOPTIONS 10/30/2017 12131/9999 m= .r+ = B0611 33050 BCC BLUEOPTIONS 10/30/2017 12/31/9999 Q) B0611 33037 BCC BLUEOPTIONS 08/01/2017 12/31/9999 80611 33040 OSO BLUEOPTIONS 06/20/2017 12/31/9999 U 80611 33040 OSO BLUEOPTIONS 10/11/2017 12/31/9999 80611 34609 BCC BLUEOPTIONS 01/02/2017 12/31/9999 B0611 33040 OTC BLUEOPTIONS 10/28/2014 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 01/04/2008 009 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 001 MONROE 06/28/2013 ""'4966 DEPENDENT 04/15/1949 068 MALE 52 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 PINELLAS 11/01/2011 5071 SPOUSE CLEARWATE 07/01/1953 064 FEMALE 52 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 PINELLAS 11/01/2011 ' *" "5071 SUBSCRIBER CLEARWATE 11/09/1988 028 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/05/2012 ' *'" "5077 SUBSCRIBER BIG PINE KEY 09/19/1957 060 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** "5078 SUBSCRIBER KEYWEST 01/15/1949 068 FEMALE 41 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MANATEE 11/01/2011 * * ** *5082 SUBSCRIBER PALMETTO 02/05/1964 053 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' ** "'5093 SUBSCRIBER MARATHON 06/23/1935 082 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ' ** "'5099 SUBSCRIBER KEYWEST 03/19/1993 024 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 03/27/2015 "* "'5105 SUBSCRIBER HOMESTEAD 04/03/1972 045 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 " "'5106 SUBSCRIBER HIALEAH 04/28/1953 064 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 04/01/2015 " "" "5109 SUBSCRIBER KEYWEST 03/07/1961 056 '.FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' " "" "5113 '.SUBSCRIBER '.KEYWEST 04/11/1951 066 MALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 11/01/2011 ` * ** "5126 SPOUSE MIAMI BEACF 01/15/1959 058 FEMALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 11/01/2011 * *" *5126 SUBSCRIBER MIAMI BEACF 05/27/1991 026 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 12/22/2015 '5131 SUBSCRIBER KEYWEST 02/25/2004 013 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 `` "` "5133 DEPENDENT T.TAVERNIER 12/24/1959 057 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " 5133 SUBSCRIBER T.TAVERNIER 02/24/2001 016 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' *'" "5133 DEPENDENT TAVERNIER 05/04/2004 013 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 " * *" "5138 DEPENDENT MARATHON 80611 33040 OTC BLUEOPTIONS 10/28/2014 B0611 37938 OSO BLUEOPTIONS 08/07/2017 12/31/9999 v B0611 34428 BCC BLUEOPTIONS 09/30/2017 12/31/9999 D r_ B0611 33027 DSO BLUEOPTIONS 07/21/2016 12/31/9999 w� w B0611 33040 BCC BLUEOPTIONS 08/21/2017 12/31/9999 � B0611 33040 BCC BLUEOPTIONS 08/21/2017 N 12131/9999 � B0611 33037 OTC BLUEOPTIONS 03/25/2017 12131/9999 w 80611 33070 BCC BLUEOPTIONS 06/29/2016 12131/9999 B0611 33040 BCG BLUEOPTIONS 11/30/2016 12/31/9999 a) 7 B0611 33755 OSO BLUEOPTIONS 11/30/2016 12/31/9999 "1a tO 80611 33755 OSO BLUEOPTIONS 08/01/2017 12/31/9999 80611 33043 BCC BLUEOPTIONS 11/12/2015 12/31/9999 tO 7 80611 33040 OPA BLUEOPTIONS 04/12/2016 12/31/9999 U 80611 34221 BCC BLUEOPTIONS 11/30/2016 12/31/9999 C ' CL B0611 33050 OSO BLUEOPTIONS 12/03/2013 12/31/9999 B0611 33040 OTC BLUEOPTIONS 03/02/2017 12/31/9999 B0611 33035 OSO BLUEOPTIONS 08/24/2016 '.. 12/31/9999 B0611 33015 OSO BLUEOPTIONS 08/01/2017 12/31/9999 L!J B0611 33040 OTC BLUEOPTIONS 06/29/2016 12131/9999 F B0611 33040 BCC BLUEOPTIONS 08/01/2017 12131/9999 B0611 33140 OSO BLUEOPTIONS 11/30/2016 12131/9999 B0611 33140 OSO BLUEOPTIONS 11/30/2016 12/31/9999 �. Ua B0611 33040 OSO BLUEOPTIONS 08/24/2016 12/31/9999 B0611 33070 BCC BLUEOPTIONS 11/12/2015 12/31/9999 80611 33070 BCC BLUEOPTIONS 11/12/2015 12/31/9999 LU U 80611 33070 BCC BLUEOPTIONS 11/12/2015 12/31/9999 80611 33050 OSO BLUEOPTIONS 12/03/2013 12/31/9999 80611 29485 CCC BLUEOPTIONS 03/10/2015 12/31/9999 LLJ 80611 33050 OSO BLUEOPTIONS 12/03/2013 12/31/9999 80611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 U B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 h B0611 89121 BCC BLUEOPTIONS 12/03/2013 12/31/9999 F Q B0611 33050 OTC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 08/07/2017 12/31/9999 N B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 w+ C B0611 '. 33051 OSO BLUEOPTIONS 09/03/2014 12/31/9999 B0611 33050 BCC BLUEOPTIONS 02/03/2017 S 12/31/9999 U U B0611 29609 OTC BLUEOPTIONS 03/10/2015 12/31/9999 � This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 03/09/1947 070 MALE 52 1 FL RETIREE 03559 EMPLOYEE ONLY 03/22/1993 024 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 08/24/1974 043 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 10/10/2002 015 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 07/19/2001 016 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 10/20/1946 071 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 08/26/1955 062 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 05/30/1961 056 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 03/04/1994 023 FEMALE 70 3 PW RETIREE 03559 EMPLOYEE & CHILDREN 12/28/1958 058 MALE 70 3 PW RETIREE 03559 EMPLOYEE & CHILDREN 01/15/1992 025 MALE 44 3 FL RETIREE 03559 EMPLOYEE & CHILDREN 01/07/1994 023 MALE 44 3 FL RETIREE 03559 EMPLOYEE & CHILDREN 02/25/1998 019 MALE 44 3 FL RETIREE 03559 EMPLOYEE & CHILDREN 08/17/1962 055 MALE 44 3 FL RETIREE 03559 EMPLOYEE & CHILDREN 08/19/1953 064 MALE 37 1 FL RETIREE 03559 EMPLOYEE ONLY 08/26/1961 056 FEMALE 44 4 FL ACTIVE 03559 FAMILY 12/04/1960 056 MALE 44 4 FL ACTIVE 03559 FAMILY 08/19/1985 032 MALE 44 4 FL ACTIVE 03559 FAMILY 05/21/1993 024 (MALE 44 1 FL ACTIVE 03559 (EMPLOYEE ONLY 10/31/1970 047 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 09/01/1927 090 FEMALE 70 1 TX RETIREE 03559 EMPLOYEE ONLY R01 PINELLAS 06/01/2013 * ** *5174 SUBSCRIBER DUNEDIN 80611 34698 OSO BLUEOPTIONS 04/08/2016 C 7 g 001 MONROE 11/01/2011 * * ** *5180 SUBSCRIBER MARATHON 80611 33050 BCC BLUEOPTIONS 08/01/2017 R01 NON - FLORIDA 11/01/2011 * " ** *5181 SPOUSE ROMNEY B0611 26757 BCC BLUEOPTIONS 11/12/2015 12/31/9999 ADDRESS R01 NON - FLORIDA 11/01/2011 * * *" *5181 SUBSCRIBER ROMNEY 80611 26757 BCC BLUEOPTIONS 11/12/2015 12/31/9999 ADDRESS 001 NJONROE 10/10/2015 " * ** *5215 SUBSCRIBER BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 R01 MONROE 02/01/2017 * * *" "5219 DEPENDENT MARATHON 80611 33050 BCC BLUEOPTIONS 02/03/2017 12/31/9999 OA 'O R01 MONROE 02/01/2017 * * *" "5219 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 02/03/2017 12/31/9999 001 MONROE 11/01/2011 "' "" "5223 SUBSCRIBER KEYWEST B0611 33045 OSO BLUEOPTIONS 08/01/2017 12/31/9999 R01 ORANGE 11/01/2011 " *" "5225 SUBSCRIBER ORLANDO B0611 32808 BCC BLUEOPTIONS 12/28/2015 12/31/9999 tti N 001 MONROE 07/04/2014 *" "5225 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 12131/9999 gy 001 MONROE 04/05/2013 ` "" "`5233 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 11/12/2015 12131/9999 001 MONROE 04/05/2013 '5233 SPOUSE KEYWEST B0611 33040 CCC BLUEOPTIONS 11/12/2015 _N 12/31/9999 't a) R01 MIAMI -DADE 02101/2015 ' * ** *5240 SUBSCRIBER HOMESTEAD B0611 33031 OSO BLUEOPTIONS 08/01/2017 12/31/9999 7 001 MONROE 11/01/2011 "" ""5243 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 04/27/2017 12/31/9999 tO 001 MONROE 01/01/2013 ` "" "`5243 DEPENDENT BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 001 MONROE 01/01/2013 ` " "" "5243 DEPENDENT BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 7 001 MONROE 11/01/2011 " °* *5269 SUBSCRIBER KEYLARGO 80611 33037 OSO BLUEOPTIONS 12/03/2013 12/31/9999 O s 001 MONROE 01/27/2012 ' * ** *5270 SUBSCRIBER CUDJOE KEY 80611 33042 BCC BLUEOPTIONS 08/01/2017 12/31/9999 CL 001 MONROE D1/01/2017 " * *" *5274 SUBSCRIBER SUMMERLAND KEY 80611 33042 BCC BLUEOPTIONS 08/01/2017 12/31/9999 R01 NON - FLORIDA 11/01/2011 * " *" "5291 DEPENDENT PALAU 80611 96940 OSO BLUEOPTIONS 08/21/2017 12/31/9999 ADDRESS Q R01 NON - FLORIDA 11/01/2D11 * " "" "5291 SUBSCRIBER PALAU 80611 96940 OSO BLUEOPTIONS 10/13/2017 12/31/9999 ADDRESS R01 MONROE )6101/2016 ""5296 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 01/03/2017 12/31/9999 Uj R01 MONROE 06101/2016 " "" "5296 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 01/03/2017 12/31/9999 R01 MONROE 06/01/2016 *" "5296 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 01/03/2017 12/31/9999 R01 MONROE 06/01/2016 *" "5296 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 �. R01 LEON 11/01/2D11 *" "5297 SUBSCRIBER TALLAHASSEE B0611 32312 BCG BLUEOPTIONS 12/03/2013 12/31/9999 Ua 001 MONROE 11/01/2011 ' * ** *5306 SUBSCRIBER CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 12/31/9999 (JJ 001 MONROE 09/22/2016 '*"'5306 SPOUSE CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 12/31/9999 LU 001 MONROE 01/01/2014 '" "'5306 DEPENDENT CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 0810112017 12/31/9999 U 001 MONROE 10/30/2016 '" "'5307 (SUBSCRIBER (KEYWEST B0611 33040 OSO IBLUEOPTIONS 04/28/2017 12/31/9999 001 MONROE 09/24/2016 "" "5309 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 R01 NON - FLORIDA 11/01/2011 ""'5313 SUBSCRIBER MANSFIELD B0611 76063 CCC BLUEOPTIONS 01/18/2017 12/31/9999 LLJ ADDRESS ME 001 MONROE 05/24/2013 ' "" "5317 SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 11/12/2015 12/31/9999 R01 MONROE 07/01/2012 "" "5317 SUBSCRIBER TAVERNIER B0611 33070 OSO BLUEOPTIONS 08/01/2017 12/31/9999 001 MONROE 08/26/2017 "" "5328 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 08/28/2017 12/31/9999 ~ h 001 MIAMI -DADE 01/01/2015 * * ** *5332 SUBSCRIBER MIAMI B0611 33193 BCC BLUEOPTIONS 08/24/2016 12/31/9999 001 MIAMI -DADE 11/01/2011 * "' *5355 DEPENDENT HOMESTEAD 80611 33030 OSO BLUEOPTIONS 11/18/2014 12/31/9999 C4 001 MIAMI -DADE 11/01/2011 " "" "5355 SUBSCRIBER HOMESTEAD 80611 33030 OSO BLUEOPTIONS 11/18/2014 12/31/9999 m= 001 MONROE O6/16/2013 " "`5355 SUBSCRIBER SUMMERLAND KEY B0611 33042 BCG BLUEOPTIONS 12/03/2013 12/31/9999 = Q) 001 MONROE 11/01/2011 "" *5360 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 12/20/2016 12/31/9999 S 001 MONROE 02/01/2015 " * ** *5360 SPOUSE KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 U 001 MONROE 11/07/2014 " *" *5371 SUBSCRIBER KEYWEST B0611 33040 OPA BLUEOPTIONS 08/01/2017 a+ 12131/9999 +' This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 08/29/2007 010 FEMALE 44 4 FL RETIREE 03559 FAMILY 02/22/1954 063 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 04/09/1951 066 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 11/10/1972 044 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 06/01/1982 035 MALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 08/12/1985 032 FEMALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 04/27/1983 034 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 03/22/1955 062 MALE 16 1 FL RETIREE 03559 EMPLOYEE ONLY 07/12/1984 033 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 11/09/1970 046 '.MALE 44 4 FL ACTIVE 03559 '.FAMILY 10/05/1996 021 MALE 44 4 FL ACTIVE 03559 FAMILY 08/31/1963 054 FEMALE 44 4 FL ACTIVE 03559 FAMILY 02/08/1955 062 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 05/16/1965 052 MALE 44 4 FL ACTIVE 03559 FAMILY 09/20/1961 056 (FEMALE 44 4 FL ACTIVE 03559 (FAMILY 10/21/1998 019 NIALE 44 4 FL ACTIVE 03559 FAMILY 05/22/1957 060 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 04/14/2017 000 FEMALE 44 4 FL ACTIVE 03559 FAMILY 04/12/1979 038 FEMALE 44 4 FL ACTIVE 03559 FAMILY 04/26/1986 031 FEMALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILD 01/18/2017 000 FEMALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILD 10/25/1959 058 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY R01 MONROE 05/01/2014 " " "" "5376 DEPENDENT BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 05/10/2014 001 MONROE 11/01/2011 " "'5441 SUBSCRIBER BIG PINE KEY 001 MONROE 11/01/2011 ""'5441 SPOUSE BIG PINE KEY 001 MIAMI -DADE 11/01/2011 * * ** *5449 SUBSCRIBER HOMESTEAD 001 MIAMI -DADE 01/01/2015 " * ** *5454 SPOUSE HOMESTEAD 001 MIAMI DADE 03/17/2012 * * ** *5454 SUBSCRIBER HOMESTEAD 001 MONROE 11/01/2011 * * *" *5460 SUBSCRIBER .BIG PINE KEY R01 DUVAL 02/01/2013 ' ** "5460 SUBSCRIBER JACKSONVILLE 001 MONROE 03/13/2016 "" "5462 SUBSCRIBER KEY LARGO 001 MONROE 11/01/2011 ' * ** *5469 '.SUBSCRIBER '.KEYWEST 001 MONROE 11/01/2011 "5469 DEPENDENT KEYWEST 001 MONROE 06/01/2015 ' ** *'5469 SPOUSE KEYWEST 001 MONROE 09/25/2015 "' *'5470 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 "' *`5479 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 * *" *5479 (SPOUSE IKEYWEST 001 MONROE 11/01/2011 " "'5479 DEPENDENT KEYWEST 001 MIAMI -DADE 11/01/2011 " *"" "5486 SUBSCRIBER PALMETTO BAY 001 MONROL 07/02/2016 ""'5512 SUBSCRIBER LONG KEY 001 MONROE 04/14/2017 *'" *5512 DEPENDENT LONG KEY 001 MONROE 04/14/2017 ''" *5512 SPOUSE LONG KEY 001 MIAMI DADE 11/01/2011 " *"" *5531 SUBSCRIBER MIAMI 001 MIAMI -DADE 01/18/2017 " * ** *5531 DEPENDENT MIAMI 001 MONROE 11/01/2011 * * ** *5531 SUBSCRIBER KEY WEST B0611 33043 BCC BLUEOPTIONS 08/01/2017 12/31/9999 v B0611 33196 BCC BLUEOPTIONS 10/05/2017 12/31/9999 D B0611 33196 BCC BLUEOPTIONS 10/05/2017 12/31/9999 B0611 33196 BCC BLUEOPTIONS 10/05/2017 12131/9999 w B0611 33040 OTC BLUEOPTIONS 11/30/2016 12131/9999 N fi B0611 33040 OTC BLUEOPTIONS 09/30/2017 12131/9999 � B0611 33040 BCC BLUEOPTIONS 12/17/2013 12131/9999 B0611 33033 OSO BLUEOPTIONS 08/01/2017 12/31/9999 7 B0611 33043 BCC BLUEOPTIONS 12/03/2013 12/31/9999 'U 80611 33043 BCC BLUEOPTIONS 12/03/2013 12/31/9999 O 80611 33032 OSO BLUEOPTIONS 12/03/2013 12/31/9999 B0611 33033 OSO BLUEOPTIONS 08/01/2017 12/31/9999 > 0 1 B0611 33033 OSO BLUEOPTIONS 05/24/2016 12/31/9999 CL CL B0611 33043 BCC BLUEOPTIONS 08/01/2017 12/31/9999 U B0611 32257 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33037 OSO BLUEOPTIONS 07/06/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 07/16/2015 12/31/9999 B0611 33040 OSO BLUEOPTIONS 07/16/2015 12/31/9999 UJI B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 CCC BLUEOPTIONS 07/19/2017 12131/9999 B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 ""' B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 80611 33158 OSO BLUEOPTIONS 08/01/2017 12/31/9999 LIJ 80611 33042 OSO BLUEOPTIONS 11/12/2015 12/31/9999 U B0611 33042 OSO BLUEOPTIONS 11/12/2015 12/31/9999 B0611 33070 OSO BLUEOPTIONS 04/27/2017 12/31/9999 B0611 33070 OSO BLUEOPTIONS 08/01/2017 12/31/9999 W B0611 33050 BCC BLUEOPTIONS 12/03/2013 12/31/9999 X B0611 33050 BCC BLUEOPTIONS 12/03/2013 12/31/9999 ~ B0611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 h B0611 33050 BCC BLUEOPTIONS 12/03/2013 12131/9999 B0611 33070 BCC BLUEOPTIONS 11/30/2016 12131/9999 C4 B0611 32134 BCC BLUEOPTIONS 04/28/2017 12131/9999 m= .r+ = B0611 33001 BCC BLUEOPTIONS 05/18/2017 12/31/9999 Q) B0611 33001 BCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33001 BCC BLUEOPTIONS 08/01/2017 S 12/31/9999 U 80611 33186 OSO BLUEOPTIONS 04/20/2017 12/31/9999 80611 33186 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 01/24/1951 066 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " * ** *5534 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 04/08/2015 10/28/1955 062 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/26/1951 066 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/25/1973 044 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/05/1943 074 NIALE 64 1 FL RETIREE 03559 EMPLOYEE ONLY R01 VOLUSIA 02/10/1976 041 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 04/20/1969 048 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 12/19/1944 072 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 11/11/1954 062 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 09/06/1980 037 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 02/12/1965 052 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/11/1980 037 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 06/20/1946 071 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/22/2007 010 '.MALE 44 3 '.. FL '.. ACTIVE '.. 03559 ' &CHILDREN 001 MONROE 06/11/1983 034 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 05/27/2000 017 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 07/27/1978 039 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 08/13/2002 015 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 06/15/2008 009 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 02/01/1970 047 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 09/28/1957 060 MALE 13 2 FL ACTIVE 03559 EMPLOYEE &SPOUT 02/08/1960 057 FEMALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOU; 01/30/1951 066 FEMALE 57 1 FL RETIREE 03559 EMPLOYEE ONLY 10/15/1957 060 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 11/21/1988 028 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 11/01/2011 '" "`5639 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 12/03/2013 11/01/2011 ` "" "5650 SUBSCRIBER TAVERNIER B0611 33070 OTC BLUEOPTIONS 11/30/2016 11/01/2011 ` "" "`5652 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 11/01/2011 ^ °* *5668 SUBSCRIBER PIERSON 80611 32180 OSO BLUEOPTIONS 08/01/2017 11/01/2011 ' * ** *5675 SUBSCRIBER HOMESTEAD 80611 33035 OSO BLUEOPTIONS 12/03/2013 D4/06/2012 " * *" *5677 SUBSCRIBER MIAMI B0611 33177 BCC BLUEOPTIONS 08/01/2017 11/01/2011 " * *" "5678 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 11/30/2016 01/01/2015 " " *" "5678 SPOUSE MARATHON B0611 33050 BCC BLUEOPTIONS 08/01/2017 01107/2017 " "'" "5692 SUBSCRIBER MIAMI BEACH B0611 33139 BCC BLUEOPTIONS 01/07/2017 01/29/2016 " "" "5698 SUBSCRIBER KEYLARGO B0611 33037 ORA BLUEOPTIONS 08/24/2016 11/01/2011 " "`5701 SUBSCRIBER HIALEAH B0611 33012 OSO BLUEOPTIONS 08/01/2017 11/01/2011 " "`5705 SUBSCRIBER SUMMERLAND KEY B0611 33042 BCC BLUEOPTIONS 12/03/2013 01/01/2016 '.. * * ** *5709 .DEPENDENT '.KEY LARGO B0611 '.. 33037 OSO BLUEOPTIONS '.. 08/01/2017 11/01/2011 * * ** *5709 SUBSCRIBER KEYLARGO B0611 33037 OSO SLUEOPTIONS 01/14/2016 11/01/2011 5722 DEPENDENT BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 03/22/2017 11/23/2011 ` "" "`5722 SPOUSE BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 10/14/2017 01/01/2017 ` "" "`5722 DEPENDENT BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 01/01/2017 DEPENDENT BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 11/01/2011 ' * ** "5722 SUBSCRIBER BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 10/31/2017 001 MWMI -DADE 11/01/2011 " "'5793 SUBSCRIBER MIAMI B0611 33170 BCC Oct MIAMI -DADE 07/16/2014 ` "* "5793 SPOUSE MIAMI B0611 33170 BCC R01 SANTA ROSA 11/01/2011 ` .... I'll SUBSCRIBER PACE B0611 32571 OSO 001 MONROE 11/01/2011 ` "" "`5826 SUBSCRIBER MARATHON B0611 33050 BCC 001 MONROE 11/18/2011 5837 SUBSCRIBER KEYWEST 80611 33040 BCC 05/27/2014 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 08/29/1980 037 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *5839 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 01/30/2017 05/27/1944 073 MALE 44 2 FL RL I IREE 03559 EMPLOYEE &SPOUSE 04/16/1955 062 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE 01/25/2016 001 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDRE 03/15/1989 028 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDRE 01/28/1968 049 FEMALE 44 4 FL ACTIVE 03559 FAMILY 06/28/1961 056 MALE 44 4 FL ACTIVE 03559 FAMILY 11/22/1995 021 MALE 44 4 FL ACTIVE 03559 FAMILY 07/09/1998 019 FEMALE 44 4 FL ACTIVE 03559 FAMILY 08/17/1999 018 MALE 44 4 FL ACTIVE 03559 FAMILY 09/16/1991 026 '.FEMALE 44 4 FL ACTIVE 03559 '.FAMILY 06/11/1981 036 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 07/06/1942 075 FEMALE 13 1 FL RETIREE 03559 EMPLOYEE ONLY 08/21/1973 044 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 04/11/1961 056 MALE 58 1 FL RETIREE 03559 EMPLOYEE ONLY 09/06/1959 058 (FEMALE 44 1 FL ACTIVE 03559 (EMPLOYEE ONLY 10/31/1969 048 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 02/23/1938 079 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 05/26/2008 009 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 04/17/1981 036 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 05/25/1964 053 MALE O6 4 FL ACTIVE 03559 FAMILY 05/15/1968 049 FEMALE O6 4 FL ACTIVE 03559 FAMILY 08/08/2000 017 MALE 06 4 FL ACTIVE 03559 FAMILY R01 MONROE 11/01/2011 " "'5879 SUBSCRIBER MARATHON 001 MONROE 01/01/2017 * * ** *5886 DEPENDENT ISLAMORADA 001 MONROE 01/01/2017 * * ** *5886 SUBSCRIBER ISLAMORADA 001 MONROE 04/24/2015 * * ** *5895 SUBSCRIBER KEYWEST 001 MONROE 04/24/2015 * * ** *5895 SPOUSE KEYWEST 001 MONROE 04/24/2015 * * *" "5895 DEPENDENT .KEYWEST 001 MONROE 04/24/2015 ' *" "5895 DEPENDENT KEYWEST 001 MONROE 04/24/2015 "" "5895 DEPENDENT KEYWEST 001 MONROE 04/24/2015 ' * ** "5895 '.DEPENDENT '.KEYWEST 001 MONROE 11/01/2011 ** *`5898 SUBSCRIBER KEYWEST R02 MIAMI -DADE 05/22/2014 ' ** *'5913 SUBSCRIBER HOMESTEAD 001 MONROE 11/01/2011 "' *'5913 SUBSCRIBER KEYWEST R01 SARASOTA 09/01/2012 "' *`5917 SUBSCRIBER SARASOTA 001 MONROE 11/01/2011 * *'" "5919 (SUBSCRIBER (BIG PINE KEY 001 MIAMI -DADE 11/01/2011 " "'5934 SUBSCRIBER HOMESTEAD 001 MONROE 11/01/2011 * * ** *5938 SUBSCRIBER KEYWEST 001 MONROE 03/04/2012 *.... I'll DEPENDENT CUDJOE KEY 001 MONROE 03/04/2012 ''" *5963 SUBSCRIBER CUDJOE KEY 001 BROV4ARD 11/01/2011 * *** *5971 SUBSCRIBER WESTON 001 BROWARD 06/04/2015 * * ** *5971 SPOUSE WESTON 001 BROVJARD 01/01/2015 * * ** *5971 DEPENDENT WESTON B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 v B0611 33040 OSO BLUEOPTIONS 01/21/2017 12/31/9999 D B0611 33050 OSO BLUEOPTIONS 07/19/2017 12/31/9999 B0611 33050 OSO BLUEOPTIONS 07/19/2017 12131/9999 w B0611 33031 BCC BLUEOPTIONS 08/01/2017 12131/9999 N fi B0611 33042 BCC BLUEOPTIONS 12/03/2013 12131/9999 � 80611 33037 BCC BLUEOPTIONS 08/01/2017 12131/9999 B0611 33050 OSO BLUEOPTIONS 03/16/2017 12/31/9999 y B0611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 'U 80611 33036 OSO BLUEOPTIONS 08/01/2017 12/31/9999 O 80611 33036 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 > O 1 B0611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 CL CL B0611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 U B0611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 UJ B0611 33030 OSO BLUEOPTIONS 08/24/2016 12/31/9999 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 80611 34232 BCC BLUEOPTIONS 04/28/2017 12/31/9999 ""' B0611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33033 OSO BLUEOPTIONS 05/12/2015 12/31/9999 80611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 LU 80611 32738 OSO BLUEOPTIONS 08/01/2017 12/31/9999 U B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 06/09/2014 12/31/9999 W B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 y B0611 33040 OPA BLUEOPTIONS 02/04/2017 12/31/9999 ~ B0611 33040 OPA BLUEOPTIONS 01/05/2017 12/31/9999 h B0611 33040 OPA BLUEOPTIONS 08/01/2017 12131/9999 B0611 33040 OTC BLUEOPTIONS 12/03/2013 12131/9999 C4 B0611 33870 BCC BLUEOPTIONS 01/02/2017 12131/9999 m= .r+ = B0611 33042 BCC BLUEOPTIONS 08/01/2017 12/31/9999 Q) 80611 33042 BCC BLUEOPTIONS 11/02/2015 12/31/9999 B0611 33042 BCC BLUEOPTIONS 01/20/2015 S 12/31/9999 U 80611 33331 OSO BLUEOPTIONS 08/01/2017 12/31/9999 80611 33331 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33331 OSO BLUEOPTIONS 08/01/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 01/28/2009 008 NIALE 06 4 FL ACTIVE 03559 FAMILY 001 BROVN /ARD 01/01/2015 * * ** *5971 DEPENDENT WESTON B0611 33331 OSO BLUEOPTIONS 08/01/2017 08/03/2000 017 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 .... I'll DEPENDENT TAVERNIER 80611 33070 OTC BLUEOPTIONS 03/09/2016 02/04/1964 053 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *5988 SPOUSE TAVERNIER B0611 33070 OTC BLUEOPTIONS 03/09/2016 12/24/1995 021 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *5988 DEPENDENT TAVERNIER B0611 33070 OTC BLUEOPTIONS 03/09/2016 02/06/1965 052 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *5988 SUBSCRIBER TAVERNIER B0611 33070 OTC BLUEOPTIONS 03/09/2016 06/14/1960 057 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * *" *5990 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 04/27/2017 06/24/1959 058 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 08/01/2017 * * *" "5993 SUBSCRIBER LITTLE TORCH KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 06/03/1962 055 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 08/01/2017 ' *" "5993 SPOUSE LITTLE TORCH KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 07/11/1964 053 FEMALE 60 1 FL RETIREE 03559 EMPLOYEE ONLY R01 SUMTER 10/01/2014 "" "6005 SUBSCRIBER THE VILLAGES B0611 32162 OSE BLUEOPTIONS 08/01/2017 03/29/1957 060 '.FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "" "6007 '.SUBSCRIBER '.KEYWEST B0611 33040 CCC BLUEOPTIONS 12/03/2013 11/16/1951 065 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 6015 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 04/15/1964 053 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/27/2015 " "6018 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 08/10/2017 05/02/1977 040 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/08/2014 "' *'6019 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 04/27/2017 04/26/1963 054 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "' *`6022 SUBSCRIBER KEYWEST B0611 33040 OPA BLUEOPTIONS 08/01/2017 01/21/1965 052 'FEMALE 44 4 FL ACTIVE 03559 'FAMILY 001 MONROE 01101/2015 * *'" "6023 'SPOUSE 'KEYWEST B0611 33040 OSO 'BLUEOPTIONS 08/01/2017 09/19/1998 019 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2015 " "'6023 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 01/01/1964 053 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *6023 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 07/03/1950 067 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** *6027 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 01/13/1981 036 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/01/2017 * * ** *6028 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 01/02/2017 07/08/1952 065 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R02 MONROE 11/01/2011 * * *" *6029 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/02/2016 09/21/1980 037 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/14/2017 * * *" "6029 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 10/14/2017 11/12/1978 038 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' "" "6043 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 04/27/2017 09/22/1989 028 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/31/2016 "" "'6049 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 09/12/1972 045 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 "" "6053 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 02/14/2017 01/10/1939 078 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 6053 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 03/10/2015 04/30/1995 022 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2017 " "6053 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 03/30/2000 017 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2017 "' *'6053 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 07/21/2004 013 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 "' *`6053 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 04/05/2017 09/12/1947 070 MALE 70 1 PA RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 11/01/2011 "" "6075 SUBSCRIBER BUTLER B0611 16001 BCC BLUEOPTIONS 11/30/2016 ADDRESS 08/14/1967 050 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/01/2017 — 6080 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 02/18/1996 021 NIALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 06/10/2017 — 6084 SUBSCRIBER TAVERNIER B0611 33070 OSO BLUEOPTIONS 10/20/2017 02/27/1998 019 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 10/20/2017 ' * ** *6084 SPOUSE TAVERNIER 80611 33070 OSO BLUEOPTIONS 10/20/2017 10/24/1952 065 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/13/2016 * * ** *6090 SUBSCRIBER CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 08/24/2016 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 F 08/13/1977 040 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " * ** "6104 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 12/17/2014 06/27/1985 032 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MWMI -0ADE 03/19/1968 049 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/08/1954 063 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 02/10/2003 014 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/24/1976 040 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/27/1993 024 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 06/12/1941 076 MALE 08 1 FL RETIREE 03559 EMPLOYEE ONLY R01 CHARLOTTE 04/12/1969 048 FEMALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 05/27/2004 013 FEMALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 12/27/1999 017 MALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 02/01/1968 049 MALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 09/22/1967 050 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 04/07/1995 022 '.FEMALE 44 3 '.. FL '.. ACTIVE '.. 03559 ' &CHILDREN 001 MONROE 08/27/1959 058 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/15/1966 051 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/13/1974 042 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 12/18/1961 055 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 08/30/1958 059 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 02/25/1982 035 FEMALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 06/02/2015 002 FEMALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 11/16/2012 004 MALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 03/21/1985 032 MALE 13 4 FL ACTIVE 03559 FAMILY 001 MIAMI -DADE 08/25/1990 027 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 07/31/1969 048 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 12/06/1990 026 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 10/21/1974 043 FEMALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 03/18/1967 050 MALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 09/11/1950 067 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 08/04/1950 067 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 03/19/1954 063 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/27/1990 026 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 10/21/1937 080 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 06/18/2016 6198 SUBSCRIBER HOMESTEAD B0611 33031 BCC BLUEOPTIONS 08/01/2017 11/01/2011 "'" "6203 SUBSCRIBER CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 02/18/2015 09/11/2015 " "'" "6205 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 08/01/2017 11/01/2011 ^ °* "6210 DEPENDENT KEYWEST 80611 33040 OPA BLUEOPTIONS 08/02/2016 11/01/2011 ' * ** "6210 SUBSCRIBER KEYWEST 80611 33040 OPA BLUEOPTIONS 08/02/2016 11/01/2011 " * *" *6210 DEPENDENT KEYWEST B0611 33040 OPA BLUEOPTIONS 08/02/2016 11/01/2011 " * *" "6214 SUBSCRIBER PORT CHARLOTTE B0611 33981 BCC BLUEOPTIONS 10/17/2017 01/01/2016 " "'" "6215 SPOUSE MIAMI B0611 33177 OSO BLUEOPTIONS 08/01/2017 01101/2016 " "'" "6215 DEPENDENT MIAMI B0611 33177 OSO BLUEOPTIONS 08/01/2017 01/01/2016 " "" "6215 DEPENDENT MIAMI B0611 33177 OSO BLUEOPTIONS 08/01/2017 11/01/2011 "" "`6215 SUBSCRIBER MIAMI B0611 33177 OSO BLUEOPTIONS 08/01/2017 07/29/2013 " "`6227 SUBSCRIBER MARATHON B0611 33050 CCC BLUEOPTIONS 12/03/2013 07/29/2013 * * ** *6227 .DEPENDENT ',MARATHON B0611 33050 CCC BLUEOPTIONS 12/03/2013 11/01/2011 ' * ** *6234 SUBSCRIBER KEYWEST B0611 33041 OPA SLUEOPTIONS 12/03/2013 11/01/2011 '6235 SUBSCRIBER DUCK KEY B0611 33050 OSO BLUEOPTIONS 03/31/2014 01/01/2014 "' "'6235 SPOUSE DUCK KEY B0611 33050 OSO BLUEOPTIONS 08/01/2017 08/21/2015 " "'" "6241 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/24/2016 08/21/2015 ' ° "* "6241 SPOUSE KEYWEST 80611 33040 CCC BLUEOPTIONS 08/24/2016 07/13/2012 ' * *" "6245 SPOUSE MIAMI 80611 33186 BCC BLUEOPTIONS 10/30/2017 11/01/2011 " "1263 SUBSCRIBER KEY LARGO B0611 33037 OSO BLUEOPTIONS 08/01/2017 12131/9999 02/05/2012 " "' "'6272 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 12/03/2013 12/31/9999 03/27/2015 " "'" "6275 SUBSCRIBER HOMESTEAD B0611 33033 OSO BLUEOPTIONS 07/07/2017 12/31/9999 11/01/2011 6276 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 12/27/2014 12/31/9999 06/14/1960 057 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 12/06/2013 ""'6277 SUBSCRIBER LITTLE TORCH KEY 80611 33042 BCC BLUEOPTIONS 08/24/2016 01/31/1944 073 FEMALE 70 1 AL RETIREE 03559 EMPLOYEE ONLY R01 NON- FLORIDA 11/01/2011 ' ** "6290 SUBSCRIBER TITUS B0611 36080 CCC BLUEOPTIONS 01/02/2017 12/31/9999 Qj ADDRESS _ -0 12/13/1989 027 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/25/2016 "* "'6290 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 06/05/2017 12/31/9999 = 10/28/1951 066 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 10/01/2015 '* "'6294 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 04/28/2017 12/31/9999 w w 06/06/1996 019 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 12/01/2015 "" "6303 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 g1 12/05/1947 069 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ' * ** "6303 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 01/02/2017 12131/9999 N fi 03/11/1979 038 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/30/2015 * * ** "6303 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12131/9999 w N 05/11/1983 034 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** *6313 SUBSCRIBER KEY LARGO 80811 33037 OSO BLUEOPTIONS 12/03/2013 12131/9999 .® 04105/1989 028 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'6314 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 02/14/2017 12/31/9999 y 10/07/1961 056 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/05/2013 * ** "6316 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 fu 10/02/1997 020 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/05/2013 ' * "' "6316 DEPENDENT KEYWEST 80611 33040 BCC BLUEOPTIONS 04/20/2017 12/31/9999 05/29/1993 024 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/05/2013 ' *'" "6316 DEPENDENT KEYWEST 80611 33040 BCC BLUEOPTIONS 04/20/2017 12/31/9999 tO 7 02/02/1986 031 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 06/09/2017 * * ** "6329 SPOUSE ISLAMORADA 80611 33036 BCC BLUEOPTIONS 08/01/2017 12/31/9999 2 s 02/08/1984 033 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 01/06/2015 * * ** *6329 SUBSCRIBER ISLAMORADA 80611 33036 BCC BLUEOPTIONS 08/01/2017 12/31/9999 C ' CL 05/17/1987 030 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' ** "'6331 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 04/27/2017 12/31/9999 12/28/2007 009 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/20/2012 ' ** "'6331 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 09/09/2012 005 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 09/09/2012 ' ** "'6331 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 01/20/1966 051 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'6334 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12/31/9999 ILLI 05/05/1985 032 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "" "6349 SUBSCRIBER KEYWEST B0611 33041 OSE BLUEOPTIONS 08/01/2017 12131/9999 '.FEMALE ' * ** "6357 '.SUBSCRIBER 08/12/1956 061 54 1 FL RETIREE 03559 EMPLOYEE ONLY R01 PUTNAM 05/01/2015 INTERLACHEN B0611 32148 BCC BLUEOPTIONS 04/28/2017 12131/9999 08/06/1944 073 FEMALE 11 1 FL RETIREE 03559 EMPLOYEE ONLY R01 COLLIER 11/01/2011 * * ** "6360 SUBSCRIBER NAPLES B0611 34112 OTC BLUEOPTIONS 03/16/2017 12131/9999 01/02/1942 075 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * * *' *6371 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 02/04/2017 12/31/9999 �. 08/10/1960 057 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/30/2015 '" **'6375 SUBSCRIBER CUDJOE KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 12/31/9999 11/24/1956 060 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 01/01/2015 ` * ** *6383 SPOUSE TAVERNIER B0611 33070 OCA BLUEOPTIONS 01/20/2015 12/31/9999 09/04/1996 021 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/01/2017 ' * "' "6383 SUBSCRIBER KEYLARGO 80611 33037 OSO BLUEOPTIONS 07/01/2017 12/31/9999 LU U 02/19/1961 056 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/12/2016 ' *'" "6384 SUBSCRIBER LONG KEY 80611 33001 BCC BLUEOPTIONS 08/01/2017 12/31/9999 07/26/1964 053 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** "6385 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 02/26/1933 084 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ' * *' *6398 SUBSCRIBER TAVERNIER 80611 33070 BCC BLUEOPTIONS 04/28/2017 12131/9999 LLJ 09/29/1966 051 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' ** "'6402 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 10/10/1955 062 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "* "'6403 SUBSCRIBER CUDJOE KEY B0611 33042 CCC BLUEOPTIONS 04/19/2017 12/31/9999 U 10/13/1938 079 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 11/01/2011 ' ** "'6403 SPOUSE DUCK KEY B0611 33050 BCC BLUEOPTIONS 03/10/2015 12/31/9999 h 04/29/1935 082 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 11/01/2011 " "'6403 SUBSCRIBER DUCK KEY B0611 33050 BCC BLUEOPTIONS 12/03/2013 12131/9999 F- 08/01/1968 049 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "" "6407 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 12/03/2013 12131/9999 M 04/27/1991 026 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/15/2014 ' * ** "6415 SUBSCRIBER TAVERNIER B0611 '. 33070 OSO BLUEOPTIONS 08/24/2016 12131/9999 ' N 02/13/1964 053 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/01/2014 * * ** "6418 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 07/22/2014 12131/9999 .w C 04/09/2006 011 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/01/2014 " "'6418 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 07/22/2014 12/31/9999 4! 06/13/1948 069 MALE 28 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 HIGHLANDS 01/01/2015 * ** "6430 SPOUSE SEBRING B0611 33870 BCC BLUEOPTIONS 05/02/2017 12/31/9999 01/03/1948 069 FEMALE 28 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 HIGHLANDS 01/01/2015 " 6430 SUBSCRIBER SEBRING B0611 33870 BCC BLUEOPTIONS 05/02/2017 12/31/9999 08/14/1985 032 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 07/10/2017 ' * "' "6443 SUBSCRIBER HOMESTEAD 80611 33033 OSO BLUEOPTIONS 08/28/2017 12/31/9999 12/03/1955 061 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * ** "6446 SUBSCRIBER SUMMERLAND KEY 80611 33042 BCC BLUEOPTIONS 12/03/2013 12/31/9999 12/27/1984 032 MALE 13 2 FL ACTIVE 03559 EMPLOYEE& SPOUSE 001 MIAMI -DADE 11/01/2011 " * "* *6452 SUBSCRIBER MIAMI 80611 33177 BCC BLUEOPTIONS 02/24/2016 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 920 06/24/1987 030 FEMALE 13 2 FL ACTIVE 03559 EMPLOYEE &SPOUSE 001 MIAMI -DADE 02/22/2016 * * ** "6452 SPOUSE MIAMI B0611 33177 BCC BLUEOPTIONS 08/01/2017 09/19/1969 048 MALE 44 4 FL ACTIVE 03559 FAMILY 11/30/1974 042 FEMALE 44 4 FL ACTIVE 03559 FAMILY 01/06/2011 006 MALE 44 4 FL ACTIVE 03559 FAMILY 04/30/1981 036 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 05/21/1994 023 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 06/07/1997 020 FEMALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 10/06/1978 039 FEMALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 09/16/1974 043 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 04/25/1997 020 '.MALE 44 3 FL ACTIVE 03559 '.EMPLOYEE &CHILDREN 05/11/1966 051 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 01/11/1970 047 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 08/05/1969 048 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 12/11/1991 025 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 12/25/1975 041 (FEMALE 44 4 FL ACTIVE 03559 (FAMILY 05/31/2006 011 NIALE 44 4 FL ACTIVE 03559 FAMILY 06/25/1968 049 NIALE 44 4 FL ACTIVE 03559 FAMILY 02/22/1964 053 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 01/24/1953 064 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 08/31/1991 026 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/15/1988 029 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 12/18/1960 056 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 002 MONROE 01/01/2015 " "'6528 SUBSCRIBER KEYLARGO 002 MONROE 01/01/2015 * * ** "6528 SPOUSE KEYLARGO 002 MONROE 01/01/2015 " * ** *6528 DEPENDENT KEYLARGO 001 MONROE 11/01/2011 " * ** "6530 SUBSCRIBER KEYWEST 001 MIAMI DADE 01/01/2016 * * ** *6535 DEPENDENT HOMESTEAD 001 MIAMI -DADE 11/01/2011 * * *" *6535 DEPENDENT HOMESTEAD 001 MIAMI -DADE 11/01/2011 ' ** "6535 SUBSCRIBER HOMESTEAD 001 MONROE 11/01/2011 "" "6538 SUBSCRIBER KEYWEST 001 MONROE 04/30/2016 ' * ** *6538 '.DEPENDENT '. KEYWEST 001 MONROE 11/01/2011 "6567 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 ' ** *'6598 SUBSCRIBER KEYLARGO 001 MONROE 11/01/2011 "' *'6598 SUBSCRIBER KEYWEST 001 MONROE 03/12/2016 "' *`6603 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 * *" *6609 (SPOUSE ICUDJOE KEY 001 MONROE 11/01/2011 " "'6609 DEPENDENT CUDJOE KEY 001 MONROE 11/01/2011 * * "* "6609 SUBSCRIBER CUDJOE KEY 001 MONROE 11/01/2011 *'" *6692 SUBSCRIBEF R01 MONROE 06/01/2013 ''" *6695 SUBSCRIBEF 001 MONROE 11/01/2011 * *** *6699 SUBSCRIBEF 001 MONROE 04/01/2017 " * ** *6702 DEPENDENT 001 MONROE 04/01/2017 * * ** *6702 SUBSCRIBEF B0611 33036 OPA BLUEOPTIONS 03/03/2017 12/31/9999 v B0611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 D B0611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 CCC BLUEOPTIONS 08/01/2017 12131/9999 w B0611 33040 OTC BLUEOPTIONS 12/03/2013 12131/9999 N fi B0611 33040 OTC BLUEOPTIONS 12/03/2013 12131/9999 � B0611 33040 OTC BLUEOPTIONS 12/03/2013 12131/9999 B0611 33042 OSO BLUEOPTIONS 08/01/2017 12/31/9999 7 B0611 33037 OSO BLUEOPTIONS 08/01/2017 12/31/9999 'U B0611 33037 OSO BLUEOPTIONS 08/01/2017 12/31/9999 O B0611 33037 OSO BLUEOPTIONS 02/18/2015 12/31/9999 B0611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 > O 1 B0611 33033 OSO BLUEOPTIONS 05/21/2016 12/31/9999 CL CL B0611 33033 OSO BLUEOPTIONS 02/14/2017 12/31/9999 U B0611 33033 OSO BLUEOPTIONS 09/27/2017 12/31/9999 B0611 33040 CCC BLUEOPTIONS 09/10/2016 12/31/9999 B0611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 12/31/2016 12/31/9999 IJJ B0611 33037 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 B0611 33040 OSO BLUEOPTIONS 04/28/2017 12/31/9999 ""' B0611 33042 OSO BLUEOPTIONS 12/03/2013 12/31/9999 B0611 33042 OSO BLUEOPTIONS 12/03/2013 12/31/9999 B0611 33042 OSO BLUEOPTIONS 12/03/2013 12/31/9999 LIJ B0611 33050 OTC BLUEOPTIONS 04/20/2017 12/31/9999 U B0611 33040 BCC BLUEOPTIONS 03/16/2017 12/31/9999 B0611 33035 BCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 BCC BLUEOPTIONS 03/09/2017 12/31/9999 W B0611 33040 BCC BLUEOPTIONS 03/09/2017 12/31/9999 X B0611 32096 DSO BLUEOPTIONS 08/01/2017 12/31/9999 ~ B0611 33870 OSO BLUEOPTIONS 08/01/2017 12/31/9999 h B0611 33050 BCC BLUEOPTIONS 06/29/2016 12131/9999 B0611 33043 BCC BLUEOPTIONS 06/29/2016 12131/9999 C4 B0611 33037 BCC BLUEOPTIONS 03/02/2017 12131/9999 m= .r+ = B0611 33810 OSO BLUEOPTIONS 08/01/2017 12/31/9999 Q) B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 CCC BLUEOPTIONS 06/29/2016 S 12/31/9999 U B0611 33040 BCC BLUEOPTIONS 04/28/2017 12/31/9999 B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 11/08/1963 053 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/17/2016 * * ** "6702 SUBSCRIBER 10/27/1941 076 MALE 64 1 FL RETIREE 03559 EMPLOYEE ONLY R01 VOLUSIA 11/01/2011 " "'6811 SUBSCRIBER NEW SMYRNA EMPLOYEE &SPOU' 057 MALE 70 2 TN RETIREE 03559 EMPLOYEE &SPOUT 037 MALE 13 1 FL BEACH 12/27/1970 046 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * "" "6813 SUBSCRIBER KEYWEST 04/15/1960 057 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 " 6814 SUBSCRIBER TAVERNIER 07/20/1968 049 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** "6815 SUBSCRIBER KEYWEST 08/11/1958 059 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * *' *6818 SUBSCRIBER KEYWEST 07/30/1971 046 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * ** "6839 SUBSCRIBER KEYWEST 05/27/1990 027 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 02/12/2016 * ** "6842 SUBSCRIBER CUTLER BAY 11/01/1991 025 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' ** "6850 DEPENDENT KEYWEST 05/28/1963 054 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " "'6850 SUBSCRIBER KEYWEST 07/06/1970 047 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 " "" "6854 SPOUSE BIG PINE KEY 02/20/1965 052 '.MALE 44 2 FL ACTIVE 03559 '.EMPLOYEE &SPOUSE 001 MONROE 11/01/2011 ' " "" "6854 '.SUBSCRIBER '.BIG PINE KEY 04/29/1979 038 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 ` * ** "6856 SUBSCRIBER MARATHON 03/23/1983 034 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 01/01/2016 * *" *6856 SPOUSE MARATHON 09/27/1953 064 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 09/01/2013 '6112 SUBSCRIBER KEYWEST 06/08/1975 042 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 "* "6865 SUBSCRIBER TAVERNIER 12/23/1995 021 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/07/2017 " 6865 DEPENDENT TAVERNIER 05/26/1999 018 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/07/2017 " 6865 DEPENDENT TAVERNIER 07/08/1945 072 FEMALE 37 1 FL RETIREE 03559 EMPLOYEE ONLY R01 LEON 11/01/2011 * * ** "6867 SUBSCRIBER TALLAHASSEE OS2 MALL 44 2 FL ACIIVL 03SS9 EMPLOYEE &SPOU1 058 FEMALE 70 2 TN RETIREE 03559 EMPLOYEE &SPOU' 057 MALE 70 2 TN RETIREE 03559 EMPLOYEE &SPOUT 037 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 054 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 065 FEMALE 08 1 FL RETIREE 03559 EMPLOYEE ONLY B0611 33040 BCC BLUEOPTIONS 04/28/2017 80611 32168 OSO BLUEOPTIONS 02/27/2016 80611 33040 BCC BLUEOPTIONS 04/18/2016 80611 33070 ISO BLUEOPTIONS 08/01/2017 B0611 33040 BCC BLUEOPTIONS 08/01/2017 B0611 33040 ORA BLUEOPTIONS 12/03/2013 B0611 33040 BCC BLUEOPTIONS 08/01/2017 B0611 33157 BCC BLUEOPTIONS 04/28/2017 B0611 33040 OSO BLUEOPTIONS '.. 03/02/2017 B0611 33040 OSO BLUEOPTIONS 02/15/2017 B0611 33043 OSO BLUEOPTIONS '.. 01/02/2017 B0611 '.. 33043 OSO BLUEOPTIONS '.. 08/01/2017 B0611 33050 OSO BLUEOPTIONS '.. 02/24/2016 B0611 33050 OSO BLUEOPTIONS 08/01/2017 B0611 33040 OSO BLUEOPTIONS 08/01/2017 B0611 33070 BCC BLUEOPTIONS 07/07/2017 80611 33070 BCC BLUEOPTIONS 08/01/2017 80611 33070 BCC BLUEOPTIONS 08/01/2017 B0611 32317 ISO BLUEOPTIONS 03/16/2017 R01 NON - FLORIDA 02/02/2015 " "'6910 SPOUSE ROAN MOUNTAIN B0611 37687 ADDRESS R01 NON - FLORIDA 02/02/2015 —I'll SUBSCRIBER ROAN MOUNTAIN B0611 37687 ADDRESS 001 MIAMI -DADE 11/01/2011 " "'6915 SUBSCRIBER MIAMI 80611 33186 001 MONROE 06/14/2013 "" "6916 SUBSCRIBER KEYWEST B0611 33040 R01 CHARLOTTE 07/01/2014 "" "`6922 SUBSCRIBER ROTONDA WEST B0611 33947 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 03/17/1941 076 FEMALE 48 1 FL RETIREE 03559 EMPLOYEE ONLY 09/08/1954 053 FEMALE 44 2 FL RL I IRLL 03559 EMPLOYEE &SPOUSE 11/12/1953 063 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE 11/16/1976 040 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 08/26/1989 028 FEMALE 44 4 FL RETIREE 03559 FAMILY 01/31/1961 056 MALE 44 4 FL RETIREE 03559 FAMILY 12/10/1965 051 FEMALE 44 4 FL RETIREE 03559 FAMILY 10/17/1986 031 MALE 44 4 FL ACTIVE 03559 FAMILY 08/16/2017 000 MALE 44 4 FL ACTIVE 03559 FAMILY 01/28/1988 029 FEMALE 44 4 FL ACTIVE 03559 FAMILY 10/08/2013 004 .FEMALE 44 4 '.. FL '.. ACTIVE '.. 03559 '.FAMILY 0710811966 051 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 03/29/1964 053 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/06/1944 073 FEMALE 13 1 FL RETIREE 03559 EMPLOYEE ONLY 06/22/1991 026 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 01/28/1982 035 (FEMALE 44 3 FL ACTIVE 03559 (EMPLOYEE &CHILDREN 08/15/2006 011 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 05/26/1948 069 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE 063 FEMALE 52 1 FL RETIREE 03559 EMPLOYEE ONLY 054 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 033 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOU: This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 R01 ORANGE 11/01/2011 ""'6925 SUBSCRIBER APOPKA B0611 32703 BCC BLUEOPTIONS 03/03/2017 R01 MONROE 03/01/2014 " "'6959 SUBSCRIBER KEYLARGO 80611 33037 BCC BLUEOPTIONS 04/30/2014 001 MIAMI -DADE 11/05/2011 " " "" *6961 SUBSCRIBER MIAMI 80611 33175 OSO BLUEOPTIONS 08/01/2017 R01 MONROE 12/01/2013 * * ** *6962 DEPENDENT KEYWEST 80611 33040 BCC BLUEOPTIONS 12/04/2013 R01 MONROE 12/01/2013 * * ** *6962 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/04/2013 R01 MONROE 12/01/2013 * * "' *6962 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 12/04/2013 001 MONROE 07/18/2014 * * "' *6962 SUBSCRIBER KEYWEST B0611 33040 OTC BLUEOPTIONS 08/24/2016 001 MONROE 08/16/2017 '* "'6962 DEPENDENT KEYWEST B0611 33040 OTC BLUEOPTIONS 09/30/2017 001 MONROE 01/01/2016 "" "6962 SPOUSE KEYWEST B0611 33040 OTC BLUEOPTIONS 08/24/2016 001 MONROE 07/18/2014 ' "' *6962 '.DEPENDENT (KEYWEST B0611 '.. 33040 OTC IBLUEOPTIONS '.. 08/24/2016 001 MONROE 11/01/2011 —I'll SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 12/03/2013 001 MONROE 01/01/2017 "' *'7026 SUBSCRIBER CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 01/02/2017 R01 MIAMI -DADE 09/01/2012 " "'7037 SUBSCRIBER FLORIDA CITY B0611 33034 BCC BLUEOPTIONS 06/29/2016 001 MONROE 03/27/2015 "' *`7041 SUBSCRIBER KEYLARGO 80611 33037 080 BLUEOPTIONS 08/24/2016 001 MONROE 11/01/2011 * *" *7048 'SUBSCRIBER 'KEYWEST B0611 33040 OSO 'BLUEOPTIONS 08/01/2017 001 MONROE 11/01/2011 " "'7048 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 R01 MONROE 11/01/2011 " " "* "7049 SUBSCRIBER BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 001 MONROE 07/15/2017 " "'7103 SUBSCRIBER KEY WEST B0611 33040 R01 PINELLAS 11/01/2011 '* "'7114 SUBSCRIBER CLEARWATER B0611 33756 R01 MONROE 02/01/2012 ` *" "7118 SUBSCRIBER KEYWEST B0611 33040 001 MONROE 11/01/2011 ` "'7133 SUBSCRIBER KEYWEST B0611 33040 08/30/1989 028 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE &SPOUSE 001 MONROE 01/01/2016 ""'7133 SPOUSE KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/02/1961 055 MALL 44 2 FL ACIIVL 03559 EMPLOYEE & SPOUSE 09/16/1970 047 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 07/07/1967 050 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/07/1991 026 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 03/21/1988 029 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/28/1947 070 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 05/01/1990 027 FEMALE 44 4 FL ACTIVE 03559 FAMILY 11/03/1997 019 : MALE 44 4 : FL : ACTIVE : 03559 : FAMILY 06/30/1968 049 MALE 44 4 FL ACTIVE 03559 FAMILY 09/13/1968 049 '.FEMALE 44 4 FL ACTIVE 03559 '.FAMILY 08/07/1979 038 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 11/30/2010 006 : FEMALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE & CHILDREN 04/09/1995 022 : FEMALE 44 1 : FL : ACTIVE : 03559 : EMPLOYEE ONLY 11/13/2007 009 : FEMALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE & CHILDREN 11/04/2010 006 (MALE 44 3 FL ACTIVE 03559 (EMPLOYEE &CHILDREN 02/03/1984 033 : MALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE & CHILDREN 09/18/1986 031 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 01/20/1961 056 : FEMALE 44 1 : FL : ACTIVE : 03559 : EMPLOYEE ONLY 07/26/1983 034 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/16/1959 058 MALE 24 1 FL RETIREE 03559 EMPLOYEE ONLY 12/08/1982 034 : MALE 44 1 FL ACTIVE 03559 : EMPLOYEE ONLY 09/04/1954 063 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 001 MONROL 10/29/2012 ""'7198 SUBSCRIBER KLYWLSI 001 MIAMI -DADE 11/01/2011 " "'7199 SUBSCRIBER HOMESTEAD 001 MONROE 06/25/2017 ""'7202 SUBSCRIBER MARATHON 001 MONROE 05/01/2015 * * ** *7208 SUBSCRIBER KEYWEST 001 MONROE 07/03/2017 * * ** *7209 SUBSCRIBER KEYWEST R01 MONROE 01/01/2015 * * ** *7212 SUBSCRIBER KEYWEST 001 MONROE 02/15/2013 * * *" *7236 DEPENDENT .KEYWEST 001 MONROE 02/15/2013 : ' ** "7236 : DEPENDENT : KEYWEST 001 MONROE 02/15/2013 "" "7236 SUBSCRIBER KEYWEST 001 MONROE 02/15/2013 ' * ** *7236 '.SPOUSE '.KEYWEST 001 MONROE 11/01/2011 '7211 SUBSCRIBER TAVERNIER 001 MONROE 01/01/2015 : ' *" *'7238 : DEPENDENT TAVERNIER 001 MONROE 06/06/2015 : "' *'7239 : SUBSCRIBER : KEYWEST 001 MONROE 11/05/2011 : "' *`7255 : DEPENDENT : KEYLARGO 001 MONROE 11105/2011 * *" *7255 (DEPENDENT IKEYLARGO 001 MONROE 11/05/2011 : " "'7255 : SUBSCRIBER :KEYLARGO 001 MIAMI -DADE 11/01/2011 " """ *7258 SUBSCRIBER HOMESTEAD 001 MONROE 11/01/2011 : ""'7273 001 MONROE 07/18/2014 '" ^7280 R01 HAMILTON 11/01/2011 " " "* "7292 001 MONROE 11/01/2011 * * ** *7296 R01 MONROE 01/01/2017 * * ** *7298 B0611 33040 OSO BLUEOPTIONS 08/24/2016 12/31/9999 v B0611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 D B0611 32425 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 32425 OSO BLUEOPTIONS 08/01/2017 12131/9999 w B0611 33050 BCC BLUEOPTIONS 04/19/2017 12131/9999 N fi B0611 33036 OSO BLUEOPTIONS 08/24/2016 12131/9999 � B0611 33040 BCC BLUEOPTIONS 08/01/2017 12131/9999 B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 y 80611 33033 OSO BLUEOPTIONS 08/01/2017 12/31/9999 'U 80611 33050 BCC BLUEOPTIONS 06/26/2017 12/31/9999 O 80611 : 33040 OTC : BLUEOPTIONS : 07/07/2017 : 12/31/9999 B0611 33040 OSO BLUEOPTIONS 07/06/2017 12/31/9999 > O 1 B0611 33040 BCC BLUEOPTIONS 11/30/2016 12/31/9999 CL CL B0611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 U B0611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33070 OSO BLUEOPTIONS 05/12/2015 12/31/9999 L!J B0611 : 33070 OSO : BLUEOPTIONS : 08/01/2017 : 12/31/9999 B0611 33040 OSO BLUEOPTIONS 08/24/2016 12131/9999 B0611 : 33037 OSO : BLUEOPTIONS : 08/01/2017 B0611 33037 OSO BLUEOPTIONS 08/01/2017 12/31/9999 80611 : 33037 OSO : BLUEOPTIONS : 08/01/2017 : 12/31/9999 80611 : 33033 BCC : BLUEOPTIONS : 02/03/2016 : 12/31/9999 LU 80611 33040 OTC BLUEOPTIONS 08/01/2017 12/31/9999 U B0611 33040 OTC : BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OTC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33155 OSO BLUEOPTIONS 08/24/2016 12/31/9999 W B0611 33155 OSO BLUEOPTIONS 08/01/2017 12/31/9999 y B0611 33324 DSO BLUEOPTIONS 05/12/2015 12/31/9999 ~ B0611 33324 OSO BLUEOPTIONS 08/01/2017 12/31/9999 h B0611 33050 OSO BLUEOPTIONS 08/01/2017 12131/9999 B0611 33050 OSO BLUEOPTIONS 08/01/2017 12131/9999 C4 B0611 33042 BCC BLUEOPTIONS 07/27/2017 12131/9999 m= .r+ = B0611 33015 OSO BLUEOPTIONS 08/01/2017 12/31/9999 Q) B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 80611 33040 BCC BLUEOPTIONS 08/24/2016 S 12/31/9999 U 80611 32096 OSO BLUEOPTIONS 08/01/2017 12/31/9999 80611 : 33050 OSO : BLUEOPTIONS : 08/01/2017 12/31/9999 B0611 33070 BCC BLUEOPTIONS 05/24/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 06/13/1943 074 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/01/2013 " * ** "7308 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 05/02/2015 08/23/2000 017 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 7319 DEPENDENT KEYWEST B0611 33040 OTC BLUEOPTIONS 11/12/2015 12/31/9999 aj 06/13/1992 025 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' DEPENDENT KEYWEST B0611 33040 OTC BLUEOPTIONS 08/01/2017 12/31/9999 D 12/16/1968 048 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " "" "7319 SUBSCRIBER KEYWEST B0611 33040 OTC BLUEOPTIONS 08/01/2017 12/31/9999 03/09/1972 045 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 06/27/2015. "7320 SUBSCRIBER MIAMI B0611 33186 BCC BLUEOPTIONS 08/01/2017 12131/9999 02/12/2010 007 FEMALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 06/27/2015 "*"7320 DEPENDENT MIAMI B0611 33186 BCC BLUEOPTIONS 08/01/2017 12131/9999 N fi 10/05/1991 026 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 10/19/2015 ' * ** *7330 SUBSCRIBER TAVERNIER B0611 33070 OSO BLUEOPTIONS 01/07/2017 12131/9999 05/12/1960 057 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "' *'7330 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 02/04/2014 12131/9999 06/27/2014 003 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2017 * * ** *7330 DEPENDENT TAVERNIER B0611 33070 OSO BLUEOPTIONS 08/01/2017 12/31/9999 7 06/09/1952 065 MALE 64 1 FL RETIREE 03559 EMPLOYEE ONLY R01 VOLUSIA 11/01/2011 . "`7334 SUBSCRIBER ORMOND BEACH 80611 32173 OSO BLUEOPTIONS 08/01/2017 12/31/9999 08/04/1983 034 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "** "7362 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 O 06/30/1953 064 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/01/2013 * * ** *7363 SUBSCRIBER BIG PINE KEY 80611 33043 CCC BLUEOPTIONS 01/02/2017 12/31/9999 fl 12/29/1973 043 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/30/2017 * * ** *7370 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 09/30/2017 12/31/9999 O 1 10/18/1976 041 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 08/09/2013 * * ** *7377 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 04/28/2017 12/31/9999 CL CL 02/07/2004 013 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2015 * * *" "7377 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 10/23/2017 12/31/9999 v 04/24/1994 023 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 08/09/2013 ' ** "7377 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 04/28/2017 12/31/9999 07/26/1943 074 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * "" "7381 SUBSCRIBER KEYWEST B0611 33040 OTC BLUEOPTIONS 03/10/2015 12/31/9999 Q 12/15/1928 088 '.FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ' * "" "7393 '.SUBSCRIBER '.KEYWEST B0611 33040 CCC BLUEOPTIONS 11/30/2016 12/31/9999 07/11/1975 042 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 10/09/2015 7400 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 04/27/2017 12/31/9999 L!J 05/20/1979 038 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 10/09/2015 " " *"7400 SPOUSE MARATHON B0611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 08/16/2012 005 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 10/09/2015 ' * ** *7400 DEPENDENT MARATHON B0611 33050 BCC BLUEOPTIONS 08/01/2017 12131/9999 07/23/2014 003 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 10/09/2015 "' *'7400 DEPENDENT MARATHON 80611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 12/31/1958 058 'FEMALE 44 4 FL ACTIVE 03559 'FAMILY 002 MONROE 08116/2013 * * ** *7404 'SUBSCRIBER 'KLYWLST B0611 33040 OSO BLUEOPTIONS 01/21/2017 12/31/9999 09/21/1962 055 NIALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 08/16/2013 .. "'7404 SPOUSE KEYWEST 80611 33040 OSO BLUEOPTIONS 02/18/2017 12/31/9999 02/10/1992 025 NIALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 08/16/2013 " *** "7404 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 04/28/2017 12/31/9999 LIJ U 11/24/1963 053 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** *7417 SUBSCRIBER BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 11/20/1995 021 NIALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 12/01/2016 * * ** *7419 DEPENDENT TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12/31/9999 12/06/1996 020 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 12/01/2016 * * ** *7419 DEPENDENT TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12/31/9999 12/26/1963 053 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 12/01/2016 * * *" "7419 SPOUSE TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12/31/9999 ME 01/30/1972 045 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 12/01/2016 ' ** "7419 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12/31/9999 03/04/1951 066 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 02/18/2015 12/31/9999 ' * "" "7429 ~ 04/10/2010 007 FEMALE 59 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 SEMINOLE 06/01/2014 DEPENDENT ALTAMONTE B0611 32701 OSO BLUEOPTIONS 08/01/2017 12/31/9999 01/12/2009 008 MALE 59 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 SEMINOLE 06/01/2014 ` *" "7429 DEPENDENT SPRINGS ALTAMONTE B0611 32701 OSO BLUEOPTIONS 08/01/2017 12131/9999 SPRINGS M 10/10/1977 040 FEMALE 59 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN `. 001 SEMINOLE 11/02/2013 " "`7429 SUBSCRIBER ALTAMONTE B0611 32701 OSO BLUEOPTIONS 08/01/2017 12/31/9999 (y SPRINGS 04/03/1981 036 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 02/08/2012 " "`7440 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 06/10/2014 12/31/9999 = Q) 05124/1990 027 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06125/2016. " "`7451 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 0812412016 12/31/9999 0611411960 057 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 .... 7452 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 10/09/2014 12/31/9999 ' r- 12/09/1970 046 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 03/04/2012 '* "'7456 SUBSCRIBER KEY LARGO 80611 33037 BCC BLUEOPTIONS 04/09/2015 12131/9999 N 07/05/1977 040 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 03/04/2012 SPOUSE KEY LARGO B0611 33037 BCC BLUEOPTIONS 04/09/2015 12/31/9999 10/18/1961 056 FEMALE 13 3 FL RETIREE 03559 EMPLOYEE & CHILDREN R01 MIAMI -DADE 07/01/2017 ` * *" "7460 SUBSCRIBER HOMESTEAD B0611 33032 OSO BLUEOPTIONS 08/07/2017 12/31/9999 06/06/1989 028 MALE 13 3 FL RETIREE 03559 EMPLOYEE & CHILDREN R01 MIAMI -DADE 07/01/2017 ` *" "'7460 DEPENDENT HOMESTEAD B0611 33032 OSO BLUEOPTIONS 08/07/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 925 06/27/1968 049 FEMALE O8 1 FL ACTIVE 03559 EMPLOYEE ONLY 07/17/1971 045 FEMALE 44 2 FL ACIIVL 03559 EMPLOYEE& SPOUSE 04/06/1965 052 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 07/21/1948 069 FEMALE 70 1 NM RETIREE 03559 EMPLOYEE ONLY 09/06/1999 018 FEMALE 44 4 FL ACTIVE 03559 FAMILY 05/21/1965 052 MALE 44 4 FL ACTIVE 03559 FAMILY 11/28/1962 054 FEMALE 44 4 FL ACTIVE 03559 FAMILY 04/15/1990 027 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/04/1978 039 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 02/12/1952 065 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 12/09/1957 059 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 08/30/1944 073 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 01/19/2015 002 '.FEMALE 44 3 '.. FL '.. ACTIVE '.. 03559 ' &CHILDREN 01/01/1984 033 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 03/15/1971 046 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 10/09/1993 024 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 03/19/2007 010 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 01/24/1991 026 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 02/11/1939 078 MALE 60 1 FL RETIREE 03559 EMPLOYEE ONLY 10/07/1944 073 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 08/10/1992 025 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 03/20/1995 022 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILD 03/03/1964 053 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/27/1972 045 MALE 44 4 FL ACTIVE 03559 FAMILY 01/03/2009 008 MALE 44 4 FL ACTIVE 03559 FAMILY 001 CHARLOTTE 11/01/2011 ""'7465 SUBSCRIBER PORT CHARLOTTE 80611 33952 BCC BLUEOPTIONS 05/09/2016 001 MONROE 11/01/2011 " "'7550 SUBSCRIBER KEYWEST R01 NON - FLORIDA 07/01/2015 " " "" "7555 SUBSCRIBER ALBUQUERQU 001 ADDRESS 11/01/2011 ' * "' "7637 SUBSCRIBER KEYLARGO 002 MONROE 11/01/2011 ' "'* "7560 DEPENDENT KEYWEST 002 MONROE 11/01/2011 * * ** "7560 SPOUSE KEYWEST 002 MONROE 11/01/2011 * * ** *7560 SUBSCRIBER KEYWEST 001 MONROE 07/01/2017 ' ** "'7561 SUBSCRIBER KEYWEST 001 MIAMI -DADE 11/01/2011 ' ** "'7565 SUBSCRIBER HOMESTEAD R01 MONROE 03/01/2017 ' ** "'7569 SUBSCRIBER ISLAMORADA 001 MONROE 11/01/2011 " "'7570 SUBSCRIBER BIG PINE KEY R01 MONROE 09/01/2015 " "" "7573 SUBSCRIBER KEYWEST 001 MONROE 01/19/2015 '.. ' " "" "7576 '.DEPENDENT IKEYWEST 001 MONROE 11/16/2012 ` * ** "7576 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 * *" *7578 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 '7171 DEPENDENT KEYWEST 001 MONROE 11/01/2011 " "'7578 DEPENDENT KEYWEST 001 MONROE 01/01/2015 ' * "' "7581 SUBSCRIBER KEYWEST R01 SUMTER 11/01/2011 ' *'" "7586 SUBSCRIBER THE VILLAGES 001 MONROE 11/01/2011 " * ** "7611 SUBSCRIBER KEYWEST 001 MONROE 01/01/2014 7111 DEPENDENT KEYWEST 001 MONROE 01/01/2014 " "'7631 DEPENDENT KEYWEST 001 MONROE 11/01/2011 ' * "' "7637 SUBSCRIBER KEYLARGO 002 MONROE 01/01/2015 ' * *" "7638 SPOUSE TAVERNIER 002 MONROE 01/01/2015 " * ** "7638 DEPENDENT TAVERNIER B0611 33024 OSO BLUEOPTIONS 08/01/2017 12/31/9999 v B0611 33884 BCC BLUEOPTIONS 03/10/2015 12/31/9999 D B0611 33040 OSO BLUEOPTIONS 07/30/2015 12/31/9999 B0611 33050 BCC BLUEOPTIONS 04/28/2017 12131/9999 w B0611 33040 OTC BLUEOPTIONS 06/02/2015 12131/9999 N fi B0611 33040 OTC BLUEOPTIONS 08/01/2017 12131/9999 � 80611 32655 BCC BLUEOPTIONS 02/18/2015 12131/9999 B0611 33040 BCC BLUEOPTIONS 11/30/2016 12/31/9999 y 80611 33040 BCC BLUEOPTIONS 11/30/2016 12/31/9999 'U 80611 87111 OTC BLUEOPTIONS 06/29/2016 12/31/9999 0 80611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 tO 7 80611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 0 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 0 ' CL B0611 33040 OSO BLUEOPTIONS 10/23/2017 12/31/9999 B0611 33035 BCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33036 BCC IBLUEOPTIONS '.. 03/09/2017 12/31/9999 B0611 33043 OPA BLUEOPTIONS 12/03/2013 12/31/9999 L!J B0611 33040 BCC BLUEOPTIONS 04/28/2017 12131/9999 F B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 B0611 33040 OTC BLUEOPTIONS 09/10/2015 12/31/9999 �. Ua B0611 33040 OTC BLUEOPTIONS 09/10/2015 12/31/9999 B0611 33040 OTC BLUEOPTIONS 09/10/2015 12/31/9999 80611 33040 OTC BLUEOPTIONS 08/24/2016 12/31/9999 LU U 80611 32162 BCC BLUEOPTIONS 04/20/2017 12/31/9999 80611 33040 BCC BLUEOPTIONS 11/30/2016 12/31/9999 80611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 W B0611 33040 BCC BLUEOPTIONS 03/10/2015 12/31/9999 B0611 33043 BCC BLUEOPTIONS 05/17/2017 12/31/9999 U B0611 33042 OSO BLUEOPTIONS 01/02/2017 12/31/9999 f— B0611 I 33042 OSO BLUEOPTIONS 01/02/2017 12131/9999 F— B0611 33042 OSO BLUEOPTIONS 01/02/2017 12131/9999 4 , M B0611 '. 33042 OSO BLUEOPTIONS 01/02/2017 12131/9999 ' N 80611 33042 OSO BLUEOPTIONS 08/01/2017 12131/9999 .w C B0811 33040 OTC BLUEOPTIONS 01/02/2017 12/31/9999 4! B0611 33040 OTC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OTC BLUEOPTIONS 08/01/2017 12/31/9999 U N 80611 33037 BCC BLUEOPTIONS 08/28/2017 12/31/9999 80611 33070 OSO BLUEOPTIONS 08/01/2017 12/31/9999 80611 33070 OSO BLUEOPTIONS 02/25/2016 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 11/25/2004 012 NIALE 44 4 FL ACTIVE 03559 FAMILY 08/31/1966 051 : FEMALE 44 4 : FL : ACTIVE : 03559 : FAMILY 01/25/1997 020 MALE 44 4 FL ACTIVE 03559 FAMILY 10/14/1993 024 NIALE 44 4 FL ACTIVE 03559 FAMILY 10/11/1967 050 NIALE 44 4 FL ACTIVE 03559 FAMILY 08/08/1946 071 MALE 01 1 FL RETIREE 03559 EMPLOYEE ONLY 03/27/1968 049 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 08/17/1966 051 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 09/26/1963 054 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 05/13/1999 018 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 10/24/1986 031 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 01/25/1962 055 MALE 44 1 '.. FL '.. ACTIVE '.. 03559 EMPLOYEE ONLY 01/17/1946 071 : MALE 44 1 : FL : RETIREE : 03559 : EMPLOYEE ONLY 03/15/1994 023 : MALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE & CHILDREN 07/05/1965 052 : FEMALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE & CHILDREN 10/25/1948 069 : NIALE 28 1 : FL : RETIREE : 03559 : EMPLOYEE ONLY 12/06/1948 068 : NIALE 44 1 : FL : ACTIVE : 03559 : EMPLOYEE ONLY 08/20/1933 084 : FEMALE 44 1 : FL : RETIREE : 03559 : EMPLOYEE ONLY 11/19/1999 017 MALE 13 4 FL ACTIVE 03559 FAMILY 04/20/2000 017 FEMALE 44 3 : FL : ACTIVE : 03559 : EMPLOYEE & CHILDRE 04/12/1953 064 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE 01/18/1949 068 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE 12/07/1983 033 MALE 06 1 FL ACTIVE 03559 EMPLOYEE ONLY 05/10/1945 072 FEMALE 35 1 FL RETIREE 03559 EMPLOYEE ONLY ' ** "'7712 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 DEPENDENT 1:19 PM Page 1 of 1 002 MONROE 01/01/2015 ""'7638 DEPENDENT TAVERNIER 80611 33070 OSO BLUEOPTIONS 02/25/2016 001 MONROE 12/03/2016 7119 : SPOUSE : BIG PINE KEY 001 MONROE 12/03/2016 — 7699 DEPENDENT BIG PINE KEY 001 MONROE 12/03/2016 ' *'" "7699 DEPENDENT BIG PINE KEY 001 MONROE 12/03/2016 * * ** "7699 SUBSCRIBER BIG PINE KEY R01 ALACHUA 01/01/2013 * * ** *7701 SUBSCRIBER HIGH SPRING 001 MONROE 11/01/2011 ' ** "'7707 SUBSCRIBER TAVERNIER 001 MIAMI -DADE 11/01/2011 ' ** "'7711 SUBSCRIBER MIAMI 001 MONROE 08/01/2017 ' ** "'7712 SUBSCRIBER ISLAMORADA 001 MONROE 08/01/2017 " "'7712 DEPENDENT ISLAMORADA 001 MIAMI -DADE 11/01/2011 " "" "7713 SUBSCRIBER HOMESTEAD 001 MONROE 11/01/2011 '.. ' " "" "7726 '.SUBSCRIBER ITAVERNIER R01 MONROE 11/01/2011 : ` * ** "7731 : SUBSCRIBER : KEYWEST 001 MONROE 01/01/2016 : * *" *7741 : DEPENDENT : KEY LARGO 001 MONROE 08/17/2012 : 7741 SUBSCRIBER :KEY LARGO R01 HIGHLANDS 11/01/2011 : `` "` "7743 : SUBSCRIBER :LAKE PLACID 001 MONROE 11/01/2011 : " 7747 :SUBSCRIBER :BIG PINE KEY R01 MONROE 11/01/2011 : ' *'" "7755 : SUBSCRIBER : ISLAMORADA 001 MIAMI -DADE 01/17/2012 " * *" "7757 DEPENDENT HOMESTEAD 001 MONROE 01/01/2012 7773 : DEPENDENT R01 MONROE 09/01/2014 ``" "7778 SPOUSE R01 MONROE 04/01/2013 — 7778 SUBSCRIBEF 001 BROVJARD 11/01/2011 ' * *" "7782 SUBSCRIBEF R01 LAKE 11/01/2011 " * ** "7805 SUBSCRIBEF B0611 33040 OSO BLUEOPTIONS 09/20/2017 12/31/9999 v B0611 33040 BCC BLUEOPTIONS 08/02/2016 12/31/9999 D B0611 33040 BCC BLUEOPTIONS 08/02/2016 12/31/9999 B0611 32168 OSO BLUEOPTIONS 08/01/2017 12131/9999 w B0611 33196 BCC BLUEOPTIONS 06/20/2017 N 12131/9999 m B0611 33040 OSO BLUEOPTIONS 04/27/2017 12131/9999 w 80611 33040 OSO BLUEOPTIONS 08/24/2016 12131/9999 B0611 33187 BCG BLUEOPTIONS 12/03/2013 12/31/9999 a) 7 B0611 33043 BCC BLUEOPTIONS 12/15/2016 12/31/9999 "1a fu B0611 33043 BCC BLUEOPTIONS 12/15/2016 12/31/9999 80611 33043 BCC BLUEOPTIONS 12/15/2016 12/31/9999 tO 7 80611 33043 BCC BLUEOPTIONS 12/15/2016 12/31/9999 O 80611 32655 BCC BLUEOPTIONS 11/30/2016 12/31/9999 C ' CL B0611 33070 OSO BLUEOPTIONS 12/31/2013 12/31/9999 B0611 33176 OSO BLUEOPTIONS 07/20/2017 12/31/9999 B0611 33036 BCC IBLUEOPTIONS '.. 08/01/2017 12/31/9999 B0611 33036 BCC BLUEOPTIONS 08/01/2017 12/31/9999 W B0611 33033 OTC BLUEOPTIONS 12/03/2013 12131/9999 F B0611 33070 OSO BLUEOPTIONS 08/01/2017 12131/9999 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 B0611 33037 ORA BLUEOPTIONS 08/01/2017 12/31/9999 �. Ua B0611 : 33037 OPA : BLUEOPTIONS : 08/01/2017 : 12/31/9999 B0611 : 33852 BCC : BLUEOPTIONS : 12/02/2014 : 12/31/9999 B0611 : 33043 OSO : BLUEOPTIONS : 12/05/2015 : 12/31/9999 LU U 80611 : 33036 BCC : BLUEOPTIONS : 03/02/2017 : 12/31/9999 80611 33033 OSO BLUEOPTIONS 04/03/2017 12/31/9999 80611 : 33033 OSO : BLUEOPTIONS 08/01/2017 12/31/9999 W B0611 33033 OSO BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 U B0611 33055 OSO BLUEOPTIONS 08/01/2017 12/31/9999 f- B0611 I 33055 OSO BLUEOPTIONS 08/01/2017 12131/9999 F- B0611 33055 OSO BLUEOPTIONS 08/01/2017 12131/9999 4 , M B0611 '. 33041 CCC BLUEOPTIONS 10/02/2014 12131/9999 ' N 80611 33050 BCC BLUEOPTIONS 08/01/2017 12131/9999 .w C B0811 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 4! B0611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 B0611 33036 OSO BLUEOPTIONS 08/01/2017 12/31/9999 U N B0611 33036 OSO BLUEOPTIONS 08/01/2017 12/31/9999 80611 33023 OSO BLUEOPTIONS 12/03/2013 12/31/9999 80611 32102 OTC BLUEOPTIONS 03/16/2017 12/31/9999 06/25/1974 043 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 001 MONROE 11/01/2011 " " "" "7808 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 04/15/2016 07/05/1991 025 FEMALE 44 3 FL ACIIVL 03559 LMPLOYLL & CHILDREN 001 MONROE 04/01/2016 ""'7852 DLPLNDLNI KEYWESI B0611 33040 050 BLUEOP I IONS 08131/2017 09/11/2002 015 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 04/01/2016 " "'7852 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 08/18/2017 12/02/1970 046 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 04/01/2016 ""'7852 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/10/2017 04/15/1964 053 FEMALE O6 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BRON /ARD 11/01/2011 * * ** *7869 SUBSCRIBER SUNRISE B0611 33313 OSO BLUEOPTIONS 08/01/2017 10/05/1957 060 NIALE 06 1 FL RETIREE 03559 EMPLOYEE ONLY R01 BROVJARD 10/01/2017 " * ** *7872 SUBSCRIBER CORAL SPRINGS B0611 33076 BCC BLUEOPTIONS 10/17/2017 02/15/1961 056 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/25/2017 * * ** *7876 SUBSCRIBER SUMMERLAND KEY B0611 33042 BCC BLUEOPTIONS 04/28/2017 02/16/1952 065 MALE 61 1 FL RETIREE 03559 EMPLOYEE ONLY R01 SUWANNEE 08/01/2013 * * *" *7877 SUBSCRIBER LIVE OAK B0611 32060 BCC BLUEOPTIONS 06/29/2016 04/19/1952 065 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 '* "'7886 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 07/28/1951 066 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 05/01/2015 "" "7887 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 01/10/1956 061 '.FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "" *7890 '.SUBSCRIBER '.MARATHON B0611 33050 OTC BLUEOPTIONS 12/03/2013 02/06/1950 067 FEMALE 13 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MIAMI -DADE 08/01/2012 *" 7890 SUBSCRIBER MIAMI B0611 33143 OSO BLUEOPTIONS 08/01/2017 02/23/1953 064 FEMALE 06 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BROWARD 11/01/2011 '" *'7906 SUBSCRIBER HALLANDALE B0611 33009 OSO BLUEOPTIONS 08/01/2017 04/25/1992 025 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 03/20/2016 "' *'7911 SUBSCRIBER MIAMI B0611 33176 BCC BLUEOPTIONS 03/13/2017 05/03/1989 028 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/28/2013 "' *`7918 SUBSCRIBER SUMMERLAND KEY 80611 33042 OSO BLUEOPTIONS 12/03/2013 08/07/1952 065 'MALL 44 1 FL ACTIVE 03559 'EMPLOYEE ONLY 001 MONROE 05108/2015 * *" *7928 'SUBSCRIBER 'BIG PINE KEY B0611 33043 BCC 'BLUEOPTIONS 08/24/2016 12/12/1983 033 NIALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/05/2011 " "'7928 SUBSCRIBER MIAMI 80611 33142 OSO BLUEOPTIONS 08/01/2017 09/26/2001 016 NIALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 01/01/2015 " *"" "7931 DEPENDENT HIALEAH B0611 33010 BCC BLUEOPTIONS 08/01/2017 05/11/1999 018 NIALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 01/01/2015 * * ** *7931 DEPENDENT HIALEAH B0611 33010 BCC BLUEOPTIONS 08/01/2017 07/08/1966 051 NIALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 11/01/2011 * * ** *7931 SUBSCRIBER HIALEAH B0611 33010 BCC BLUEOPTIONS 08/01/2017 07/21/1966 051 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** *7940 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 08/11/1964 053 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * *" *7950 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 03/17/1955 062 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 12/01/2012 '" "'7973 SPOUSE BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 08/01/2017 09/27/1957 060 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 03/10/2012 "" "'7973 SUBSCRIBER BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 08/01/2017 07/01/1993 024 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2015 * "' *7973 DEPENDENT BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 08/01/2017 03/13/1995 022 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 07/12/2014 "" 7974 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 02/27/2017 11/26/1952 064 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2012 " — '7974 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 02/04/2017 04/23/1993 024 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 03/31/2017 "' *'7974 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 04/06/2017 06/12/1957 060 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 01/01/2012 " "'7974 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 09/19/1991 026 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/13/2016 " "'7983 SUBSCRIBER LONG KEY 80611 33001 0SO BLUEOPTIONS 07/06/2017 06/04/1956 061 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'7988 SUBSCRIBER MARATHON 80611 33050 BCC BLUEOPTIONS 01/02/2016 01/09/1972 045 NIALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 " * "" "7991 SUBSCRIBER HIALEAH B0611 33015 BCC BLUEOPTIONS 08/01/2017 08/15/1947 070 NIALE 70 1 MS RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 11/01/2011 * * ** *7999 SUBSCRIBER GULFPORT B0611 39501 OSO BLUEOPTIONS 08/01/2017 ADDRESS 02/19/2016 001 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 08/31/2016 * * ** *8005 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 01/02/2017 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 F 05/23/2001 016 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE &CHILDREN 001 MONROE 08/31/2016 ..... I'll DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 01/02/2017 10/15/1979 038 FEMALE 13 2 FL ACIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DA 11/01/1968 048 MALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DA 06/09/1962 055 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DA 09/19/1950 067 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 06/28/1959 058 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/1965 051 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 01/05/1983 034 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 12/02/1983 033 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 12/11/1970 046 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/06/1956 061 '.FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/24/1964 053 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/24/1948 069 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 04/11/1945 072 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 06/24/1963 054 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 09/21/1992 025 (FEMALE 44 4 FL ACTIVE 03559 (FAMILY 002 MONROE 08/10/1962 055 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 06/30/1983 034 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 03/03/2010 007 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 09/29/2014 003 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 07/07/1950 067 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 12/08/2013 ' " "' "8032 DEPENDENT KEYLARGO B0611 33037 0SO BLUEOPTIONS 05/02/2017 12/31/9999 Qj 12/08/2013 " "" "8032 SUBSCRIBER KEYLARGO B0611 33037 0SO BLUEOPTIONS 08/19/2017 12/31/9999 D 12/08/2013 " "" "8032 SPOUSE KEYLARGO B0611 33037 0SO BLUEOPTIONS 02/15/2017 12/31/9999 wN 04/25/2014 ' " "" "8047 SUBSCRIBER KEYWEST B0611 33040 0SO BLUEOPTIONS 08/01/2017 12131/9999 N = U 04/25/2014 '` *' "8047 DEPENDENT KEYWEST B0611 33040 0SO BLUEOPTIONS 08/01/2017 12131/9999 N fi 04/25/2014 ' * ** *8047 DEPENDENT KEYWEST B0611 33040 0SO BLUEOPTIONS 08/01/2017 12131/9999 � 11/01/2011 * * ** *8053 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 05/31/2013 12131/9999 01/01/2015 ` * "" "8057 SPOUSE MIAMI B0611 33187 BCC BLUEOPTIONS 08/01/2017 12/31/9999 7 12/29/2014 I'll SUBSCRIBER MIAMI 80611 33187 BCC BLUEOPTIONS 08/24/2016 12/31/9999 'U t0 11/01/2011 "'" "8067 SUBSCRIBER HOMESTEAD 80611 33033 BCC BLUEOPTIONS 08/16/2017 12/31/9999 O 07/01/2012 ' * ** "8071 SUBSCRIBER MARATHON 80611 33050 BCC BLUEOPTIONS 04/20/2017 12/31/9999 08/30/2017 " * ** "8073 SPOUSE KEYWEST B0611 33040 CCC BLUEOPTIONS 08/31/2017 12/31/9999 > O 08/30/2017 ' * "* *8073 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/31/2017 12/31/9999 CL CL 11/01/2011 " "" "8079 SUBSCRIBER KEYWEST B0611 33040 0SO BLUEOPTIONS 12/03/2013 12/31/9999 U 11/01/2011 ' " "' "8094 SUBSCRIBER BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 12/03/2013 12/31/9999 06/22/2014 " "" "8097 SUBSCRIBER KEYWEST B0611 33040 0SO BLUEOPTIONS 08/01/2017 12/31/9999 11/01/2011 .. " . 1099 '.SUBSCRIBER '.SUMMERLAND KEY B0611 33042 0SO BLUEOPTIONS 07/20/2016 12/31/9999 11/01/2011 ' " "" "8104 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 12/03/2013 12/31/9999 L!J 11/01/2011 " — '8107 SUBSCRIBER KEYWEST B0611 33045 0SO BLUEOPTIONS 08/01/2017 12/31/9999 Z 11/01/2011 ' ** *'8107 SPOUSE KEYWEST B0611 33045 OSO BLUEOPTIONS 08/01/2017 12131/9999 11/01/2011 * * ** *8112 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 02/16/2017 12/31/9999 11/01/2011 ' " "" "8112 'DEPENDENT 'KEYWEST B0611 33040 BCC BLUEOPTIONS 03/22/2017 12/31/9999 11/01/2011 " "'8112 SPOUSE KEYWEST 80611 33040 BCC BLUEOPTIONS 02/28/2017 12/31/9999 11/19/2016 - - 8113 SUBSCRIBER KEY COLONY BEACH 80611 33050 BCC BLUEOPTIONS 11/21/2016 12/31/9999 LIJ U 11/19/2016 "'" "8113 DEPENDENT KEY COLONY BEACH 80611 33050 BCC BLUEOPTIONS 11/21/2016 12/31/9999 11/19/2016 - - 8113 DEPENDENT KEY COLONY BEACH 80611 33050 BCC BLUEOPTIONS 11/21/2016 12/31/9999 06/01/2014 ' ""8120 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/21/2015 12/31/9999 LLJ 11/01/2011 - - 8120 SUBSCRIBER MARATHON 80611 33050 0SO BLUEOPTIONS 08/01/2017 12/31/9999 )7/20/21)14 * " "" "8120 SUBSCRIBER MARATHON 80611 33050 0SO BLUEOPTIONS 08/24/2016 12/31/9999 () D1/28/2012 ' " "8128 DEPENDENT KEYWEST 80611 33040 0SO BLUEOPTIONS 08/01/2017 12/31/9999 h ~ 01/28/2012 "' "' "8128 DEPENDENT KEYWEST 80611 33040 0SO BLUEOPTIONS 08/01/2017 12/31/9999 Q 01/28/2012 " "" "8128 DEPENDENT KEYWEST B0611 33040 0SO BLUEOPTIONS 08/01/2017 12/31/9999 y 11/01/2011 " "8128 SUBSCRIBER KEYWEST B0611 33040 0SO BLUEOPTIONS 08/01/2017 12/31/9999 CV 11/01/2011 ' " "" "8129 SUBSCRIBER ELPASO B0611 79938 0SO BLUEOPTIONS 08/01/2017 12/31/9999 .r.. C ay 11/01/2011 ' *" "8139 SUBSCRIBER KEYWEST B0611 33040 0SO BLUEOPTIONS 12/03/2013 12/31/9999 S 11/01/2011 " * *' "8149 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 U U 11/01/2011 "' *'8151 SUBSCRIBER MARATHON B0611 33050 0SO BLUEOPTIONS 12/03/2013 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 10/22/1935 082 FEMALE 70 1 NM RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 11/01/2011 ""'8176 SUBSCRIBER ALBUQUERQUE 80611 87112 BCC BLUEOPTIONS 04/20/2017 �* 7 ADDRESS 07/08/1939 078 FEMALE 70 1 TX RETIREE 03559 EMPLOYEE ONLY R02 NON - FLORIDA 11/01/2011 ^"* "8182 SUBSCRIBER HOUSTON 80611 77057 OSO BLUEOPTIONS 12/12/2014 12/31/9999 ADDRESS 03/19/1951 066 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 04/01/2017 ^ °" "8185 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 10/03/1987 030 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 08/19/2017 " * ** "8191 SPOUSE TAVERNIER 80611 33070 OSO BLUEOPTIONS 09/09/2017 12/31/9999 07/01/2011 006 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 08/19/2017 " * *" *8191 DEPENDENT TAVERNIER 80611 33070 OSO BLUEOPTIONS 09/09/2017 12/31/9999 06/25/1979 038 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 08/19/2017 " * *" "8191 SUBSCRIBER TAVERNIER 80611 33070 OSO BLUEOPTIONS 09/09/2017 12/31/9999 6i 02/15/2006 011 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 08/19/2017 " * *" "8191 DEPENDENT TAVERNIER B0611 33070 OSO BLUEOPTIONS 09/09/2017 12/31/9999 02/18/1964 053 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'" "8197 SUBSCRIBER BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 12/03/2013 12/31/9999 w 03/29/1951 066 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "" "8200 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 12131/9999 6i N 10/16/1957 060 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "" "8218 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 12131/9999 m 05/19/1952 065 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 11/01/2011 "" "8220 SPOUSE KEYWEST B0611 33040 OTC BLUEOPTIONS 03/16/2017 12131/9999 w 08/08/1943 074 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 11/01/2011 " *` "'8220 SUBSCRIBER KEYWEST B0611 33040 OTC BLUEOPTIONS 03/16/2017 12/31/9999 _N 't a) 10130/1945 072 MALE 35 1 FL RETIREE 03559 EMPLOYEE ONLY R01 LAKE 11/01/2011 ' * ** *8225 SUBSCRIBER FRUITLAND PARK B0611 34731 OSO BLUEOPTIONS 08/01/2017 12/31/9999 7 07/04/1994 023 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/25/2016 "" *"8227 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 09/27/2016 12/31/9999 tO 05/27/1961 056 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 "' "`8236 SUBSCRIBER BIG PINE KEY B0611 33043 BCC BLUEOPTIONS 06/29/2016 12/31/9999 04/07/1950 067 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'" "8243 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 07/27/2015 12/31/9999 7 12/27/2016 000 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 12/27/2016 ^ °" "8251 DEPENDENT KEYWEST 80611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 O 10/14/2014 003 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 10/14/2014 " * ** 8251 DEPENDENT KEYWEST 80611 33040 CCC BLUEOPTIONS 08/31/2017 12/31/9999 CL Q, 10/07/1988 029 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/16/2012 " * *" "8251 SUBSCRIBER KEYWEST 80611 33040 CCC BLUEOPTIONS 03/24/2017 12/31/9999 05/31/1990 027 FEMALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 01/01/2016 " * *" "8260 SPOUSE MIAMI 80611 33187 BCC BLUEOPTIONS 04/26/2017 12/31/9999 06/28/1990 027 MALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 01/01/2016 " "'" "8260 SUBSCRIBER MIAMI B0611 33187 BCC BLUEOPTIONS 08/01/2017 12/31/9999 05/25/1973 044 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'" "8268 SUBSCRIBER KEYWEST B0611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 LIJ 05/25/1969 048 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 " "" "8276 SUBSCRIBER TAVERNIER B0611 33070 OSO BLUEOPTIONS 08/01/2017 12131/9999 05/22/1970 047 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 01/01/2013 "" "`8276 SPOUSE TAVERNIER B0611 33070 OSO BLUEOPTIONS 08/01/2017 12131/9999 10/14/1934 083 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 " "'8279 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 03/02/2017 12/31/9999 07/01/1970 047 '.FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * ** *8279 SUBSCRIBER '.KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 05/29/1957 060 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ` * ** *8284 SUBSCRIBER KEYWEST B0611 33045 OSO SLUEOPTIONS 08/15/2016 12131/9999 01/08/2001 016 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 02/11/2017 '1286 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 02/13/2017 12/31/9999 LIJ 07/29/1962 055 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 02/11/2017 "' "'8286 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 U 12/09/1961 055 MALE 01 1 FL RETIREE 03559 EMPLOYEE ONLY R01 ALACHUA 06/01/2015 " "'" "8304 SUBSCRIBER HIGH SPRINGS B0611 32655 BCC BLUEOPTIONS 05/25/2017 12/31/9999 05/07/1955 062 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/11/2015 " ° "* "8316 SUBSCRIBER KEYLARGO 80611 33037 BCC BLUEOPTIONS 08/01/2017 12/31/9999 09/29/1970 047 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 03/05/2017 ' * *" "8316 SUBSCRIBER TAVERNIER 80611 33070 BCC BLUEOPTIONS 03/09/2017 12/31/9999 LLJ 03/12/1969 048 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE D3/05/2017 " * *" *8316 SPOUSE TAVERNIER 80611 33070 BCC BLUEOPTIONS 03/09/2017 12/31/9999 09/26/1958 059 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 03/01/2017 " * *" "8317 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 03/02/2017 12/31/9999 V 08/20/1974 043 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'" "8330 SUBSCRIBER KEYWEST B0611 33040 OPA BLUEOPTIONS 12/17/2013 12/31/9999 h 05/01/2009 008 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " "'" "8331 DEPENDENT KEYWEST B0611 33040 CCC BLUEOPTIONS 02/28/2017 12/31/9999 h 08/18/2006 011 FEMALE 44 3 FL ACTIVE 03559 .EMPLOYEE &CHILDREN 001 MONROE 11/01/2011 "" "`8331 DEPENDENT KEYWEST B0611 33040 CCC BLUEOPTIONS 03/10/2017 12131/9999 . M 01/23/1980 037 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN `. 001 MONROE 11/01/2011 "" "`8331 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 N 02/20/1957 060 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 09/22/2017 " "'8339 SPOUSE KEYWEST B0611 33040 CCC BLUEOPTIONS 09/30/2017 12/31/9999 . . = 08/15/1963 054 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 09/22/2017 ' * ** *8339 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 09/30/2017 12/31/9999 iy 11/05/1958 058 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 *' *'8344 SUBSCRIBER KEYWEST 80611 33041 BCC BLUEOPTIONS 08/01/2017 12/31/9999 S U 06/29/1991 026 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/14/2017 "" "`8367 SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 07/14/2017 12/31/9999 N 08/03/1987 030 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "' "'8368 SUBSCRIBER KEYLARGO B0611 33037 OTC BLUEOPTIONS 06/05/2017 12/31/9999 02/28/1942 075 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'" "8369 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 12/03/2013 12/31/9999 06/17/1987 030 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/15/2017 " * °* "8369 SUBSCRIBER MARATHON 80611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 930 11/12/1961 055 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 02/05/2016 " *** "8372 SUBSCRIBER KEYLARGO 80611 33037 BCC BLUEOPTIONS 02/03/2017 04/10/1987 030 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/22/2015 ' * "" "8431 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 12/31/9999 aj 04/04/1960 057 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * "" "8441 SUBSCRIBER TAVERNIER B0611 33070 OSO BLUEOPTIONS 02/18/2015 12/31/9999 D 08/02/1956 061 MALE 70 1 IL RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 01/01/2014 ' * *" "8441 SUBSCRIBER BUCKLEY B0611 60918 OSO BLUEOPTIONS 08/01/2017 12/31/9999 = 4i ADDRESS +t= 04/10/1989 028 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2017 ' *" "8444 DEPENDENT KEYLARGO B0611 33037 CCC BLUEOPTIONS 01/02/2017 12/31/9999 g1 09/30/1951 066 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " * ** "8444 SUBSCRIBER KEYLARGO B0611 33037 CCC BLUEOPTIONS 01/02/2017 N 12131/9999 fi 07/17/1951 066 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 " * ** "8445 SUBSCRIBER SUMMERLAND KEY B0611 33042 OSO BLUEOPTIONS 11/30/2016 12131/9999 w N 05/06/1966 051 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** *8446 SUBSCRIBER KEYWEST 80811 33041 CCC BLUEOPTIONS 02/18/2015 .® 12131/9999 02117/1958 059 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07101/2017 " "'8452 SUBSCRIBER MARATHON B0611 33050 BCG BLUEOPTIONS 0810112017 12/31/9999 y 01/02/1933 084 MALE 28 1 FL RETIREE 03559 EMPLOYEE ONLY R01 HIGHLANDS 11/01/2011 " " "" "8464 SUBSCRIBER SEBRING B0611 33876 BCC BLUEOPTIONS 03/10/2015 12/31/9999 fu 01/31/1999 018 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' * "" "8465 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 03/05/1995 022 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' *'" "8465 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 tO 7 02/24/1969 048 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " * ** "8465 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 O s 07/01/1993 024 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/25/2016 * * ** *8472 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 C ' CL 09/09/1983 034 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * *" "8472 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 05/20/1958 059 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/25/2013 ' * *" "8475 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 04/27/2017 12/31/9999 11/01/1968 048 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * *" "8477 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 12/03/2013 12/31/9999 05/29/1971 046 MALE 16 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 DUVAL 04/21/2017 """ "8477 SUBSCRIBER JACKSONVILLE BCH B0611 32250 BCC BLUEOPTIONS 08/01/2017 12/31/9999 IJj 05/24/1969 048 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 11/01/2011 ' * "" "8479 SUBSCRIBER MIAMI B0611 33145 OSO BLUEOPTIONS 12/03/2013 12131/9999 '.MALE '.EMPLOYEE " * ** "8479 '.DEPENDENT '.MIAMI 09/11/2005 012 13 3 FL ACTIVE 03559 &CHILDREN 001 MIAMI -DADE 11/01/2011 B0611 33145 OSO BLUEOPTIONS 12/03/2013 12131/9999 12/29/2009 007 FEMALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 11/01/2011 " * ** "8479 DEPENDENT MIAMI B0611 33145 OSO BLUEOPTIONS 12/03/2013 12131/9999 10/22/1957 060 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * *' *8483 SUBSCRIBER KEY LARGO B0611 33037 BCC BLUEOPTIONS 08/01/2017 12/31/9999 �. 10/21/1970 047 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 " * "* "8487 SUBSCRIBER MIAMI B0611 33222 OSO BLUEOPTIONS 08/01/2017 12/31/9999 11/13/1958 058 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2014 ' * "" *8492 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 01/25/1990 027 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 12/31/2015 ' * "" "8494 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 08/24/2016 12/31/9999 LU U 11/20/1958 058 MALE 36 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 LEE 08/31/2017 ' *'" "8495 SUBSCRIBER CAPE CORAL 80611 33904 BCC BLUEOPTIONS 08/31/2017 12/31/9999 10/16/1956 061 FEMALE 36 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 LEE 08/31/2017 " * ** "8495 SPOUSE CAPE CORAL 80611 33904 BCC BLUEOPTIONS 08/31/2017 12/31/9999 01/22/1971 046 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * *' *8510 SUBSCRIBER KEYLARGO 80611 33037 OSO BLUEOPTIONS 08/01/2017 12/31/9999 ILLJ 11/27/1935 081 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * *" "8515 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 12/03/2013 12/31/9999 10/16/1977 040 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * *" "8522 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 04/27/2017 12/31/9999 U 03/11/1959 058 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * *" "8530 SUBSCRIBER KEYWEST B0611 33041 BCC BLUEOPTIONS 04/23/2015 12/31/9999 (- 11/08/1961 055 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 """ "8532 SUBSCRIBER CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 11/30/2016 12131/9999 F- 12/08/1951 065 MALE 44 2 FL ACTIVE 03559 EMPLOYEE &SPOUSE 001 MONROE 01/01/2013 ' *" "8532 SPOUSE CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 12131/9999 M 09/08/1969 048 '. MALE 44 2 FL ACTIVE 03559 EMPLOYEE &SPOUSE 001 MONROE 08/26/2017 " * ** "8541 SUBSCRIBER KEYLARGO B0611 '. 33037 BCC BLUEOPTIONS 09/09/2017 12131/9999 ' N 01/16/1975 042 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 08/26/2017 * * ** "8541 SPOUSE KEY LARGO 80611 33037 BCC BLUEOPTIONS 08/28/2017 12131/9999 .w C 07/11/2003 014 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2017 " "'8545 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 4! 03/19/2010 007 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2017 " * "` "8545 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 09/08/1971 046 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " "" "8545 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 09/16/1982 035 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/01/2017 ' * I'll SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 07/01/2017 12/31/9999 11/19/1938 078 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ' * * I'll SUBSCRIBER GRASSY KEY 80611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 10/09/1998 019 MALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 11/01/2011 " * ** *8574 DEPENDENT SUMMERLAND KEY 80611 33042 OSO BLUEOPTIONS 05/29/2014 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 07/25/2003 014 FEMALE 44 4 FL ACTIVE 03559 FAMILY 09/30/1985 032 FEMALE 44 12/10/1957 059 MALE 44 03/06/1986 031 NIALE 13 01/01/1928 089 FEMALE 64 08/09/1968 049 FEMALE 44 01/26/1951 066 MALE 44 09/06/1988 029 MALE 44 07/14/1952 065 FEMALE 13 03/16/2003 014 MALE 44 12/30/2008 008 FEMALE 44 12/22/1972 044 FEMALE 44 07/03/1938 079 FEMALE 44 08/28/1969 048 MALE 44 04/18/1968 049 (FEMALE 44 01/28/1998 019 FEMALE 44 11/07/1949 067 NIALE 53 1 FL ACTIVE 03559 EMPLOYEE ONLY 1 FL ACTIVE 03559 EMPLOYEE ONLY 1 FL ACTIVE 03559 EMPLOYEE ONLY 1 FL RETIREE 03559 EMPLOYEE ONLY 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 1 FL ACTIVE 03559 EMPLOYEE ONLY 1 FL ACTIVE 03559 EMPLOYEE ONLY 3 '.. FL '.. ACTIVE '.. 03559 ' &CHILDREN 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 1 FL RETIREE 03559 EMPLOYEE ONLY 4 FL ACTIVE 03559 FAMILY 4 FL ACTIVE 03559 (FAMILY 4 FL ACTIVE 03559 FAMILY 1 FL RETIREE 03559 EMPLOYEE ONLY 11/12/1982 034 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 04/04/1974 043 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/22/1996 021 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 09/26/1971 046 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 10/20/1994 023 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 002 MONROE 11/01/2011 " " "" "8574 DEPENDENT SUMMERLAND KEY 80611 33042 OSO BLUEOPTIONS 05/29/2014 001 MONROL 05/07/2016 ""'8609 SUBSCRIBER SUGARLOAF KL 001 MONROE 09/01/2013 " "'8610 SUBSCRIBER KEYWEST 001 MONROE 11/01/2011 ""'8622 SUBSCRIBER CUDJOE KEY 001 MIAMI -DADE 10/04/2013 " " "" "8625 SUBSCRIBER PALMETTO BAY R01 VOLUSIA 11/01/2011 " 8630 SUBSCRIBER DELAND 001 MONROE 01/01/2016 " " "* "8631 SPOUSE KEYLARGO 001 MONROE 12/23/2011 " "" "'8631 SUBSCRIBER KEYLARGO 001 MONROE 10/17/2014 " "" "8631 SUBSCRIBER MARATHON 001 MIAMI -DADE 11/01/2011 "" "8634 SUBSCRIBER HOMESTEAD 001 MONROE 01/01/2014 .. " . 8639 '.DEPENDENT (KEYWEST 001 MONROE 01/01/2014 ' " "" "8639 DEPENDENT KEYWEST 001 MONROE 11/01/2011 ` "" "'8639 SUBSCRIBER KEYWEST R01 MONROE 11/01/2011 - - 8647 SUBSCRIBER BIG PINE KEY 001 MONROE 11/01/2011 - - 1649 SUBSCRIBER BIG PINE KEY 001 MONROE 11/01/2011 - - 8649 (SPOUSE (BIG PINE KEY 001 MONROE 11/01/2011 " "'8649 DEPENDENT BIG PINE KEY R01 POLK 11/01/2011 " """ "8660 SUBSCRIBER LAKELAND B0611 33040 BCC BLUEOPTIONS 08/01/2017 80611 33042 OSO BLUEOPTIONS 08/01/2017 80611 33157 BCC BLUEOPTIONS 07/17/2017 B0611 32724 BCC BLUEOPTIONS 04/28/2017 B0611 33037 BCC BLUEOPTIONS 08/01/2017 B0611 33037 BCC BLUEOPTIONS 11/09/2016 B0611 33050 OSO BLUEOPTIONS '.. 08/01/2017 B0611 33032 OSO BLUEOPTIONS '.. 12/03/2013 B0611 '.. 33040 OPA BLUEOPTIONS '.. 08/01/2017 B0611 '.. 33040 OPA BLUEOPTIONS '.. 08/01/2017 B0611 33040 OPA BLUEOPTIONS 08/01/2017 B0611 33043 BCC BLUEOPTIONS 11/30/2016 B0611 33043 OSO BLUEOPTIONS 08/01/2017 B0611 33043 OSO IBLUEOPTIONS 08/01/2017 B0611 33043 OSO BLUEOPTIONS 08/01/2017 80611 33801 BCC BLUEOPTIONS 03/16/2017 001 MONROL 06/06/2016 ""'8742 SUBSCRIBER KLYWLSI B0611 33040 OSO BLUEOP I IONS 08124/2016 001 MONROE 10/19/2012 "" "8744 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 001 MONROE 11/01/2011 " "'8761 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 07/18/2016 001 MONROE 09/25/2016 " """ "8769 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 09/27/2016 001 MONROE 11/01/2011 " " "" "8777 SUBSCRIBER KEYLARGO 80611 33037 BCC BLUEOPTIONS 12/03/2013 001 MONROE 03/06/2017 " " "* "8778 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 04/28/2017 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 03/05/1944 073 NIALE 52 1 FL RETIREE 03559 EMPLOYEE ONLY R01 PINELLAS 11/01/2011 " "*" "8781 SUBSCRIBER LARGO 80611 33771 BCC BLUEOPTIONS 03/16/2017 11/01/1940 076 FEMALE 36 1 FL RETIREE 03559 EMPLOYEE ONLY R01 LEE 11/01/2011 8820 SUBSCRIBER NORTH FT MYERS B0611 33917 BCC BLUEOPTIONS 06/23/2015 12/31/9999 Qj 12/17/1951 065 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 03/01/2016 * "" "8829 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 02/03/2017 12/31/9999 D 03/26/1969 048 MALE 44 2 FL COBRA 03559 EMPLOYEE & SPOUSE C01 MONROE 04/29/2017 " "" "8837 SPOUSE RAMROD KEY B0611 33042 OCA BLUEOPTIONS 05/23/2017 12/31/9999 12/12/1957 059 FEMALE 44 2 FL COBRA 03559 EMPLOYEE & SPOUSE 001 MONROE 04/29/2017. 8837 SUBSCRIBER RAMROD KEY B0611 33042 OCA BLUEOPTIONS 05/23/2017 12131/9999 10/01/2004 013 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " " *"8846 DEPENDENT KEYLARGO B0611 33037 BCC BLUEOPTIONS 03/13/2014 12131/9999 N fi 06/10/1964 053 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' * ** "8846 SUBSCRIBER KEY LARGO B0611 33037 BCC BLUEOPTIONS 03/13/2014 12131/9999 10/17/1996 021 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 "' *'8846 DEPENDENT KEYLARGO 80611 33037 BCC BLUEOPTIONS 03/13/2014 12131/9999 07/03/1992 025 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 * * ** *8846 DEPENDENT KEYLARGO B0611 33037 BCC BLUEOPTIONS 03/13/2014 12/31/9999 7 11/25/2003 013 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2016 . "'8853 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 'U 02/04/1977 040 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 . " "" "8853 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 O 02/16/1966 051 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 * * ** *8867 SUBSCRIBER DORAL 80611 33178 OSO BLUEOPTIONS 08/01/2017 12/31/9999 fl 06/03/1982 035 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/30/2016 * * ** *8871 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 12/21/2016 12/31/9999 O 1 09/26/2012 005 MALE 06 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 BROWARD 01/01/2016 * * ** *8878 DEPENDENT PLANTATION B0611 33313 OSO BLUEOPTIONS 08/01/2017 12/31/9999 CL CL 01/28/1975 042 FEMALE 06 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 BROWARD 11/01/2011 * * *" "8878 SUBSCRIBER PLANTATION B0611 33313 OSO BLUEOPTIONS 08/01/2017 12/31/9999 v 04/04/1993 024 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 07/23/2016 ' ** "8880 SUBSCRIBER MIAMI B0611 33177 BCC BLUEOPTIONS 08/24/2016 12/31/9999 01/02/1968 049 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 12/07/2015 ' * "" "8880 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 12/31/9999 Q 12/22/1962 054 '.MALE 44 2 FL ACTIVE 03559 '.EMPLOYEE &SPOUSE 001 MONROE 07/24/2016 ' * "" "8886 '.SUBSCRIBER '. KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 02/10/1959 058 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 10/28/2016 ' * "" "8886 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 LLI 07/02/1939 078 MALE 42 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MARION 11/01/2011 " * ** "8893 SUBSCRIBER OCALA B0611 34471 OPA BLUEOPTIONS 03/03/2017 12/31/9999 09/08/1944 073 FEMALE 42 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MARION 11/01/2011 ' * ** "8893 SPOUSE OCALA B0611 34471 OPA BLUEOPTIONS 03/03/2017 12131/9999 09/24/1995 022 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2013 "' *'8894 DEPENDENT MARATHON 80611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 12/16/1993 023 'MALE 44 3 FL ACTIVE 03559 'EMPLOYEE &CHILDREN 001 MONROE 01101/2013 * * ** *8894 'DEPENDENT 'MARATHON B0611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 07/05/1958 059 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 02/18/2012 .. "'8894 SUBSCRIBER MARATHON 80611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 07/06/1963 054 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 " * "" "8907 SPOUSE SUMMERLAND KEY 80611 33042 BCC BLUEOPTIONS 03/08/2016 12/31/9999 LU U 03/11/1962 055 NIALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 * * ** *8907 SUBSCRIBER SUMMERLAND KEY 80611 33042 BCC BLUEOPTIONS 03/08/2016 12/31/9999 08/11/1967 050 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 12/31/2014 * * ** *8919 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 04/25/1988 029 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/23/2017 * * ** *8920 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 04/28/2017 12/31/9999 04/01/1971 046 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/01/2012 * * *" "8926 SUBSCRIBER MARATHON B0611 33050 OSO BLUEOPTIONS 12/03/2013 12/31/9999 Llj 10/17/1981 036 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' ** "8928 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 01/02/2017 12/31/9999 09/07/2012 005 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2017 * "" "8928 DEPENDENT TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12/31/9999 ' * "" "8928 ~ 05/08/2002 015 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 04/30/2016 DEPENDENT TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12/31/9999 h 03/05/1985 032 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2017 " * "" "8928 SPOUSE TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12131/9999 12/20/2007 009 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 04/30/2016 " " *"8928 DEPENDENT TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12131/9999 C4 09/15/1959 058 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/22/2016 ' * ** "8934 SUBSCRIBER LITTLE TORCH KEY B0611 33042 CCC BLUEOPTIONS 08/24/2016 12131/9999 _ 07/08/1965 052 MALE 06 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BROWARD 11/01/2011 „ », 8950 SUBSCRIBER PLANTATION B0611 33317 OSO BLUEOPTIONS 08/01/2017 12/31/9999 ay 01/16/1975 042 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " * *' "8951 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 01/15/2015 12/31/9999 01/10/1983 034 NIALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 .. "'8951 SUBSCRIBER MIAMI 80611 33170 BCC BLUEOPTIONS 04/09/2015 12/31/9999 S U 08/15/2012 005 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 08/15/2012 " " "" "8951 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 a+ *' 03/08/1975 042 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/25/2016 " * ** *8951 SUBSCRIBER BIG PINE KEY 80611 33043 BCC BLUEOPTIONS 08/01/2017 12/31/9999 10/17/2007 010 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2013 * * ** *8951 DEPENDENT KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 933 08/18/1976 041 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 06/11/1958 059 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY 05/20/1960 057 MALE 31 1 FL ACTIVE 03559 EMPLOYEE ONLY 12/10/1977 039 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 05/14/1977 040 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 11/08/1974 042 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 07/25/1947 070 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 03/31/2012 005 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 10/08/1988 029 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 07/15/1974 043 MALE 70 1 CA ACTIVE 03559 EMPLOYEE ONLY 03/07/1937 080 MALE 05 1 FL RETIREE 03559 EMPLOYEE ONLY 07/11/2008 009 FEMALE 44 4 FL ACTIVE 03559 FAMILY 07/07/1984 033 MALE 44 4 FL ACTIVE 03559 FAMILY 02/01/1970 047 FEMALE 44 4 FL ACTIVE 03559 FAMILY 12/24/1999 017 MALE 44 4 FL ACTIVE 03559 FAMILY 02/14/1966 051 (FEMALE 44 1 FL ACTIVE 03559 (EMPLOYEE ONLY 03/21/1964 053 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 10/28/1997 020 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 11/03/2000 016 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 01/13/1989 028 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 008 FEMALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILD 036 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILD 053 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 001 MIAMI -DADE 11/01/2011 " * ** *8956 SUBSCRIBER NARANJA B0611 33032 OSO BLUEOPTIONS 12/03/2013 R01 MONROE 01/01/2017 '" "`9048 SUBSCRIBER SUMMERLAND KEY B0611 33042 BCC BLUEOPTIONS 01/16/2017 001 INDIAN RIVER 11/19/2016 " ' SUBSCRIBER SEBASTIAN B0611 32958 BCC BLUEOPTIONS 08/01/2017 001 MONROE 10/05/2017 ` "" "9079 SUBSCRIBER SUMMERLAND KEY B0611 33042 BCC BLUEOPTIONS 10/24/2017 001 MONROE 11/01/2011 ^ °* *9087 SUBSCRIBER RAMROD KEY 80611 33042 BCC BLUEOPTIONS 08/01/2017 001 MONROE 04/29/2017 ' * ** *9097 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 05/22/2017 001 MONROE 11/01/2011 " * ** *9108 SUBSCRIBER KEYWEST 80611 33040 OCA BLUEOPTIONS 08/01/2017 001 MONROE 03/01/2016 " * *" "9119 DEPENDENT KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 001 MONROE 07/17/2015 " " "" "9119 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 04/28/2017 001 NON - FLORIDA 11/01/2011 " "`" "9126 SUBSCRIBER SAN DIEGO B0611 92107 BCC BLUEOPTIONS 08/07/2017 ADDRESS R01 BREVARD 11/01/2011 " "" "9132 SUBSCRIBER MERRITT ISLAND B0611 32953 OSO BLUEOPTIONS 05/02/2017 001 MONROE 11/01/2011 ""`9149 DEPENDENT CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 04/06/2016 001 MONROE 11/01/2011 " "`9149 SUBSCRIBER CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 001 MONROE 01/01/2014 " "`9149 SPOUSE CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 001 MONROE 01/01/2014 * * ** *9149 DEPENDENT CUDJOE KEY B0611 33042 OSO BLUEOPTIONS 0810112017 001 MONROE 11/ 01/ 2011 " "'9150 'SUBSCRIBER 'MARATHON B0611 33050 BCC 'BLUEOPTIONS 08/01/2017 001 MONROE 01/23/2012 '* "`9161 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 001 MONROE 01/23/2012 ` "" "9161 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 001 MONROE 01/23/2012 ` "" "9161 DEPENDENT KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 001 MIAMI -DADE 07/08/2017 ` "9177 SUBSCRIBER MIAMI B0611 33165 BCC BLUEOPTIONS 07/08/2017 001 MIAMI -DADE 04/01/2014 '*"'9290 DEPENDENT MIAMI B0611 33186 001 MIAMI -DADE 01/01/2013 ``" "9290 SUBSCRIBER MIAMI B0611 33186 001 MONROE 11/01/2011 ` '1291 SUBSCRIBER KEYWEST B0611 33040 08/22/1968 049 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " * ** "9295 SUBSCRIBER 80611 33040 BCC BLUEOPTIONS 12/03/2013 08/03/1967 050 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 9324 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 aj 08/09/1961 056 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 09/13/2013 " "" "9325 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 08/14/2017 12/31/9999 D 09/12/1957 060 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 09/01/2017 " "" "9328 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 09/09/2017 12/31/9999 08/09/1983 034 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * *"1333 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 06/14/2016 12131/9999 11/05/1953 063 MALE 70 1 OH RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 11/01/2011 "*"9333 SUBSCRIBER GENEVA B0611 44041 OSO BLUEOPTIONS 08/01/2017 12131/9999 N ADDRESS m 06/13/2016 001 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -DADE 06/13/2016 ' * ** 1337 DEPENDENT HOMESTEAD B0611 33032 OSO BLUEOPTIONS 08/01/2017 12131/9999 w N 08/26/1974 043 MALE 13 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MIAMI -0ADE 11/01/2011 * * ** *9337 SUBSCRIBER HOMESTEAD 80811 33032 OSO BLUEOPTIONS 07/15/2016 .® 12131/9999 01127/1987 030 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03127/2015 " "'9337 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 0810112017 12/31/9999 y 12/13/1954 062 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " " "" "9352 SUBSCRIBER KEYWEST B0611 33040 OCA BLUEOPTIONS 03/10/2016 12/31/9999 fu 08/13/1985 032 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 ' * "" "9358 SUBSCRIBER HOMESTEAD 80611 33033 BCC BLUEOPTIONS 08/01/2017 12/31/9999 11/16/1965 051 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' *'" "9360 SUBSCRIBER MARATHON 80611 33050 OSO BLUEOPTIONS 08/01/2017 12/31/9999 tO 7 01/06/1957 060 FEMALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 09/01/2016 " * ** "9383 SPOUSE MIAMI 80611 33185 OSO BLUEOPTIONS 08/01/2017 12/31/9999 O s 09/15/1958 059 MALE 13 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MIAMI -DADE 11/01/2011 * * ** *9383 SUBSCRIBER MIAMI 80611 33185 OSO BLUEOPTIONS 08/01/2017 12/31/9999 C ' CL 04/30/2012 005 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2017 ' * *" "9386 DEPENDENT TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12/31/9999 06/29/2008 009 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2017 ' * *" "9386 DEPENDENT TAVERNIER B0611 33070 BCC BLUEOPTIONS 08/01/2017 12/31/9999 11/27/1974 042 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' * *" "9386 SUBSCRIBER TAVERNIER B0611 33070 BCC BLUEOPTIONS 01/02/2017 12/31/9999 10/01/1991 026 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 05/23/2014 """ "9386 SUBSCRIBER MIAMI B0611 33175 OTC BLUEOPTIONS 08/24/2016 12/31/9999 ULI 04/29/1949 068 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 04/01/2016 " "" "9387 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 05/02/2017 12131/9999 '.MALE " " "" "9388 '.SUBSCRIBER '.CAPE 10/27/1928 089 36 1 FL RETIREE 03559 EMPLOYEE ONLY R01 LEE 11/01/2011 CORAL B0611 33991 BCC BLUEOPTIONS 12/03/2013 12131/9999 12/26/1985 031 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/27/2015 " * ** "9402 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/16/2017 12131/9999 01/28/1972 045 MALE 08 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 CHARLOTTE 03/03/2017 * * ** "9405 SPOUSE PUNTA GORDA B0611 33955 BCC BLUEOPTIONS 10/31/2017 12/31/9999 �. 02/06/1981 036 FEMALE 08 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 CHARLOTTE 01/17/2014 " * "` "9405 SUBSCRIBER PUNTA GORDA B0611 33955 BCC BLUEOPTIONS 10/31/2017 12/31/9999 05/26/1960 057 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/01/2015 " "" "9412 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 10/01/1989 028 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2015 ' * "" "9413 DEPENDENT BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 10/30/2017 12/31/9999 LU U 01/11/1973 044 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/05/2011 ' *'" "9413 SUBSCRIBER BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 10/30/2017 12/31/9999 12/24/1950 066 FEMALE 13 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MIAMI -DADE 09/01/2017 " * ** "9418 SUBSCRIBER MIAMI 80611 33176 OSO BLUEOPTIONS 09/09/2017 12/31/9999 11/02/1995 021 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' * *' *9424 DEPENDENT KEYLARGO 80611 33037 OSO BLUEOPTIONS 04/26/2017 12/31/9999 LLJ 01/24/1968 049 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 ' * *" "9424 SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 08/01/2017 12/31/9999 07/28/2008 009 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2016 ' * *" "9427 DEPENDENT KEYLARGO B0611 33037 OSO BLUEOPTIONS 02/08/2016 12/31/9999 U 05/21/2005 012 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2016 ' * *" "9427 DEPENDENT KEYLARGO B0611 33037 OSO BLUEOPTIONS 02/08/2016 12/31/9999 h 08/27/1970 047 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/01/2016 """ "9427 SUBSCRIBER KEYLARGO B0611 33037 OSO BLUEOPTIONS 08/01/2017 12131/9999 F- 06/09/1961 056 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 01/01/2015 "" "9431 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12131/9999 M 09/29/1962 055 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 " " "" "9431 SUBSCRIBER KEYWEST B0611 '. 33040 BCC BLUEOPTIONS 07/06/2017 12131/9999 ' N 07/13/1962 055 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/06/2017 * * ** "9440 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 12131/9999 .w C 12/16/2001 015 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 "' *'9457 DEPENDENT DUCK KEY B0611 33050 OSO BLUEOPTIONS 07/06/2017 12/31/9999 4! 08/02/1973 044 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 " * "` "9457 SUBSCRIBER DUCK KEY B0611 33050 OSO BLUEOPTIONS 07/06/2017 12/31/9999 09/28/1962 055 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/04/2013 " "" "9457 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 08/01/2017 12/31/9999 01/23/1944 073 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ' * "" "9465 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 12/28/2015 12/31/9999 11/29/2006 010 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 06/01/2016 ' * *" "9487 DEPENDENT CUDJOE KEY 80611 33042 BCC BLUEOPTIONS 08/01/2017 12/31/9999 12/26/1970 046 FEMALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 06/01/2016 " * ** "9487 SPOUSE CUDJOE KEY 80611 33042 BCC BLUEOPTIONS 06/09/2016 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 03/21/1971 046 NIALE 44 4 FL ACTIVE 03559 FAMILY 002 MONROE 06/01/2016 * *** *9487 SUBSCRIBER CUDJOE KEY B0611 33042 BCC BLUEOPTIONS 06/09/2016 01/25/1973 044 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' "" "9516 SPOUSE TAVERNIER B0611 33070 OSO BLUEOPTIONS 04/09/2015 12/31/9999 Qj 05/01/2007 010 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' "" "9516 DEPENDENT TAVERNIER B0611 33070 OSO BLUEOPTIONS 04/09/2015 12/31/9999 D 05/15/1959 058 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 ' *" "9516 SUBSCRIBER TAVERNIER B0611 33070 OSO BLUEOPTIONS 08/01/2017 12/31/9999 07/08/1986 031 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 06/18/2016. ' * ** *9524 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 08/24/2016 12131/9999 01/17/1949 068 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * ** *'9527 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 11/30/2016 12131/9999 N fi 04/30/1930 087 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 07/01/2014 "* *'9531 SUBSCRIBER MARATHON B0611 33050 BCC BLUEOPTIONS 11/30/2016 12131/9999 03/28/1989 028 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/08/2015 ' * ** *9542 SUBSCRIBER SUMMERLAND KEY 80611 33042 OSO BLUEOPTIONS 08/24/2016 12131/9999 10/30/1954 053 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 01/01/2014 * *" *9543 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 08/23/2017 12/31/9999 7 01/04/1958 059 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 05/01/2015 . "'9548 SUBSCRIBER KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 'U 03/30/1951 066 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 05/01/2015 * * ** *9548 SPOUSE KEYWEST 80611 33040 OSO BLUEOPTIONS 08/01/2017 12/31/9999 O 08/03/1964 053 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 06/01/2015 * * ** *9549 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 06/29/2016 12/31/9999 fl 03/26/1961 056 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 10/01/2015 * * ** *9549 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 O 1 11/20/2000 016 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/09/2015 * * ** *9557 DEPENDENT KEYWEST B0611 33040 CCC BLUEOPTIONS 01/15/2015 12/31/9999 CL CL 03/29/1965 052 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * ** "'9557 SUBSCRIBER ISLAMORADA B0611 33036 BCC BLUEOPTIONS 07/08/2016 12/31/9999 v 04/02/1971 046 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 01/09/2015 ' "" "9557 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 06/20/1973 044 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 08/12/2017 ' "" "9563 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/12/2017 12/31/9999 Q 05/31/1959 058 '.MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' ** "9573 '.SUBSCRIBER '.SUMMERLAND KEY B0611 33042 OSO BLUEOPTIONS 03/09/2017 12/31/9999 08/19/1951 066 MALE 12 1 FL RETIREE 03559 EMPLOYEE ONLY R01 COLUMBIA 11/01/2011 ' * ** *9576 SUBSCRIBER FORTWHITE B0611 32038 OSO BLUEOPTIONS 08/01/2017 12/31/9999 UJ 04/21/1974 043 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/14/2014 ' ** *'9604 SUBSCRIBER KEYWEST B0611 33040 CCC BLUEOPTIONS 08/01/2017 12/31/9999 06/30/1954 063 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 "* *'9627 SPOUSE MARATHON B0611 33050 BCC BLUEOPTIONS 04/20/2017 12131/9999 05/16/1948 069 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 ' * ** *9627 SUBSCRIBER MARATHON 80611 33050 BCC BLUEOPTIONS 06/02/2015 12/31/9999 04/08/1954 063 'MALE 44 2 FL ACTIVE 03559 'EMPLOYEE &SPOUSE 001 MONROE 11/01/2011 * *" *9638 'SUBSCRIBER 'KEYLARGO B0611 33037 OSO BLUEOPTIONS 08/01/2017 12/31/9999 01/11/1960 057 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 03/06/2015 .. "'9638 SUBSCRIBER KEYWEST 80611 33040 OPA BLUEOPTIONS 08/01/2017 12/31/9999 09/18/1949 068 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 11/01/2011 * *** *9638 SPOUSE KEYLARGO 80611 33037 OSO BLUEOPTIONS 01/22/2015 12/31/9999 LU U 12/26/1959 057 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** *9641 SUBSCRIBER TAVERNIER 80611 33070 BCC BLUEOPTIONS 12/03/2013 12/31/9999 05/18/1945 072 NIALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 05/01/2012 * * ** *9655 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 11/30/2016 12/31/9999 09/25/1927 090 MALE 70 1 MI RETIREE 03559 EMPLOYEE ONLY R01 NON - FLORIDA 11/01/2011 * * ** *9665 SUBSCRIBER STERLING HEIGHTS B0611 48310 BCC BLUEOPTIONS 03/02/2017 12/31/9999 ADDRESS LLJ 12/22/1936 080 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 * ** "'9666 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 03/02/2017 12/31/9999 09/14/1993 024 MALE 44 3 FL RETIREE 03559 EMPLOYEE & CHILDREN R01 MONROE 03/01/2016 * ** "'9667 DEPENDENT SUMMERLAND KEY B0611 33042 OSO BLUEOPTIONS 03/02/2016 12/31/9999 V 02/13/1965 052 MALE 44 3 FL RETIREE 03559 EMPLOYEE & CHILDREN R01 MONROE 03/01/2016 * ** "'9667 SUBSCRIBER SUMMERLAND KEY B0611 33042 OSO BLUEOPTIONS 08/01/2017 12/31/9999 h 08/19/1981 036 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 11/01/2011 '" "'9672 SUBSCRIBER KEYWEST B0611 33040 OSO BLUEOPTIONS 01/02/2017 12131/9999 F- 07/31/1985 032 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 11/01/2011 ' *" "`9672 SUBSCRIBER HOMESTEAD B0611 33033 OSO BLUEOPTIONS 04/28/2017 12131/9999 M 10/03/2016 001 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 10/03/2016 ' ** *'9672 DEPENDENT KEYWEST B0611 '. 33040 OSO BLUEOPTIONS 08/01/2017 12131/9999 ' N 09/16/1963 054 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** *9699 SUBSCRIBER KEY LARGO B0611 33037 OCA BLUEOPTIONS 12/03/2013 12131/9999 .w C 11/06/1939 077 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R02 MONROE 11/01/2011 ' * ** *9707 SUBSCRIBER BIG PINE KEY B0611 33043 OSO BLUEOPTIONS 12/03/2013 12/31/9999 4! 10/31/1975 042 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' * *` *9719 SUBSCRIBER KEYWEST B0611 33040 OCA BLUEOPTIONS 08/01/2017 12/31/9999 11/03/1961 055 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 *`* "9721 SUBSCRIBER KEYWEST B0611 33040 BCC BLUEOPTIONS 12/03/2013 12/31/9999 02/19/1961 056 FEMALE O6 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BROWARD 11/01/2011 — 9723 SUBSCRIBER PEMBROKE PINES 80611 33027 OSO BLUEOPTIONS 03/27/2017 12/31/9999 03/06/2016 001 NIALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 03/06/2016 ' * ** *9740 DEPENDENT KEYWEST 80611 33040 BCC BLUEOPTIONS 08/01/2017 12/31/9999 09/19/1971 046 MALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 11/01/2011 * * ** *9740 SUBSCRIBER KEYWEST 80611 33040 BCC BLUEOPTIONS 02/13/2017 12/31/9999 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 1 Packet pg. 936 08/10/1984 033 FEMALE 44 4 FL ACTIVE 03559 FAMILY 001 MONROE 01/01/2016 ""'9740 SPOUSE KEYWEST B0611 33040 BCC BLUEOPTIONS 08/09/2017 08/10/1982 035 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " "'9810 SUBSCRIBER 05/08/1972 045 MALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 06/07/2015 " " "" "9820 SUBSCRIBER 04/14/1998 019 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 08/07/2015 " " "" "9820 DEPENDENT 02/23/2000 017 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 08/07/2015 " 9820 DEPENDENT 12/01/2004 012 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 08/07/2015 ' " "* "9820 DEPENDENT 08/22/1962 055 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 ' "" "'9822 SUBSCRIBER 12/19/1935 081 FEMALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 ' "" "9830 SUBSCRIBER 07/16/2014 003 FEMALE 50 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 PALM BEACH 08/01/2015 "" "9837 DEPENDENT 07/16/2014 003 '.MALE 50 3 FL ACTIVE 03559 '.EMPLOYEE &CHILDREN 001 PALM BEACH 08/01/2015 ' "" "'9837 '.DEPENDENT 08/24/1987 030 MALE 50 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 PALM BEACH 04/30/2012 ' "' "`9837 SUBSCRIBER 10/28/1978 039 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 07/01/2017 "' "'9837 SUBSCRIBER 09/09/1997 020 MALE 44 4 FL RETIREE 03559 FAMILY R01 MONROE 11/01/2014 " "'9840 DEPENDENT 03/17/2000 017 FEMALE 44 4 FL RETIREE 03559 FAMILY R01 MONROE 11/01/2014 " "'9840 DEPENDENT 09/14/1987 030 'FEMALE 44 3 FIL ACTIVE 03559 'EMPLOYEE &CHILDREN 001 MONROE 09104/2017 ' ""'9840 'SUBSCRIBER 01/25/2014 003 NIALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 09/04/2017 " "'9840 DEPENDENT 06/30/2007 010 FEMALE 44 3 FL ACTIVE 03559 EMPLOYEE & CHILDREN 001 MONROE 09/04/2017 " """ "9840 DEPENDENT 09/19/1970 047 FEMALE 44 4 FL RETIREE 03559 FAMILY R01 MONROE 01/05/2015 " " "" "9840 SPOUSE 10/20/1955 062 NIALE 44 4 FL RETIREE 03559 FAMILY R01 MONROE 11/01/2014 " " "" "9840 SUBSCRIBER 11/25/1963 053 MALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 06/02/2017 ' " "* "9844 SPOUSE 06/13/1968 049 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 03/26/2016 " "" "'9844 SUBSCRIBER 02/01/1940 077 MALE 44 1 FL RETIREE 03559 EMPLOYEE ONLY R01 MONROE 11/01/2011 "" "9849 SUBSCRIBER 06/04/1954 063 FEMALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 02/01/2017 "" "'9849 SPOUSE 02/10/1960 057 MALE 44 2 FL RETIREE 03559 EMPLOYEE & SPOUSE R01 MONROE 02/01/2017 " "'9849 SUBSCRIBER 08/08/1990 027 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/19/2013 " "'9855 SUBSCRIBER 03/13/1975 042 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 04/24/2015 ""9856 SUBSCRIBER 08/15/1990 027 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/30/2013 "' "9861 SUBSCRIBER 01/08/1934 083 MALE 06 1 FL RETIREE 03559 EMPLOYEE ONLY R01 BROWARD 02/01/2014 " "'9870 SUBSCRIBER 01/09/1984 033 MALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 09/12/2014 .... I'll SUBSCRIBER 09/25/1980 037 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 02/26/2017 "' "9890 SUBSCRIBER 09/29/1989 028 NIALE O6 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 BROV4ARD 07/11/2014 ' " "' "9903 SUBSCRIBER 05/18/1943 074 FEMALE 50 1 FL RETIREE 03559 EMPLOYEE ONLY R01 PALM BEACH 11/01/2011 "" "9904 SUBSCRIBER 01/17/1959 058 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 01/04/2013 ' " "* "9905 SUBSCRIBER This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 WEST 80611 33040 OSO BLUEOPTIONS 04/20/2017 .E TORCH KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 .E TORCH KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 .E TORCH KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 E TORCH KEY B0611 33042 BCC BLUEOPTIONS 08/01/2017 LARGO B0611 33037 OSO BLUEOPTIONS 08/01/2017 WEST B0611 33040 BCC BLUEOPTIONS 04/20/2017 FH BAY B0611 33493 OSO BLUEOPTIONS 08/01/2017 FH BAY B0611 '.. 33493 OSO BLUEOPTIONS '.. 08/01/2017 FH BAY B0611 '.. 33493 OSO BLUEOPTIONS '.. 08/01/2017 WEST B0611 33040 OSO BLUEOPTIONS 0710112017 WEST B0611 33040 OSO BLUEOPTIONS 06/29/2016 WEST B0611 33040 OSO BLUEOPTIONS 06/29/2016 WEST B0611 33040 BCC IBLUEOPTIONS 09/09/2017 WEST 80611 33040 BCC BLUEOPTIONS 09/09/2017 WEST B0611 33040 BCC BLUEOPTIONS 09/09/2017 MIAMI B0611 33176 BCC KEY W EST 80611 33040 OSO PEMBROKE PINES B0611 33029 BCC BOYNTON BEACH B0611 33474 CCC KEY W EST B0611 33045 BCC 08/24/2016 04/28/2017 08/24/2016 03/16/2017 10/10/2016 02/02/1988 029 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 10/17/2014 "" "9911 SUBSCRIBER RAMROD KEY B0611 33042 OSO BLUEOPTIONS 04/27/2017 C.7.9 06/29/1948 069 NIALE 70 1 NC RETIREE 03559 EMPLOYEE ONLY R01 NON- FLORIDA 11/01/2011 * "" "9921 SUBSCRIBER MINT HILL B0611 28227 BCC BLUEOPTIONS 01/02/2017 ADDRESS 12/08/1943 073 NIALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 " * "" "9920 SUBSCRIBER MARATHON 80611 33050 BCC BLUEOPTIONS 08/01/2017 12/31/9999 06/001948 069 MALL 44 2 FL RL I IREE 03SS9 LMYLOYLL &SPOUSE R01 MONROE 02/01/2012 " "1110 5UI33GRII3LR MARAIHON 130611 33050 BGG ULUEOF'I IONS 11/30/2016 12/11/1971 045 MALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * *' *9955 SUBSCRIBER KEYLARGO B0611 33037 BCC BLUEOPTIONS 04/26/2017 12/08/1954 062 NIALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 10/04/2014 "" "9956 SPOUSE KEY W EST B0611 33040 BCC BLUEOPTIONS 08/24/2016 12/14/1959 057 FEMALE 44 2 FL ACTIVE 03559 EMPLOYEE & SPOUSE 001 MONROE 10/04/2014 ' "'" "9956 SUBSCRIBER KEY W EST 80611 33040 BCC BLUEOPTIONS 08/24/2016 05/18/1964 053 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/23/2017 " * ** "9964 SUBSCRIBER BIG PINE KEY 80611 33043 OSO BLUEOPTIONS 05/23/2017 02/22/1949 068 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * ** *9968 SUBSCRIBER BIG PINE KEY 80611 33043 BCC BLUEOPTIONS 10/21/2015 04/15/1994 023 FEMALE 13 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MIAMI -DADE 03/27/2015 * * *" *9969 SUBSCRIBER HOMESTEAD B0611 33030 OSO BLUEOPTIONS 08/24/2016 09/23/1975 042 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 05/29/2017 * * *" *9989 SUBSCRIBER KEY W EST B0611 33040 OSO BLUEOPTIONS 08/31/2017 12/11/1964 052 FEMALE 44 1 FL ACTIVE 03559 EMPLOYEE ONLY 001 MONROE 11/01/2011 * * *" *9990 SUBSCRIBER MARATHON B0611 33050 ORA BLUEOPTIONS 08/01/2017 This Florida Blue report is proprietary and confidential. Report Run: 11/22/2017 1:19 PM Page 1 of 1 Monroe County Board of County Commissioners EMPLOYEE DEPENDENTS ONLY HIRED ON OR AFTER 1/1/18 Spouse Only Spouse + 1 child Spouse + 2 or more children One child only Two children only Three children only Four children only Five + Children RULE OF 70 RETIREES ONLY 25+ YRS < 65 20 -24 YRS < 65 10 -19 YRS < 65 10+ YRS Medicare Eligible Staying on County Plan 10+ YRS Medicare Eligible Staying on County Plan - County 10+ YRS Medicare Eligible Staying on County Plan - Net Retiree 10+ YRS Medicare Eligible Leaving County Plan - County Subsidy (Can be used to purchase Medicare Supplement) OTHER RETIREES Non Rule of 70 Retirees < 65 Non Rule of 70 Retirees 65+ Surviving Spouse < 65 Surviving Spouse 65+ RETIREE DEPENDENTS ONLY: Spouse Only <65 Spouse only <65 + 1 child Spouse only <65 + 2 or more children Spouse Only >65 (Retiree must remain on County plan for Spouse to be eligible) One child only $332 $480 $701 $148 $295 $443 $591 $739 FRS FRS FRS FRS $508 $733 $1,072 $226 $451 $677 $903 $1,128 FRS $127 $137 $677 $250 $427 $250 tetiree Rates 2018 Actuarial Rates 2018 Employ $752 Current Current Current Traditional Traditional Traditional Plan Plan Employee and Retiree Contributions Effective January 1, 2018 Monthly Rate Monthly Rate mployees Paying $25 Premium (Hired prior to 5/1/2012) $25 $50 mployees Paying $50 Premium (Hired 5/1/12 or later) $50 $75 MPLOYEE DEPENDENTS ONLY HIRED PRIOR TO 1/1/18 Monthly Rate $566 pouse Only $332 $382 pouse + 1 child $480 $552 pouse + 2 or more children $701 $806 )ne child only $148 $170 wo children only $295 $340 hree children only $443 $510 our children only $591 $680 ive + Children $739 $849 EMPLOYEE DEPENDENTS ONLY HIRED ON OR AFTER 1/1/18 Spouse Only Spouse + 1 child Spouse + 2 or more children One child only Two children only Three children only Four children only Five + Children RULE OF 70 RETIREES ONLY 25+ YRS < 65 20 -24 YRS < 65 10 -19 YRS < 65 10+ YRS Medicare Eligible Staying on County Plan 10+ YRS Medicare Eligible Staying on County Plan - County 10+ YRS Medicare Eligible Staying on County Plan - Net Retiree 10+ YRS Medicare Eligible Leaving County Plan - County Subsidy (Can be used to purchase Medicare Supplement) OTHER RETIREES Non Rule of 70 Retirees < 65 Non Rule of 70 Retirees 65+ Surviving Spouse < 65 Surviving Spouse 65+ RETIREE DEPENDENTS ONLY: Spouse Only <65 Spouse only <65 + 1 child Spouse only <65 + 2 or more children Spouse Only >65 (Retiree must remain on County plan for Spouse to be eligible) One child only $332 $480 $701 $148 $295 $443 $591 $739 FRS FRS FRS FRS $508 $733 $1,072 $226 $451 $677 $903 $1,128 FRS $127 $137 $677 $250 $427 $250 tetiree Rates 2018 Actuarial Rates 2018 COBRA Rates $752 Current $767 Current $621 $677 Traditional $677 Traditional $691 HDHP /HSA Plan HDHP /HSA Plan HDHP /HSA lonthly Rate Monthly Rate Monthly Rate Monthly Rate Monthly Rate $0 $299 $432 $631 $133 $266 $399 $532 $665 $425 $614 $897 $189 $378 $566 $755 $944 $56 $66 $76 $566 $250 $316 $250 $752 $1,015 $1,467 $2,144 $451 $903 $1,354 $1,805 $2,257 $1,015 $1,467 $2,144 $451 $903 $1,354 $1,805 $2,257 $752 $752 $752 $677 $629 $850 $1,227 $1,793 $378 $755 $1,133 $1,510 $1,888 $850 $1,227 $1,793 $378 $755 $1,133 $1,510 $1,888 $629 $629 $629 $566 $767 $1,036 $1,496 $2,187 $460 $921 $1,381 $1,841 $2,302 $1,036 $1,496 $2,187 $460 $921 $1,381 $1,841 $2,302 $642 $642 $867 $1,252 $1,829 $385 $770 $1,155 $1,540 $1,926 $867 $1,252 $1,829 $385 $770 $1,155 $1,540 $1,926 $1,035 $752 $629 $752 $629 $767 $642 $621 $677 $566 $677 $566 $691 $578 $332 $382 $299 $1,015 $850 $1,036 $867 $559 $677 $566 $677 $566 $691 $578 $332 $382 $299 $1,015 $850 $1,036 $867 $480 $552 $432 $1,467 $1,227 $1,496 $1,252 $701 $806 $631 $2,144 $1,793 $2,187 $1,829 $559 $677 $566 $677 $566 $691 $148 $170 $133 $451 $378 $460 Pp c Departme Rate un $1,102.( $1,102.( 0 L CL CL ITwo children only 1 $2951 40 $2661 $9031 $551 %»1 $7aL� I Ty F- z LLJ M F- CV E 0 Exhibit A — Scope of Services 2 " i The Proposer will be evaluated on compliance with the below service requirements. By submitting a proposal, the Proposer agrees that these provisions will be part of the agreement between the parties. Deliverables: If necessary, the Proposer shall provide an Amendment, Endorsement, or Rider to the County to accommodate non - standard contract provisions agreed to by the Proposer. Check the applicable box for each service offered. Only provide explanations if you cannot comply fully with the requested service. Yes No Yes, Can Comply but with Service Requirement Can Cannot Specified Deviations Comply Comply (please detail deviations below This Agreement shall be governed by and construed in accordance with the laws of the State of Florida applicable to Agreements made and to be performed entirely in the State. The Proposer shall maintain compliance with all federal, state, and local laws, ordinances, rules, professional license requirements and regulations that in any manner affect the services to be provided. Provide firm pricing for the effective date of the contract based on the information provided in the RFP. Variations in actual enrollment shall have no effect on the proposal. The proposal shall be valid regardless of the final enrollment mix, number of Awardees, number of plan designs, or outcome. All charges for any service or optional service must be clearly outlined in the Pricing Exhibit. The Current TPA has a contractual provision to assess a $150,000 early termination fee. If the contract is terminated prior to 1/112020, please indicate whether you will assume this expense on the County's behalf if you are awarded this business. Exhibit A — Scope of Services 1 " x Yes No Yes, Can Comply but with Service Requirement Can Cannot Specified Deviations Comply Comply (please detail deviations below) Provide accurate and seamless integration of the Medical and Pharmacy claim accumulators information for the carved out Prescription Drug Program. If there are integration costs involved, provide funding to cover those costs. Disclose any commissions and /or service fees (if any are included) in your rate quotation, including the amount of the commissions and /or service fees, to whom they may be paid and your reason(s) for including them. Disclosure must be on an annual basis. Provide a toll free number and sufficient staffing to handle inquiries directly from staff and plan members. Provide an experienced Implementation Manager responsible for the accuracy and timeliness of the implementation. Provide an Account Manager responsible for the overall relationship. Participate in open enrollment meetings on an annual basis. Participate in onsite meetings at various County locations to review plan results, as needed. Duplicate and administer current benefits. Administer in- network and out of network benefits. Make timely and accurate claims payments to medical providers in accordance with plan provisions. Provide billing & eligibility services to the County Exhibit A — Scope of Services 2 " x W , Yes No Yes, Can Comply but with Service Requirement Can Cannot Specified Deviations Comply Comply (please detail deviations below) Accept enrollment via paper, online enrollment, or electronic files Provide effective programs to manage participant health as well as claim costs. Provide services, including but not limited to: • Coordination of benefits • Subrogation /recovery • Fraud investigation • Utilization Review Integrate Large Claim Management, Case Management, and Disease Management services to provide seamless and effective care and cost management services to the County and its Participants. Report potential large claims with sufficient detail for the County to anticipate increased costs. Provide monthly, quarterly, and annually detailed claims reports to the County and the consultant electronically. Provide appropriate reports to assist with mandated State and Federal filings. Provide ad hoc reports, upon request, at no charge Provide accurate and seamless integration of the Medical and Pharmacy claim accumulators information for the carved out Prescription Drug Program. Provide prior authorization of specific procedures, such as advanced imaging (MRI, CAT scans, PT, OT, Speech Therapy, Home Health, etc.). Provide a 24 hour nurseline for participants' use. W , Exhibit A — Scope of Services 2 " x W , Yes No Yes, Can Comply but with Service Requirement Can Cannot Specified Deviations Comply Comply (please detail deviations below) Provide a telehealth benefit for participants" use. Provide outreach to members with targeted conditions or risk factors. Solicit, screen, evaluate credentials, and approve providers to participate in the network. Secure discounts from network providers to enable the County to achieve plan savings through effective network contracting. Monitor and manage networks to ensure sufficient coverage for all medical services. Collaborate with the County to ensure continued network satisfaction. Ensure appropriate transition of care to the County's plan participants as needed. Provide a $100,000 annual budget for a wellness program and activities Provide Health Risk Assessments — online or in person — at least once annually. Provide Biometric Screening for all plan participants, at least once annually. Provide one -on —one health coaching. Provide professional staff to help drive the development of Wellness Initiatives. Design, develop, and direct Health Fairs for plan participants. Design, develop and direct employee wellness activities — at least quarterly. W , Exhibit A — Scope of Services 2 " x W , Yes No Yes, Can Comply but with Service Requirement Can Cannot Specified Deviations Comply Comply (please detail deviations below) Provide outreach to employees with critical scores on the HRA /Biometric Screenings. Provide the results of Biometric screenings to the Claims Administrator/ Disease Management vendor. Design, develop and direct employee educational activities — at least quarterly. Provide estimated renewal rates 120 days in advance of renewal. Produce and distribute all appropriate materials, including but not limited to: enrollment materials, plan booklets & schedules of benefits, summary of benefits (SBC's), provider lists, etc. Provide sufficient time for the County to review and approve all open enrollment communication materials prior to release to employees. Provide performance guarantees with financial penalties for non- performance. Performance guarantees should include: • Maintaining Network Access • Maintaining promised discounts • Claim turnaround time • Claim payment accuracy • Participant satisfaction No party to this Agreement shall be required to enter into any arbitration proceedings related to the Agreement. Comply with the Florida Local Government Prompt Payment Act, Section 218.70, Florida Statutes. The Provider shall submit to the County an invoice with supporting documentation in a form W , Exhibit A — Scope of Services 2 " x W , Yes No Yes, Can Comply but with Service Requirement Can Cannot Specified Deviations (please detail deviations Comply Comply below) acceptable to the Clerk. Following receipt of the invoice, the County will have 45 days to pay the invoice without interruption of service. The Proposer may terminate this Agreement with ninety (90) days' notice to the County. The County may terminate this Agreement with or without cause upon thirty (30) days' notice to the Proposer. County shall pay Proposer for work performed through the date of termination. Agree to the following: "Pursuant to Florida Statute §119.0701, Proposer and its subcontractors shall comply with all public records laws of the State of Florida, specifically to: (a) Keep and maintain public records that ordinarily and necessarily would be required by Monroe County in the performance of this Agreement. (b) Provide the public with access to public records on the same terms and conditions that Monroe County would provide the records and at a cost that does not exceed the cost provided in Florida Statutes, Chapter 119 or as otherwise provided by law. (c) Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law. (d) Meet all requirements for retaining public records and transfer, at no cost, to Monroe County all public records in possession of the Proposer upon termination of this Agreement and destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. All records stored electronically must be provided to Monroe County in a format that is compatible with the information technology systems of Monroe W , Exhibit A — Scope of Services 2 " x Service Requirement Yes Can Comply No Cannot Comply Yes, Can Comply but with Specified Deviations (please detail deviations below) County." The Proposer does hereby consent and agree to indemnify and hold harmless the County, its Mayor, the Board of County Commissioners, appointed Boards and Commissions, Officers, and the Employees, and any other agents, individually and collectively, from all fines, suits, claims, demands, actions, costs, obligations, attorney's fees, or liability of any kind arising out of the sole negligent actions of the Proposer or substantial and unnecessary delay caused by the W , Exhibit A — Scope of Services 2 " x Service Requirement Yes Can Comply No Cannot Comply Yes, Can Comply but with Specified Deviations (please detail deviations below) willful nonperformance of the Proposer and shall be solely responsible and answerable for any and all accidents or injuries to persons or property arising out of its performance of this contract. The amount and type of insurance coverage requirements set forth hereunder shall in no way be construed as limiting the scope of indemnity set forth in this paragraph. Further the Proposer agrees to defend and pay all legal costs attendant to acts attributable to the sole negligent act of the Proposer. W , EXHIBIT B Questionnaire Self- Funded Questionnaire Submit responses in Hard Copy and Electronic Version in a useable Microsoft Word format. For your convenience, Exhibit B is also available as a separate downloadable document in a useable Microsoft Word format. y ' ii 1. On what date did your organization enroll its first group in Florida for coverage and for what type of coverage? Type of Coverage Date PPO products Consumer- Driven products Self- Funding Well Management 2. Provide the enrollment data (including all plans) requested below for the organization submitting this Proposal a.) Florida Enrollment 1/112015 11112016 1/112017 Commercial Enrollment Medicare Enrollment Medicaid Enrollment Other Enrollment Total Enrollment b.) South Florida (Miami -Dade and Monroe Counties) Enrollment 1/112015 11112016 1/112017 Commercial Enrollment Medicare Enrollment Medicaid Enrollment Other Enrollment Total Enrollment c.) Monroe County Enrollment 1/112015 11112016 1/112017 Commercial Enrollment Medicare Enrollment Medicaid Enrollment Other Enrollment Total Enrollment 3. What percent of your Florida enrollment in 2016 and 2017 is from public sector clients? What percentage is fully - Insured vs. self- funded for 2017? Florida Enrollment Total 2016 % of 2017 % of 2016% 2017% Enrollment Public Public Fully- Self- Funded Sector Sector Insured Total Enrollment 4. Provide NCQA, JCAHO, AAA and /or any other accreditation status that applies to the programs you are proposing. Provide a copy of your accreditation letter(s). i ii Page 11 5. Detail any mergers /acquisitions involving your organization which have occurred in the last 12 -month period, and any which are planned for the next 12 to 24 months. 6. Confirm whether your organization can administer all current benefits. Yes _ No _. Explain any deviations to covered services, limitations /exclusions and system limitations in Exhibit D. Failure to disclose deviations that contribute to additional claims cost may result in the Awardee(s) being financially liable for the additional claims cost. 7. Address any system limitations you would face if the County made any changes with the plan of benefits such as a. Change in copays for PCP and /or Specialist b. Change in copays /coinsurance for Hospitals, Emergency Room, Diagnostic Testing c. Administering different copay /coinsurance by type of facility (i.e., hospital vs. freestanding facility). 8. Address any system limitations or vendor data sharing issues you would face due to: d. Carving out wellness /disease management programs e. Maintaining the carved out pharmacy program through Envision Rx. f. Maintaining their exemption from the Mental Health Parity and Addition Equity Act (MHPAEA) 9. Describe, in detail, your out -of -area coverage for members, both within and outside the United States who may either reside out of area or who maybe travelling out of area. Describe your capabilities for negotiating fees with out -of -area providers and the cost for such services. 10. Does your plan cover members that utilize services offered through a walk -in facility such as those located in a retail environment? Yes_ No _. If yes, are there any limitations? 11. Do you provide Telehealth services? Yes _ No _ At what costs? 12. Have you changed the size or structure of either the primary care or specialty care network for Monroe or Miami - Dade Counties during the past 12 months? Yes _ No _. If yes, explain. 13. Complete the following GeoAccess summary for the County's employees. Your study should include a summary report for each of the items listed below. Each summary should indicate the total number and percentage of employees with access by zip code and by city for all networks that you are proposing. Please include GeoAccess Reports in tab 6. All GeoAccess Reports are to be based on driving distance. a. Number and percentage of employees with two adult Primary Care Physicians (Family Practice, General Practice, Internists) within ten miles of the employee's zip code. b. Number and percentage of employees with two Pediatricians within ten miles of the employee's zip code. c. Number and percentage of employees with two OB /GYNs within ten miles of the employee's zip code. d. Number and percentage of employees with two Specialists within twelve miles of the employee's zip code. e. Number and percentage of employees with one hospital within twenty miles of the employee's zip code. Page 12 Adult PCP's Pediatricians OB /GYN Specialists > Hospitals 2 in 10 miles '2 in 1 »0 miles '> 2 in 10 miles 12 in 12 miles' 1 in 20 miles Page 12 14. Complete the following GeoAccess summary for the County's participants using the same access standards as above. Please list the number of participants in the top 5 CITIES that do not meet the access standards. List City and numberwithou#'' access Adult PCP's 2 in 10 miles Pediatricians 2 in 10 miles OBIGYN 2 in 10 miles Specialists 2 in 12 miles Hospitals 1 in 20 miles EXAMPLE 3 Marathon - 5 3 Key West - 3 4 Key Largo - ? 4 Key West-1 5 None 15. Provide an electronic list (on a thumb drive or CD, in a usable Excel format) of your most up -to -date provider directory for Monroe and Miami -Dade Counties. Please provide individual participating providers by name even if they have the same TIN or NPID. The required format for the list follows: Last Namel First Namel Middle Initial I Address I City) Zip Codel TINS NPIDI Specialty) Network designation FORMATTING: Each item must be separated into separate cells and all numbers must be formatted as numbers. Provide this information for all of the networks that you are proposing. If you are using different networks, provide all networks proposed and identify each network. 16. Have there been any changes to your South Florida (Monroe and Miami -Dade) hospital network in 2016 or 2017? Yes _ No _. If yes, please explain the changes. 17. List what steps your organization will take to ensure that the proposed hospital network remains stable specifically within the Monroe County area. 18. Are there any hospitals in the South Florida (Monroe and Miami -Dade) area with which you are not contracted? Yes _ No _. If yes, list all hospitals. 19. Indicate your contract status for each of your participating hospitals as well as your top ten physician /physician group providers (by number of encounters) in Monroe County Only Indicate the current contract status and the contract's expiration date. If these differ by networks proposed, please complete for each network proposed. PPO — MONROE COUNTY 2 2 3 3 4 4 5 5 W c� Page 13 20. Indicate your contract status for your top ten hospital providers (by number of admissions) as well as your top ten physician /physician group providers (by number of encounters) in Miami -Dade County Only Indicate the current contract status and the contract's expiration date. If these differ by networks proposed, please complete for each network proposed. PPO — MIAMI -DADE COUNTY 21. Complete the following table for Monroe and Miami -Dade Counties. Use your current provider panel. (Use actual number of individual providers, not offices). Provider Type Monroe County Miami -Dade County Allergy & Asthma Cardiologists Cardiovascular Surgeons Chiropractors Dermatologists Endocrinologists ENT Gastroenterologists General Surgeons Geriatricians Hematologists HIV /AIDS Physicians that specialize in HIV /AIDS y •i' Page 14 Hospital Contract Status »> Contract Expiration Date Date of Last Contract Chan Physicians/ Physician Group Contract Status Contract '> Expiration Date Date of Last Contract Change 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 21. Complete the following table for Monroe and Miami -Dade Counties. Use your current provider panel. (Use actual number of individual providers, not offices). Provider Type Monroe County Miami -Dade County Allergy & Asthma Cardiologists Cardiovascular Surgeons Chiropractors Dermatologists Endocrinologists ENT Gastroenterologists General Surgeons Geriatricians Hematologists HIV /AIDS Physicians that specialize in HIV /AIDS y •i' Page 14 treatment Infectious Disease Neurologists Neurosurgeons Non-013 Gynecologists Obstetrician /Gynecologists Oncologists Ophthalmologists Orthopedic Surgeons Pediatricians Podiatrists Primary Care Physicians Pulmonolo ists Rheumatologists Urologists 22. Complete the following exhibit for Monroe and Miami -Dade Counties for your PPO networks. County Number of Number of Percentage of Percentage of Percentage of Number of PCPs Specialty PCPs Accepting Specialty Physicians Board Hospitals Lab Physicians New Patients Physicians Certified or Board -' Care Offering Offering Facilities Accepting New eligible Care Facilities Tertiary Care Patients Monroe Hospitals Miami -Dade Agencies 23. Are all hospital -based physicians (e.g., emergency, pathology, anesthesia and radiology) affiliated with network hospitals contracted? Yes _ No_. If no, list any hospital physician group(s) not contracted. Please include the hospital affiliation. 24. If covered services are not available within the contracted network, how will members obtain necessary services? 25. What fee schedule do you use for out -of- network benefits on the PPO plan? Can you administer alternate fee schedules upon the County's request? Yes _ No_ 26. Are PCP and Specialist contracts evergreen? Yes _ No _ If no, what are the termination requirements within your provider contracts as far as timeframes and notification? 27. What provisions are made for transition of care if a provider is terminated by your plan? What provisions are made if the provider terminates the contract? Will ongoing services be treated as in- network? Yes _ No a i ' ■ •i ii- Page 15 Number Number of Number of Number of Number of Number of Number of County of Urgent Hospitals Hospitals Lab Home Pharmacies Acute Care Offering Offering Facilities Health Care Facilities Tertiary Care Inpatient Care Hospitals Behavioral Agencies Health Care Monroe Miami -Dade 23. Are all hospital -based physicians (e.g., emergency, pathology, anesthesia and radiology) affiliated with network hospitals contracted? Yes _ No_. If no, list any hospital physician group(s) not contracted. Please include the hospital affiliation. 24. If covered services are not available within the contracted network, how will members obtain necessary services? 25. What fee schedule do you use for out -of- network benefits on the PPO plan? Can you administer alternate fee schedules upon the County's request? Yes _ No_ 26. Are PCP and Specialist contracts evergreen? Yes _ No _ If no, what are the termination requirements within your provider contracts as far as timeframes and notification? 27. What provisions are made for transition of care if a provider is terminated by your plan? What provisions are made if the provider terminates the contract? Will ongoing services be treated as in- network? Yes _ No a i ' ■ •i ii- Page 15 28. Do you have a network in the following areas where the County has a high concentration of college dependents? Daytona Beach ❑ Yes ❑ No Gainesville, Florida ❑ Yes ❑ No Tallahassee, Florida ❑ Yes ❑ No Orlando, Florida ❑ Yes ❑ No Tampa, Florida ❑ Yes ❑ No 29. Provide the number of contracted ancillary facilities /locations by plan type in each County listed: Ambulatory Surgery Centers Bone Density Testing Convenient Care Clinics /Retail Clinics DME Providers Home Health Care Agencies Hospice Agencies Hospice Facilities Mammogram Facilities Occupational Therapists Outpatient Laboratories Physical Therapists Radiology Centers Rehabilitation Facilities (Inpatient) Skilled Nursing Facilities Speech Therapists Urgent Care Facilities 30. Do you offer a high quality /low cost network of hospitals and physicians? Provide the quality and cost indicators employed to designate high - quality hospitals /physicians. 31. What types of Accountable Care Organization (ACO) or similar programs /models do you have in place already and what do you have planned for 2019 and 2020? Will any of these programs be available to Monroe County's participants? s a .......:......:.: ii k Page 16 32. Are there any costs /charges to the County in order for employees to receive care from an ACO or similar program /model? If yes, what are the costs and how will it work? 33. When would the County realize a cost savings from implementing the ACO or similar program /model? How would savings being shared between the parties (i.e. ACO, your company and the County)? 34. Who funds the incentive for the providers that participate in an ACO or similar program /model and how do they fund it? 35. How will members determine which providers are participants of the ACO or similar program /model? 36. Will you allow Employee Assistance Programs (EAP) to be provided by another firm at the County's discretion? Yes No 37. Describe your procedures and processes for integration of the County's EAP. Can the County's EAP directly refer a member to a Behavioral Health care provider? Yes _ No _. If no, describe the process for the EAP to obtain authorization for services. 38. What is the target and actual ratio of clinical staff to members (MD, PhD, LCSW, LMFT, LMHC and ARNP) In Monroe County and Miami -Dade County? 39. Does your case management program provide patient- specific information back to the patient's Primary Care Physician? Yes —No 40. How would transition of care be handled for members currently under care with a provider that is not in your existing network, including timeframes? How would transition of care be handled if a provider is terminated during the course of treatment? 41. Are the "V codes" (i.e., marriage /couples /family counseling) covered? Yes _ No _. Do they require prior approval in order to be covered? Yes _ No 42. List the Behavioral Health facilities under contract in South Florida (Monroe and Miami -Dade Counties). Mental Health Facilities Inpatient Intensive Outpatient Substance Abuse Facilities Inpatient Intensive Residential Treatment Facilities 43. Provide the number of Behavioral Health professionals (broken down by MD, PhD, LCSW, LMFT, LMHC and ARNP) included in your South Florida (Monroe and Miami -Dade) network. Provider Type Monroe Miami -Dade ARNP El Page 17 LCSW LMFT LMHC MD PhD 44. What percentage of your contract physicians are board certified in Psychiatry? % 45. What was the Monroe County and Miami -Dade turnover rate of your Behavioral Health network in 2016 and 2017? Break down the turnover rate by MD, PhD, LCSW, LMFT, LMHC and ARNP for each year. 46. What is your overall network pricing as compared to prevailing Medicare reimbursement for hospitals and for physicians? Please answer separately for Monroe and Miami -Dade Counties. 47. Do any network contracts include outlier provisions? Yes_ No_ If yes, explain. 48. Are changes to your network pricing planned for 2018 or 2019? If so, describe. 49. The County intends to exclude claims payment for "Never Events" in the future and wants members to be held harmless. Do all of your contracts include language to address non - payment and hold harmless for such events? 50. How does each hospital report and address "Never Events" as described by the National Quality Forum (NQF) and how does the health plan oversee the protocol? 51. What database do you utilize to determine reasonable and customary (R &C)? What percentile do you use to pay medical claims? How often is the database updated? 52. Provide hospital cost data for Monroe County Only 2016 Monroe 2016 Miami -Dade 2017 Monroe 2017 Miami -Dade ARNP PPO PPO Average allowed cost per admission LCSW Average allowed cost per day LMFT Average discount level LMHC Days per 1000 MD Admissions per 1000 PhD 46. What is your overall network pricing as compared to prevailing Medicare reimbursement for hospitals and for physicians? Please answer separately for Monroe and Miami -Dade Counties. 47. Do any network contracts include outlier provisions? Yes_ No_ If yes, explain. 48. Are changes to your network pricing planned for 2018 or 2019? If so, describe. 49. The County intends to exclude claims payment for "Never Events" in the future and wants members to be held harmless. Do all of your contracts include language to address non - payment and hold harmless for such events? 50. How does each hospital report and address "Never Events" as described by the National Quality Forum (NQF) and how does the health plan oversee the protocol? 51. What database do you utilize to determine reasonable and customary (R &C)? What percentile do you use to pay medical claims? How often is the database updated? 52. Provide hospital cost data for Monroe County Only a i y •i' ii k Page 18 2015 2016 2017 PPO PPO PPO Average allowed cost per admission Average allowed cost per day Average discount level Average length of sta Days per 1000 Admissions per 1000 a i y •i' ii k Page 18 53. Indicate your current 2017 network payment method employed for each type of service /product and network proposed. You may copy the chart below for each additional network offered. Clearly indicate the network proposed relating to each chart. Provider Type /Service Capitation DRG /Case Rates Per Diem % of Charges Fee Schedule Adult Primary Care PPO PPO PPO Medical/Surgical Ambulatory Surgery Centers Maternit Chiropractic Neonatal Complex Imaging Emergency Room Gynecolo Hospital Based Providers Anesthesia Radiology Pathology Emergency Hospital Inpatient Hospital Outpatient Surgical Non - Surgical Obstetrics Outpatient Laboratory Pediatric Transplant Services Urgent Care Center Behavioral (MH and Substance ) Outpatient 54. Hospital Pricing Analysis for Monroe and Miami -Dade Counties. Complete the following tables for hospital inpatient and hospital outpatient services based on your PPO book of business only, for the periods specified. Specify your experience for your population in 2015, 2016 and 2017 for Medical ( non - Behavioral Health /Substance Abuse inpatient services: Hospital Inpatient— Monroe County 2015 Average Length of Stay IN NETWORK AVERAGE COST PER DAY IN NETWORK ALOS TOTAL AVERAGE COST PER DAY TOTAL PPO PPO PPO PPO Medical/Surgical Maternit Neonatal El Page 19 Intensive Care CCU /PCU Total 2016 Average Length of Stay IN NETWORK AVERAGE COST PER DAY IN NETWORK ALOS TOTAL AVERAGE COST PER DAY TOTAL PPO PPO PPO PPO Medical /Surgical Maternity Neonatal Intensive Care CCU /PCU Total 2017 Average Length of Stay IN NETWORK AVERAGE COST PER DAY IN NETWORK ALOS' TOTAL AVERAGE COST PER DAY TOTAL PPO PPO PPO PPO Medical /Surgical Maternity Neonatal Intensive Care CCU /PCU Total Hospital Inpatient— Miami -Dade County 2015 Average Length of Stay IN NETWORK AVERAGE COST PER DAY IN NETWORK ALOS> TOTAL AVERAGE COST PER DAY TOTAL PPO PPO PPO PPO Medical /Surgical Maternity Neonatal Intensive Care CCU /PCU Total 2016 Average Length of Stay IN NETWORK AVERAGE COST PER DAY IN NETWORK ALOS> TOTAL AVERAGE COST PER DAY TOTAL PPO PPO PPO PPO Medical/Surgical Maternit Neonatal a �+1 ii k Page 110 Intensive Care CCU /PCU Total 2017 Average Length of Stay IN NETWORK AVERAGE COST PER DAY IN NETWORK ALOS TOTAL AVERAGE COST PER DAY TOTAL PPO PPO PPO PPO Medical /Surgical Method Per Encounter Encounter Discount % Maternity PPO PPO PPO PPO Neonatal $ $ % Intensive Care $ $ % CCU /PCU $ $ % Total $ $ % Hospital Outpatient — Monroe County Hospital Outpatient — Miami -Dade Count Average Allowed Reimbursement Average Eligible Charge Amount Per Net Effective Type of Service Method Per Encounter Encounter Discount % PPO PPO PPO PPO Surgery $ $ % Emergency Room $ $ % Radiology $ $ % Pathology $ $ % Therapy (PT /OT /ST) $ $ % Other $ $ % Total Hospital Outpatient — Miami -Dade Count Note: Eligible charges are submitted charges less ineligible charges such as duplicates, non - covered items, etc. Note: Reimbursement Method refers to case rates, flat fees, % of Medicare, Allowable, % Discount, etc. El Page 111 Average Allowed Reimbursement Average Eligible Charge Amount Per Net Effective Type of Service Method Per Encounter Encounter Discount % PPO PPO PPO PPO Surgery $ $ % Emergency Room $ $ % Radiology $ $ % Pathology $ $ % Therapy (PT /OT /ST) $ $ % Other $ $ % Total Note: Eligible charges are submitted charges less ineligible charges such as duplicates, non - covered items, etc. Note: Reimbursement Method refers to case rates, flat fees, % of Medicare, Allowable, % Discount, etc. El Page 111 55. Proposer must complete the CPT list (Exhibit E) in full. The rates should be based on average reimbursements for Monroe County and Miami -Dade County providers separately, NOT on statewide or MSA provider averages. Use reimbursement rates as of January 1, 2018. 56. Have you changed affiliations for ancillary services (diagnostic services, mental health services, chiropractic services, etc.) in Monroe or Miami -Dade Counties during the past 12 months? Yes_ No_. If yes, describe such changes. 57. If your plan has capitated charges (i.e., behavioral health, labs, chiropractic, etc.) built into your claim and expense charges, disclose all such charges, fees and detail what they cover, and specify the amount for each item. 58. Indicate if you have a "Centers of Excellence" program for each of the following and list your designated facilities for each: 59. Describe your organization's policies regarding your "Centers of Excellence" program. Is the program voluntary or mandatory? Voluntary— Mandatory 60. Will your organization provide information directly to the plan participant to make provider selections that are cost effective for the plan? If so, please explain. 61. What quality and cost data do you make available to members for selecting hospitals, clinics, imaging centers, labs and physicians in your network for provider comparison? How is this data updated and what additional data will be available in 2018 and 2019? 62. What quality, cost, satisfaction and outcome data is available for both the plan sponsor and members for selecting in network providers (specifically cancer care, orthopedics, maternity, heart disease, behavioral health, pediatrics, emergency care, etc.)? How is this data updated and what additional data will be available in 2018 and 2019? 63. Provide your 2017 per member /per month claim (PMPM) claim cost for Monroe County for your PPO network. PMPM – PPO Diagnostic Hospital Inpatient Hospital Outpatient Medical Pharmacy (office and facility based drugs) Primary Care (PCP) Specialist 64. Based on the historical claims information provided, please provide claims projections for the network proposed for the Monroe County medical plan (assume no plan changes). El PPO Plan – Claim Projections Estimated 2018 Estimated 2019 Page 112 Facility(ies) Name(s): In Network or Out of Network Transplants ❑ Yes ❑ No Cardiovascular ❑ Yes ❑ No Cancer ❑ Yes ❑ No HIV /AIDS ❑ Yes ❑ No Neonatal ❑ Yes ❑ No Other ❑ Yes ❑ No 59. Describe your organization's policies regarding your "Centers of Excellence" program. Is the program voluntary or mandatory? Voluntary— Mandatory 60. Will your organization provide information directly to the plan participant to make provider selections that are cost effective for the plan? If so, please explain. 61. What quality and cost data do you make available to members for selecting hospitals, clinics, imaging centers, labs and physicians in your network for provider comparison? How is this data updated and what additional data will be available in 2018 and 2019? 62. What quality, cost, satisfaction and outcome data is available for both the plan sponsor and members for selecting in network providers (specifically cancer care, orthopedics, maternity, heart disease, behavioral health, pediatrics, emergency care, etc.)? How is this data updated and what additional data will be available in 2018 and 2019? 63. Provide your 2017 per member /per month claim (PMPM) claim cost for Monroe County for your PPO network. PMPM – PPO Diagnostic Hospital Inpatient Hospital Outpatient Medical Pharmacy (office and facility based drugs) Primary Care (PCP) Specialist 64. Based on the historical claims information provided, please provide claims projections for the network proposed for the Monroe County medical plan (assume no plan changes). El PPO Plan – Claim Projections Estimated 2018 Estimated 2019 Page 112 Estimate of Incurred Claims for 1/1 through 12/31 Estimate of Paid Claims for 1/1 through 12/31 Medical claims trend factor — excluding retail /mail order pharmac 65. Do you have a network management /provider services department that assists with provider issues? Yes No List the staff members /titles to be assigned to the County. 66. Where is the network management/provider services staff that services your South Florida (Monroe and Miami -Dade Counties) network located? 67. Describe how your organization will communicate with providers the County's schedule of benefits, changes to the schedule of benefits and general administrative policies and procedures specific to the County's Medical Plan. 68. Describe how your organization will ensure that providers in your network refer to network facilities and other network Providers. 69. What is your average lag time for claims? 70. Are eligibility and claims administered on the same system? Yes_ No If no, how are these functions integrated? 71. Provide the location(s) where claims and eligibility will be processed for the County. 72. Will the County have a dedicated team for eligibility, claims and customer service? Yes_ No 73. Do you plan on major changes or upgrades to your administrative system or the platform you are proposing for the County in the next 24 months? Yes_ No If yes, please explain. 74. Will you provide the County with an eligibility contact person for eligibility file issues and questions? Yes_ No 75. What eligibility responsibilities does your organization expect the County to perform? 76. Are network contracts /fee schedules loaded into your claims administration system or must claims be submitted elsewhere for re- pricing? 77. Can your claims adjudication process block J Codes (except for neoplastic drugs from oncologists /hematologists) from processing? How does your organization propose to educate your network on this process? 78. What percentage of your claims is submitted electronically by facilities? % By physicians? % 79. What percentage of your claims submitted by facilities are auto adjudicated? % By physicians? % 80. Provide details on the system edits that are contained in your organization's claims processing system that assist examiners in accurately processing claims. Indicate how your system adjusts for coding errors. W c� Page 113 81. How does your claim system manage claims from sources that are specifically excluded from payment according to the plan booklet, such as: care provided by a relative; care provided for injuries caused by an act of war; care provided for injuries caused during the commission of a felony? 82. Does your claim system currently integrate data from Envision RX to administer a combined maximum out of pocket? If not currently sharing data with Envision RX, provide a complete breakout of the costs to initiate data sharing with Envision RX. In the pricing exhibit F, please indicate the amount of credit you will provide to the County to cover these costs. Are you willing to absorb the charges from the Rx vendor as well? 83. Describe your explanation of benefits (EOB) process. Are EOBs available hard copy and /or online? Is there any flexibility? 84. What is included on the EOB statements? Do the EOBs reflect the prescription data if the client utilizes an outside Pharmacy Benefit Manager? 85. Will you process run -out claims after plan termination? Yes _ No _ If yes, for how long? _ At what cost? 86. Are you willing to accept delegation of fiduciary responsibility with respect to claim adjudication under your ASO contract? Yes _ No _. Is there an additional charge for this? 87. What access will County auditors have to claims and administrative data necessary to complete an annual audit? Describe any limitations. 88. Are you willing to allow access to a full claims audit, at your expense, in the event of significant performance issues? Yes _ No _. If no, please explain. 89. Provide details regarding your organization's claims processing performance for the most recent year for PPO plans. 90. Describe how a claims history is maintained for members who utilize both in and out -of- network services. 91. In one page or less, describe how you review, edit and process claims. 92. What categories of edits do you have? (e.g., NCCI, Assistant Surgeon, etc.) 93. Describe your claims editing software (i.e., third - party, proprietary). How was it developed? How is it used? s a i y ii ■ k Page 114 Target Goal Actual Performance Clean claims processed within 10 days % within days % within days Clean claims processed within 30 days % within days % within days Average days turnaround Business Days Business Days Coding accuracy Financial accuracy 90. Describe how a claims history is maintained for members who utilize both in and out -of- network services. 91. In one page or less, describe how you review, edit and process claims. 92. What categories of edits do you have? (e.g., NCCI, Assistant Surgeon, etc.) 93. Describe your claims editing software (i.e., third - party, proprietary). How was it developed? How is it used? s a i y ii ■ k Page 114 94. How do you pay claims for services performed in a network hospital by out of network providers such as radiologists, anesthesiologists, pathologists, etc.? What is reimbursement based on (i.e. U &C, Average contracted fees, average charges, etc.)? Are participants subject to balance billing? 95. What percentage of claims submitted are denied for processing (pre- discount, pre- adjudication)? a. number of claims denied / total of claims submitted b. dollars of billed charges denied / total billed charges submitted 96. What percentage of services was denied for medical necessity in 2016, 2017 and year to date 2018? Of those denials, what percentage was appealed and subsequently approved? Describe what types (top 5) of services are most frequently denied and why these services are denied. 97. Who is responsible for reviewing claim payments for correctness? Is this an internal or external process? Is there a charge for this? Yes _ No _ If yes, what is the cost? 98. Describe your use of Independent Review Organizations, as required by PPACA. Include the names and qualifications of the review organizations with which you contract, how they are rotated, and how the cost of the review is handled. 99. How often do you visit physicians on -site to explain contracts and contract changes? 100. Is your provider credentialing process conducted in -house or delegated to another organization? If delegated, provide name of the organization and how long the functions have been delegated. 101. Do credentialing policies and procedures meet accreditation standards? Yes _ No _ If yes, what accreditation organization? 102. How long does it take to credential a new physician? How often does your Credentialing Committee meet? 103. How often do you re- credential network providers? 104. Between re- credentialing cycles, do you conduct ongoing monitoring of practitioner sanctions, complaints and quality issues? Yes _ No _ If yes, how often? 105. How many physicians have you terminated from Monroe and Miami -Dade Counties in 2016 and 2017 who failed to maintain credentialing standards and how many have been terminated due to quality assurance reasons? 106. Detail the structure, process and outcome criteria and standards you use to select physicians, hospitals and other providers for participation in your networks. Provide a list of minimum thresholds for each metric you use. Page 115 2016 2017 2018 (YTD) % Denied % Appealed Subsequently Approved 97. Who is responsible for reviewing claim payments for correctness? Is this an internal or external process? Is there a charge for this? Yes _ No _ If yes, what is the cost? 98. Describe your use of Independent Review Organizations, as required by PPACA. Include the names and qualifications of the review organizations with which you contract, how they are rotated, and how the cost of the review is handled. 99. How often do you visit physicians on -site to explain contracts and contract changes? 100. Is your provider credentialing process conducted in -house or delegated to another organization? If delegated, provide name of the organization and how long the functions have been delegated. 101. Do credentialing policies and procedures meet accreditation standards? Yes _ No _ If yes, what accreditation organization? 102. How long does it take to credential a new physician? How often does your Credentialing Committee meet? 103. How often do you re- credential network providers? 104. Between re- credentialing cycles, do you conduct ongoing monitoring of practitioner sanctions, complaints and quality issues? Yes _ No _ If yes, how often? 105. How many physicians have you terminated from Monroe and Miami -Dade Counties in 2016 and 2017 who failed to maintain credentialing standards and how many have been terminated due to quality assurance reasons? 106. Detail the structure, process and outcome criteria and standards you use to select physicians, hospitals and other providers for participation in your networks. Provide a list of minimum thresholds for each metric you use. Page 115 107. In three pages or less, please outline your core medical management program. Include examples of how you have added significant value and how you differentiate yourself from your competitors. If you describe programs other than those included in your base TPA fee, please clearly identify those programs and the cost to the County for those programs. 108. With respect to your overall member contact rates, a. In a 12- month period, what percentage of members is "contacted" by the medical management program? For this question, "contact" is a LIVE attempt to contact a member by a medical management professional either through a phone call to the member or to the member's spouse or the member's physician. If you have other means of contacting members such as automated calls, mailings, text messaging or email blasts, please exclude those from your contact statistics. b. Of the members in a., what percentage of them initially agrees to discuss their situation with the medical management professional? This is the "participation rate ". c. Of the members in b., what percentage of them stays involved with the medical management professional to the end? (For example, if a member agrees to work with a case manager or a health coach, do they stay engaged until the case manager or health coach closes the case ?) 109. In one page or less, outline your prece rtifi cation program. Explain the nature of the program (i.e., notification, notification and steerage, denials) and why you chose that particular approach. Also provide a list of services that require pre- authorization or pre- notification and clearly identify which applies. a. How many specific services do you include for precertification? i. Number ii. Dollars b. Of the services identified in a., what percentage of those services was altered (steered, denied, delayed until another test was done, etc.)? i. Number ii. Dollars 110. In one page or less, outline your Concurrent Review and Discharge Planning (Rounding) program. Please specify how the program is triggered (i.e. from Prior Authorization, Notification of admission, diagnosis, etc.). a. Of all hospital confinements, what percentage is subject to Rounding? i. Number ii. Dollars b. Of the hospital confinements identified in a., what percentage of those confinements was altered (transferred, discharged early, kept longer)? i. Number ii. Dollars Q 111. Is your Utilization Management (UM) service located in your claims office? Yes _ No _. If no, where is it located? n- 112. What is the size of the UM staff in the claims office that you are proposing for the County? Page 116 113. Do you have a physician on staff to intervene on "problem" admissions or certifications? Yes _ No 114. Describe the participant's responsibility for compliance with UM programs, in- network, out -of- network, and out -of- area. 115. Are your utilization review service /requirements different in any way for in- network, out -of- network, or out -of -area participants? If yes, please explain. 116. Do providers have access to your coverage positions or clinical guidelines? How? 117. Are network providers at risk for not following your Medical Management Program? Yes _ No _ Please explain. 118. Describe how inpatient utilization is managed. Specifically address after hours, emergency, in and out -of- network. 119. Is inpatient census reviewed on a daily basis? Yes _ No _ If no, how often? 120. How do you communicate with patients and family members regarding length of stay and discharge planning? 121. In two pages or less, describe your Case Management Program. 122. Provide a copy of the appeals /denial case management process. Provide documentation to demonstrate when /how these protocols are shared with providers and members. 123. How many Case Managers do you have per 100,000 members? How many active cases per case manager? Average length of case? 124. Are there any cases the Case Management Program will not manage? Yes _ No _ If yes, list and describe. 125. Do members in Case Management have a consistent Nurse Manager presiding over each case? Yes _ No 126. How is clinical progress communicated to patients and physicians? 127. Describe how providers and participants are made aware of Case Management. 128. What are your parameters for notifying the County of high cost cases? 129. Do you report your Case Management results? Yes _ No _ If yes, include samples. 130. What are the readmission rates (within 30 days of discharge) for Monroe and Miami -Dade Counties? 131. What are the minimum qualifications for Clinical Case Managers and Utilization Management staff? 132. Will specific clinical staff members (such as MDs, RNs, LPNs, other) be assigned /dedicated to the County's account for the purpose of case management and utilization review? Yes _ No 133. Describe your medical protocols to determine: a. Medical necessity b. Medical appropriateness c. Experimental and investigational treatment Page 117 134. In three pages or less, describe your disease management program. Include details on how your Disease Management Programs remain current based on research and industry trends. a. Intervention Model. How would you characterize your program? High reach, low intensity model? A low reach, high- intensity model? A nurse -based program? A technology -based program? b. Patient identification. What percentage of members is identified for intervention? i. Through claims ii. Through other programs (case management, wellness coach) 135. Of the patients identified, how many are contacted by a medical management professional? For this question, "contact" is a LIVE attempt to contact a member by a medical management professional either through a phone call to the member or to the member's spouse or the member's physician. If you have other means of contacting members such as automated calls, mailings, text messaging or email blasts, please note them here. 136. With regard to specific diseases: a. What diseases do you actively manage? b. Do you use different interventionists for different disease states? C. When do you begin to manage a particular disease? For example, with cancer do you offer assistance at the time of diagnosis or during an active course of treatment? 137. Is your disease management group in house? If not, how does your subcontractor access patient benefits, eligibility, etc.? How are services charged to the group? 138. Describe, in one page or less, how different parts of the clinical model capture and share information. 139. With regard to "Hand Offs and Overlaps ", how does a hand off work? A hand off is when one part of the clinical model needs to involve another part of the clinical model. How does case management interact with disease management? Is it possible that more than one part of the clinical model is "touching" a patient at the same time? If so, how is information shared between parts of the clinical model? 140. Are your Disease Management Programs accredited? Yes_ No If yes, by which accreditation organization and status achieved? 141. How are network providers made aware of the availability of your Disease Management Program? 142. List the total number of employer groups and total members to which your company provided Disease Management Programs as of January 1, 2017 and January 1, 2018. Complete the table below: El Page 118 As of Jan ary 1, 2017'> As of January 1, 2018'> Employer Groups '> Members Employer Groups '> Members National) El Page 118 Florida South Florida (Monroe and, Miami - Dade) 143. Are members identified for Disease Management automatically enrolled (requiring them to opt -out if they choose not to participate) or do members identified for Disease Management have to enroll to participate? 144. What are your organization's criteria to discharge /disenroll a member? 145. Provide patient attrition rate (patient disenrolls) in 2017 for each Disease Management Program offered 146. Describe the type and number of staff professionals (PA's, LPN's, RN's and Nurse Practitioners) who will be handling the County's members. How is the staff assigned to each case? Describe oversight/supervision by physicians. 147. Are patient's physicians notified of the Disease Management care plan? Progress or lack of progress? 148. All members in the Disease Management Program should have a specific nurse manager regardless of whether they are suffering from one or more than one chronic condition. If there are exceptions, explain each. 149. How does your organization measure clinical impact of each Disease Management Program? 150. Please describe any evidence you have that demonstrates how your disease management program stands out among the competition. 151. In three pages or less, describe your wellness program. Be sure to provide the basic nature of the program, inclusive of the following: Participation rates, incentives, outcomes, and guarantees. 152. Patient identification - What percentage of members are identified for intervention? a. Through claims b. Through other programs (case management, wellness coach) 153. Of the patients identified, how many are contacted by a medical management professional? For this question, "contact" is a LIVE attempt to contact a member by a medical management professional either through a phone call to the member or to the member's spouse or the member's physician. If you have other means of contacting members such as automated calls, mailings, text messaging or email blasts, please footnote them here. 154. Please describe any evidence you have that demonstrates how your wellness program stands out among the competition. 155. Complete the chart below for each service your organization provides (check all that apply). Provide examples of your resources: Ir- Page 119 DELIVERY MODE P UTSOURCED VENDOR Direct Seminars /One- Wellness Services Mail Online Telephonic Onsite on -One Name of Vendor Counseling Ir- Page 119 156. Describe the medical staff and /or advisory board who are responsible for developing and reviewing your programs. 157. Describe the support that you provide in the development of a client's wellness program. Please include specifics regarding the strategic resources that are available to the client. 158. Is a wellness consultant assigned to the client to assist with the development and management of the wellness program? What are the qualifications of the wellness consultant? How is time allocated to the client? 159. Describe your capabilities to manage rewards and incentives. Provide examples of incentives and a recommended budget for incentives for a client of this size. 160. The County currently receives contributions from the vendor to support wellness activities and to drive participation into wellness programs. Describe your strategy to drive participation and maintain participant engagement, and outline the funds that will be provided to the County to support the wellness program. 161. Indicate participation and completion rates (pre and post) for clients you have provided the following types of onsite and online initiatives. Describe the initiatives and your support of the client in these programs. Onsite Initiatives Participation Rates Completion Rates DELIVERY MODE OUTSOURCED Weight Loss Challenges Total Weight Loss Nutrition Programs VENDOR Direct Seminars /One- Wellness Services Mail Online Telephonic Onsite on -One Name of Vendor Counseling Health Risk Assessment Biometric Screenings Diabetic Counseling Health Coaching Health Education & Awareness Campaigns Lunch and Learns Self Directed Programs Resource Facilitator Health Partnerships Follow Up Reports Other (add rows as needed) 156. Describe the medical staff and /or advisory board who are responsible for developing and reviewing your programs. 157. Describe the support that you provide in the development of a client's wellness program. Please include specifics regarding the strategic resources that are available to the client. 158. Is a wellness consultant assigned to the client to assist with the development and management of the wellness program? What are the qualifications of the wellness consultant? How is time allocated to the client? 159. Describe your capabilities to manage rewards and incentives. Provide examples of incentives and a recommended budget for incentives for a client of this size. 160. The County currently receives contributions from the vendor to support wellness activities and to drive participation into wellness programs. Describe your strategy to drive participation and maintain participant engagement, and outline the funds that will be provided to the County to support the wellness program. 161. Indicate participation and completion rates (pre and post) for clients you have provided the following types of onsite and online initiatives. Describe the initiatives and your support of the client in these programs. Onsite Initiatives Participation Rates Completion Rates Programs — Walking Exercise Programs Weight Loss Challenges Total Weight Loss Nutrition Programs Gym /Fitness Center Participation /Encouragement s a y k Page 120 162. Complete the chart below and provide documentation and evidence for the Lifestyle Management Programs you provide (check all that apply). Provide evidence for gender specific education and awareness (i.e., breast care for women, cardiovascular disease for women, prostate for men). 163. Describe your capabilities to manage or offer the following (check all that apply): Lifestyle Management Programs — Delivery Made OUTSOURCED VENDOR Mailings Self Directed Telephonic Onsite Seminars One -on -One Other Programs Coaching Lunch and Learns Counseling Heart Disease Diabetes & Diabetic Counseling Cholesterol Hypertension Asthma Nutrition Fitness & Exercise Women's Health Men's Health Self Care Smoking Cessation Weight Management Stress Management Other: (identify) 163. Describe your capabilities to manage or offer the following (check all that apply): Page 121 SERVICES OUTSOURCED VENDOR Offer Manage Coordinate Community Partnership Name of Vendor Service Not Offered Page 121 164. Describe the type of reporting you use to track, analyze and assess cost savings: REPORTS J - Monthly, FREQUENCY Quarterly or Annuo SERVICES OUTSOURCED VENDOR Participation Offer Manage Coordinate Community Partnership Name of Vendor Service Not Offered Onsite Clinic Clinical Outcomes Participant Satisfaction Lunch and Learns ❑ Medical ❑ RX ❑ Diagnosis Short -Term Disability Fitness Center Discounts Absenteeism Productivity Weight Loss Competitions Quality of Life RO1 Stress Management (Yoga, Tai Chi, etc.) Wellness Savings Wellness Impact Walking Programs Other: (identify) 164. Describe the type of reporting you use to track, analyze and assess cost savings: 165. In two pages or less, describe your Quality Assurance program. 166. Provide specific examples as to how your objective measurement and information sharing process has improved clinical and financial outcomes in South Florida over the past two years. 167. Describe the process to share information with providers, facilities and hospitals. 168. What clinical studies were conducted or evaluated in the past two years? 169. What interventions were put into place to improve outcomes as a result of the clinical studies? 170. Have any providers, facilities or hospitals in South Florida been sanctioned or terminated for quality reasons? Page 122 REPORTS J - Monthly, FREQUENCY Quarterly or Annuo Enrollment Participation Utilization (Gyms) Health Risk Change (Pre & Post) Clinical Outcomes Participant Satisfaction Claims Savings ❑ Medical ❑ RX ❑ Diagnosis Short -Term Disability Absenteeism Productivity Quality of Life RO1 Administration Wellness Savings Wellness Impact 165. In two pages or less, describe your Quality Assurance program. 166. Provide specific examples as to how your objective measurement and information sharing process has improved clinical and financial outcomes in South Florida over the past two years. 167. Describe the process to share information with providers, facilities and hospitals. 168. What clinical studies were conducted or evaluated in the past two years? 169. What interventions were put into place to improve outcomes as a result of the clinical studies? 170. Have any providers, facilities or hospitals in South Florida been sanctioned or terminated for quality reasons? Page 122 Yes _ No _ If yes, describe. 171. Provide a copy of your most recent member satisfaction survey results and indicate the following: a. What percentage of survey participants were very satisfied or extremely satisfied with your plan? 170. How do you track verbal and written complaints received by your organization? 171. Are you able to report the number and types of complaints (both written and telephonic) received in a calendar year for all plan members (total population) and the County's members specifically? Yes _ No 172. How many verbal and written complaints were received per 1,000 members during 2015, 2016 and 2017? Year Number per 1000 2015 2016 2017 173. Are the member grievances /appeals tracked and reported? Yes _ No _ If yes, are you able to provide the County with a report capturing the number and types of grievances /appeals which are received from the County's members? Yes No 174. Can your plan track and report on customer service activity? Yes _ No 175. Does your plan have a 24 -hour toll free number for member services and provider services? Yes _ No _. If no, what are the days and hours of operation? 176. Describe the services and features members have access to on your website? 177. How are providers instructed to handle members who have not yet been issued member ID cards? 178. Can you accommodate information from carve -out vendors for ID cards? Describe any requirements and limitations. 179. How many ID cards will be distributed per family? 180. Is there a charge for replacement cards? Yes _ No _. If yes, what is the charge? 181. What is your normal turnaround time for production and mailing of ID cards? 182. Describe your 24 -hour nurse line. Do you report on usage? Yes _ No 183. What are your organization's target goals for the following metrics? Member Service Target Goal 2017 Actual Performance Average Speed of Answer Average Length of Call El Page 123 First Call Resolution Rate Call Abandonment Rate 184. Describe online resources that are available specifically in South Florida (Monroe and Miami -Dade Counties) to the County's members: Member Online Resources Yes No Planned Provider Directory Links to Physicians' Websites Claim Status Claims History Explanation of Benefits Provider Performance Information (Hospital Comparison /Profiles) Health Risk Assessment Personalized Health Record Plan Policies or benefit booklets Personalized Health News /Information Health Coaching Ask a Nurse /Medical Questions Disease Specific Chat Rooms File Complaints E -mail Member Service Order Replacement ID Cards Other *Must indicate date of anticipated implementation. 185. In one page or less, describe your provider fraud and abuse unit from a staffing, qualifications, and systems perspective. 186. How are services determined to be "excessive ", "abusive ", or "of questionable need "? Please provide examples of the three most frequent /costliest areas of abuse and what actions you take to control them. 187. In the South Florida market (Monroe and Miami - Dade), how many providers are investigated each year for fraud and abuse? How many of these providers have been removed from the network? How many dollars have been recovered from these providers? If you are not able to segregate Monroe County and Miami -Dade County, please respond with information for the smallest area possible that includes these Counties. 188. In the South Florida market (Monroe and Miami - Dade), what is the overall savings as a percent of claims attributed to your fraud and abuse unit? If you are not able to segregate Monroe County and Miami -Dade County, please respond with information for the smallest area possible that includes these Counties. i y ' k Page 124 189. If your fraud and abuse function is outsourced, how will the County be charged for this? 190. In one page or less, describe your patient fraud and abuse unit from a staffing, qualifications, and systems perspective. 191. How are services determined to be "excessive ", "abusive ", or "of questionable need "? Please provide examples of the three most frequenticostliest areas of abuse and what actions you take to control them. 192. Explain how you integrate patient abuse with provider abuse investigations. If the patient fraud and abuse function is separate from your provider fraud and abuse function, please answer the following two questions specifically for the patient fraud and abuse function: otherwise, indicate NA. 193. In the South Florida market (Monroe and Miami - Dade), what is the overall savings as a percent of claims attributed to your fraud and abuse unit? If you are not able to segregate Monroe County and Miami -Dade County, please respond with information for the smallest area possible that includes these Counties. 194. If your fraud and abuse function is outsourced, how will the County be charged for this? 195. Provide a listing of your standard reports that will be provided to the County, and at what intervals these reports will be available. 196. Ad hoc reports shall be available upon request. There is currently no charge for ad hoc reports. Will your company agree that there will be no charge for these reports? Yes_ No _. If no, what is the cost per report? 197. Describe your implementation process if you are awarded the contract, including significant deliverables, project manager and timelines for an implementation date of January 1, 2019. 198. Describe your standard banking arrangement for self- funded clients. Include: a. How and when is the account funded? b. Options you have available for reimbursement frequency and method. c. The minimum funding balance requirement and its development, and any initial deposit requirements. d. A description (including any report samples) of the services you can provide the County to fund, monitor and reconcile the self- funding account. 199. The County's current arrangement for claims payments follows: claims are paid by the TPA who subsequently Ld issues a weekly claim invoice to the County. The County by Florida Statute, has 45 days to pay without penalty. Please describe whether you will match this arrangement and describe your requirements of the County for this arrangement. Please note that the County will not agree to establish an Escrow or Imprest Account. 200. Describe how you develop your administrative pricing for self- funded accounts. a. What do administrative costs (including network charges) represent? i. As a percent of claims? ii. As a capitated dollar amount per employee? Page 125 201. Do you maintain an in -house subrogation unit to subrogate claims? Yes _ No _. If not, please identify how you propose to provide subrogation and recovery services to the County, including the charge to the County for this service. 202. Please describe your process for monitoring and identifying claims for which subrogation is appropriate. Please be specific with regard to system edits, clinical screening, research of public records, etc. that you use to ensure that all potential recoveries are pursued. 203. Do you provide reports on subrogation and other recovery activities to the client? How frequently? Is there a charge for this? 204. Are there any charges to the client for subrogation, COB, third party recoveries? Yes _ No _. Please identify all charges associated with subrogation, COB, third party vendors, etc. Page 126 C.7.k Company: MONROE COUNTY BOGC Group; B06 Current Paid Period: Eer m 1['2016 fin 09 ?2017 Report Type: Combined Report EXHIBIT C - NETWORK DISRUPTION 1 XXX -XX -7152 ADVANCED URGENT CARE OF THE MIDDLE KEYS AND KEY WE 1980 N ROOSEVELT BLVD KEY WEST FL 33040 URGENT CARE CENTER 495 956 $156,009.58 2 XXX -XX -5899 PANOFF, JOSEPH E 1201 NW 16TH ST MIAMI FL 33125 PHYSICIAN - M.D. RADIATION THERAPY 6 82 $80,879.13 3 XXX XX 6953 MONROE COUNTY BOARD OF COUNTY COMMISSIONERS 490 63RD ST OCEAN E STE 170 MARATHON FL 33050 AMBULANCE SERVICE 11 18 $58,080 4 XXX XX 5899 GREENE, HENRY R 3426 N ROOSEVELT BLVD KEY WEST FL 33040 PHYSICIAN - M.D. HEMATOLOGY /ONCOLOGY 17 88 $55,753,88 5 .XXX -XX -9254 PRUETT, DAREL 82883 OVERSEAS HWY ISLAMORADA FL 33036 PHYSCIAN - OSTEOPATH DERMATOLOGY 158 298 $53,025.03 6 ',XXX -XX -5524 PETERSON, GEORGE D 10300 SW 216TH STREET MIAMI ',FL .33190 PHYSICIAN- M.D. !GYNECOLOGICAL ONCOLOGI, 77 150 $42,078.26 7 XXX XX 5133 MELGEN, VICTOR W 1639 N VOLUSIA AVE STE B ORANGE CITY FL 32763 PHYSICIAN - M.D. HEMATOLOGY /ONCOLOGY 1 21 ',. $42,040.48 8 XXX -XX -5899 AHAMAD, AN ESA W 1192 E NEWPORT CENTER DR DEERFIELD BEACH FL 33442 PHYSICIAN - M.D. RADIATION THERAPY 6 131 $40,986.61 9 'XXX -XX -5899 NYBERG, DAVID A 3426 N ROOSEVELT BLVD KEY WEST FL 33040 PHYSICIAN - M.D. 'HEMATOLOGY /ONCOLOGY 9 30 $31,397.87 10 '.XXX -XX -0983 LEAVITT, JAMES S 7500 SW 87TH AVE STE 200 MIAMI FL 33173 PHYSICIAN - M.D. GASTROENTEROLOGY 7 17 $29,665.29 11 XXX -XX -4481 WARD, SHARON V 3134 NORTHSIDE DR KEY WEST FL 33040 PHYSICIAN- M.D. '.OB /GYN 70 146 $28,578.30 12 XXX -XX -4724 SCHNAPP, WILLIAM 111112TH STREET SUITE 212 KEY WEST FL 33040 PHYSICIAN - M.D. NEUROLOGY 58 223 $28,007.29 13 XXX -XX -3459 SANTIAGO, STANLEY 10300 SW 216TH STREET MIAMI FL 33190 PHYSICIAN- M.D. GYNECOLOGICAL ONCOLOGI 36 85 $26,448.89 14 XXX -XX -0937 MARTIN, WILLIAM C 11400 OVERSEAS HWY STE 224 MARATHON FL 33050 CLINICAL SOCIAL WORKER 7 115 $24,165.00 15 XXX XX 2473 BEYSOLOW, TAWEH_D 111112TH ST STE 203 KEY WEST FL 33040 PHYSICIAN - M.D. NEPHROLOGY _ 52 333 ',. $23,731.06 16 'XXX -XX -9494 'TAKAS, STEVEN 1111 12TH ST STE 311 'KEY WEST 'FL 33040 PHYSICIAN- M.D. 'PEDIATRIC MEDICINE 56 188 $22,277.21 17 XXX -XX -3822 LIFENET 4375 NE 48TH AVE GAINESVILLE FL 32609 AMBULANCE SERVICE 6 11 $21,561.66 18 XXX -XX -8238 CASTANEDA, EMILIO E 11300 NW 87TH CT STE 149 HIALEAH FL 33018 PHYSICIAN - M.D. '.INTERNAL MEDICINE 35 141 $20,733.15 19 XXX -XX -6188 BLASS, LAWRENCE W 3136 NORTHSIDE DR KEY WEST FL 33040 PHYSICIAN- M.D. GENERALSURGERY 28 64 $20,004.55 20 '.XXX -XX -5908 GERTH,ELIASI 2505 FLAGLER AVE KEY WEST '.FL 33040 PHYSICIAN- M.D. '.INTERNAL MEDICINE 44 205 $19,680.46 21 'XXX -XX -7089 CHARITY, JENNIFER A 111112TH ST STE 210 KEY WEST FL 33040 PHYSICIAN - M.D. INTERNAL MEDICINE 76 336 $19,644.31 22 XXX XX 9002.. CARABIN, IOANA G KENNEDY DR KEY WEST FL 33040 PHYSICIAN. - M.D. OTOLOGY, LARYNGOLOGY, R 38 ,. $19,261.26....... 23 XXX XX 9038 GRIDER, . DAVID F 29960 OVERSEAS HWY BIG PINE KEY FL 33043 PHYSCIAN - OSTEOPATH FAMILY PRACTICE _ 101 290 ',. $19,040.42 _ 24 'XXX -XX -0634 IZUBA, STANLEY M 91550 OVERSEAS HWY STE 209 TAVERNIER 'FL 33070 PHYSICIAN- M.D. 'PEDIATRIC MEDICINE 34 94 $17,891.40 25 'XXX -XX -5133 ROHATGI, RAI(ESH 1400 N US HIGHWAY 441 STE 557 THE VILLAGES FL 32159 PHYSICIAN - M.D. 'HEMATOLOGY /ONCOLOGY 1 29 $17,771.28 26 XXX -XX -2713 WHITESIDE, MART( 3134 NORTHSIDE DR KEY WEST FL 33040 PHYSICIAN - M.D. '.INTERNAL MEDICINE 168 249 $17,541.35 27 XXX -XX -7286 SHULTZ, SANDY W 100 S ASHLEY DR STE 600 TAMPA FL 33602 PHYSICIAN - M.D. RADIOLOGY 153 263 $16,479.89 28 XXX -XX -5899 CHEN, CHRISTOPHER T 1201 NW 16TH ST MIAMI FL 33125 PHYSICIAN - M.D. RADIATION THERAPY 3 43 $16,260.85 29 'XXX -XX -6188 SMITH, RHODA M 3136 NORTHSIDE DR KEY WEST FL 33040 PHYSICIAN - M.D. !GENERAL SURGERY 35 62 $15,054.09 30 XXX -XX -9335 WAGSTAFF, BRIAN 1501 GOVERNMENT RD KEY WEST FL 33040 PHYSICIAN - M.D. FAMILY PRACTICE 120 246 $14,945.20 31 XXX XX 0983 FELLER, EDWARD J 8353 SW 124TH ST STE 203 MIAMI FL 33156 PHYSICIAN - M.D. GASTROENTEROLOGY 3 9 $14,587.17 32 'XXX -XX -9147 SCHIFF, MARTIN A 1905 CLINT MOORE RD STE 103 BOCA RATON FL 33496 PHYSICIAN - M.D. 'DERMATOLOGY 70 108 $14,311.30 33 XXX -XX -6098 TORREGROSA, JOHN F 91550 OVERSEAS HWY STE 107 TAVERNIER FL 33070 PODIATRIST DOCTOR OF SURGICAL CHIR( 23 127 $14,206.53 34 XXX -XX -2365 VALDES, ERNESTO 215 GRAND AVE CORAL GABLES FL 33133 PHYSICIAN- M.D. NEONATOLOGY 3 7 $14,128.06 35 XXX XX 8260 NORRIS, JOHN W 508 SOUTHARD ST STE 103 KEY WEST FL 33040 PHYSICIAN - M.D. '.INTERNAL MEDICINE 72 248 $13,948,00 36 XXX -XX -4952 EID, ROBERT E 5900 COLLEGE RD KEY WEST FL 33040 PHYSICIAN - M.D. !ANESTHESIOLOGY 41 44 $13,541.08 37 'XXX -XX -2365 CAMPA, MANUELA 215 GRAND AVE ! CORAL GABLES FL . 33133 PHYSICIAN - M.D. NEONATOLOGY 1 10 $13,469.13 38 XXX XX 9817 MANZANO, GLEN R 1321 NW 14TH ST STE 306 MIAMI FL 33125 PHYSICIAN - M.D. NEUROLOGICAL SURGERY 1 ',. $13,457.91 39 XXX XX 4803 SURGERY CENTER OF KEY WEST LLC 931 TOPPINO DR KEY WEST FL 33040 AMBULATORY SURGICAL CENTER 7 9 ',. $13,384.63 _ 40 'XXX -XX -7286 FOGEL, ANDREW A 10101 FOREST HILL BOULEVARD WELLINGTON FL 33414 PHYSICIAN - M.D. 'RADIOLOGY 152 239 $12,948.76 41 XXXX -XX -4103 AMBIENT HEALTHCARE OF SOUTH FLORIDA INC 15951 SW 41ST ST STE 500 DAVIE FL 33331 PHARMACY WITH INFUSION THERAO 3 19 $12,733.78 42 XXX -XX -5131 JONES, DAN M 1111 12TH ST STE 103 KEY WEST FL 33040 PHYSICIAN - M.D. GASTROENTEROLOGY 34 84 $12,705.54 C.7.k 43 XXX XX 9332 KELLOGG, SPENCER F 3225 AVIATION AVE STE 700 COCONUT GROVE FL 33133 PHYSICIAN - M.D. '.OB /GYN 25 46 $12,692,22 44 .XXX -XX -5859 GILL, DANIEL K 5900 COLLEGE RD KEY WEST FL 33040 PHYSICIAN - M.D. PATHOLOGY 101 126 $12,575.08 45 XXX -XX -6262 RAMIREZ, JOSE A 11750 SW 40TH ST MIAMI FL 33175 PHYSICIAN - M.D. VASCULAR SURGERY 4 15 $12,512.15 46 XXX -XX -5899 KATZ, ANDREA 11382 PROSPERITY FARMS RD STE 228 PALM BEACH GARDENS FL 33410 PHYSICIAN - M.D. HEMATOLOGY /ONCOLOGY 1 7 $12,346.66 47 XXX -XX -3459 DELL'API, PASQUALE 29755 OVERSEAS HWY BIG PINE KEY FL 33043 PHYSCIAN - OSTEOPATH FAMILY PRACTICE 41 117 $12,332.84 48 XXX XX 3033 MCIVOR, MICHAEL E 1010 KENNEDY DR STE 400 KEY WEST FL 33040 PHYSICIAN - M.D. 'CARD IOLOGY /CARDI OVASCU 42 232 $12,172.85 49 XXXX -XX -0560 CATANA, ROBERT D 3428 N ROOSEVELT BLVD KEY WEST FL 33040 PHYSCIAN- OSTEOPATH 'CRITICAL CARE 25 92 $11,808.92 50 XXX -XX -1841 BLY, KRIS M 3420 DUCK AVE KEY WEST FL 33040 PHYSCIAN - OSTEOPATH EMERGENCY MEDICINE, GEN 26 146 $11,754.94 Sl XXX -XX -8303 SACK, STANLEY 1201 WHITE ST STE 103 KEY WEST FL 33040 PHYSICIAN - M.D. PEDIATRIC MEDICINE 28 58 $11,226.24 52 XXX -XX -2971 FLORIDA KEYS AMBULANCE SERVICE INC 91421 OVERSEAS HWY STE 10 TAVERNIER FL 33070 AMBULANCE SERVICE 10 16 $11,104.95 S3 XXX -XX -9983 BOYKIN, MICHELLE L 5955 PONCE DE LEON BOULEVARD CORAL GABLES FL 33146 PHYSICIAN - M.D. NEONATOLOGY 1 4 $11,073.32 54 XXX -XX -9983 SHAH, PARUL V 5955 PONCE DE LEON BOULEVARD CORAL GABLES FL 33146 PHYSICIAN - M.D. NEONATOLOGY 1 5 $10,900.57 55 XXX XX 3459 TINGLE, NORMAN R 29755 OVERSEAS HWY _ BIG PINE KEY 33043 PHYSICIAN - M.D. FAMILY PRACTICE 38 90 ',. $10,726.69 56 XXX -XX -1984 PINIELLA, CARLOSJ 3712 N ROOSEVELT BLVD UNIT C KEY WEST FL 33040 PHYSICIAN - M.D. '.ALLERGY 18 227 $10,458.53 57 'XXX -XX -7108 MAKIMAA, BRADLEY J 2407 N ROOSEVELT BLVD KEY WEST 'FL 33040 PODIATRIST DOCTOR OF SURGICAL CHIR( 65 231 $10,430.68 58 XXX -XX -3665 SCHELL, ANDREW P 4302 ALTON RD SUITE 115 MIAMI BEACH FL 33140 PHYSICIAN - M.D. '.OTOLOGY, LARYNGOLOGY, R 4 10 $10,240.21 59 XXX -XX -0634 WEARE, JOHN 2336TH AVE INDIALANTIC FL 32903 PHYSICIAN - M.D. PEDIATRIC MEDICINE 38 90 $10,001.10 60 '.XXX -XX -7042 FARISS, BRUCE 3714 N ROOSEVELT BLVD KEY WEST FL 33040 PHYSICIAN - M.D. UROLOGY 46 122 $9,720.79 61 ',XXX -XX -8554 KAPLITZ, NANCY I 111112TH ST STE 110 KEY WEST ',FL 33040 PHYSICIAN - M.D. NEUROLOGY 36 73 $9,605.39 62XXX -XX -6188 LARRAURI, JUAN M 3136 NORTHSIDE DR KEY WEST FL 33040 PHYSICIAN - M.D. GENERALSURGERY 18 40 $9,505.95 63 XXX XX 9983 HUSSEIN, SAMEH NI 5955 PONCE DE LEON BOULEVARD CORAL GABLES_ FL 33146 PHYSICIAN - M.D. NEONATOLOGY 1 2 ! $9,280.24 64 'XXX -XX -1051 GRIZZLE, ARTHUR J 10300 SW 216TH STREET MIAMI 'FL 33190 PHYSICIAN - M.D. GYNECOLOGICAL ONCOLOG) 23 36 $9,243.83 65 '.XXX -XX -7089 ATILLA, MEHMET A 1111 12TH ST STE 210 KEY WEST FL 33040 PHYSICIAN - M.D. '.INTERNAL MEDICINE 66 202 $8,974.70 66 XXX -XX -3627 TAMPA BAY PROSTHETICS 5109 N ARMENIA AVE TAMPA FL 33603 MEDICAL SUPPLY COMPANY WITH C 1 10 $8,943.69 67 XXX -XX -3208 FOREST, DAVID W 11400 OVERSEAS HWY SUITE 106 MARATHON FL 33050 PHYSICIAN - M.D. '.OB /GYN 39 90 $8,687.78 68 XXX -XX -3459 LOEFFLER, ROBERT D 1111 12TH ST STE 211 KEY WEST FL 33040 PHYSICIAN - M.D. '.ORTHOPEDIC SURGERY 20 40 $8,498.11 69 XXX -XX -6399 DIAZ, MIGUEL 3301 OVERSEAS HWY MARATHON FL 33050 PHYSICIAN - M.D. EMERGENCY MEDICINE, GEN 27 102 $8,485.42 70 XXX XX 9983 ACOSTA, ALESSANDRO 5955 PONCE DE LEON BOULEVARD CORAL GABLES_ FL 33146 PHYSICIAN - M.D. NEONATOLOGY 1 4 ! $8,253.10 71 XXX XX 5636 DOUVILLE, ROBERT W 1111 12TH ST STE 107 KEY WEST FL 33040 PHYSICIAN - M.D. 'OPHTHAMOLOGY 61 118 $8,170.18 72 'XXX -XX -6758 MAGRANE, BRIAN P 91550 OVERSEAS HWY STE 109 TAVERNIER ' FL 33070 PHYSICIAN - M.D. FAMILY PRACTICE 45 122 $8,153.63 73 'XXX -XX -9332 TURMERO, ALEJANDRA Y 3225 AVIATION AVE STE 700 COCONUT GROVE FL 33133 PHYSICIAN - M.D. 'OB /GYN 20 35 $8,050.91 74 XXX -XX -8642 MACKEY, TIMOTHY W 540 TRUMAN AVE KEY WEST FL 33040 PHYSCIAN - OSTEOPATH FAMILY PRACTICE 42 102 $8,034.78 75 XXX -XX -5483 MAURER, PAUL W 1201 NW 16TH ST MIAMI FL 33125 PHYSICIAN - M.D. OPHTHAMOLOGY 37 64 $7,965.45 76 .XXX -XX -0438 GUERDAN, BRUCE R 5900 COLLEGE RD KEY WEST FL 33040 PHYSICIAN - M.D. EMERGENCY MEDICINE, GEN 38 47 $7,832.55 77 XXX XX 6284.. MURCIANO, ALFREDO I 2834 DE SOTO BLVD CORAL GABLES_ FL 33134 M.D. INFECTIOUS DISEASES 11 ',. $7,796,71 78 XXX XX 2487 HOMESTEAD DIAGNOSTIC CENTER 387 S HOMESTEAD BLVD HOMESTEAD FL 33030 INDEPENDENT DIAGNOSTIC TESTINC'. 31 47 $7,397.85 79 IXXX -XX -5899 QUINTERO- HERENCIA, RICARDO J 10230 SW 86TH CIR OCALA 'FL 34481 PHYSICIAN - M.D. 'HEMATOLOGY /ONCOLOGY 8 14 $7,150.45 80 'XXX -XX -7358 AGUINAGA, JORGE A 300041ST STREET OCEAN MARATHON 'FL 33050 PHYSICIAN - M.D. 'CRITICAL CARE 16 72 $7,145.00 81 XXX -XX -4361 ZAIAC, MARTIN IN 1150 E HALLANDALE BEACH BLVD STE A HALLANDALE BEACH FL 33009 PHYSICIAN - M.D. DERMATOLOGY 7 9 $7,123.50 82 XXX -XX -4103 MINIMED DISTRIBUTION CORP 18000 DEVONSHIRE ST NORTHRIDGE CA 91325 DURABLE MEDICAL EQUIPMENT 2 9 $7,121.76 83 XXX -XX -5995 DONKOR, CHARANY 11400 OVERSEAS HWY SUITE 106 MARATHON FL 33050 PHYSICIAN - M.D. GENERALSURGERY 9 21 $7,084.03 84 'XXX -XX -4239 QUEST DIAGNOSTICS INC 100 NW 170TH ST STE 204 NORTH MIAMI BEACH FL 33169 CLINICAL LABORATORY 221 282 $7,058.47 85 'XXX -XX -5133 LINARES, ERNESTO B 2572 W STATE ROAD 426 SUITE 3080 'OVIEDO FL 32765 PHYSICIAN - M.D. HEMATOLOGY /ONCOLOGY 1 1 $6,903.79 86 XXX XX 0949 TELADOC PHYSICIANS PA 1060 NAUTICA DR WESTON FL 33327 PHYSICIAN - M.D. INTERNAL MEDICINE 125 198 $6,880.00 87 'XXX -XX -4103 LIBERATOR MEDICAL SUPPLY INC 2979 SE GRAN PKWY 'STUART 'FL 34997 DURABLE MEDICAL EQUIPMENT 1 17 $6,801.80 88 XXX -XX -0684 LISCHER ,GARRETT 9245 PARKWEST BLVD KNOXVILLE TN 37923 1... 9 $6,725.83 89 XXX -XX -1468 MARQUEZ, JULIAN 2140 W 68TH ST STE 401A HIALEAH FL 33016 PHYSICIAN- M.D. GENERAL PRACTICE 1 4 $6,714.04 90 XXX -XX -7034 STEINFELD, ROGER 3401 NORTHSIDE DR KEY WEST FL 33040 PHYSICIAN- M.D. CARD IOLOGY /CARDI OVASCU 38 68 $6,696.08 91 .XXX -XX -8825 TURBESSI, EILEEN M 91550 OVERSEAS HWY STE 109 TAVERNIER FL 33070 PHYSICIAN - M.D. FAMILY PRACTICE 35 99 $6,677.87 92 !XXX -XX -0090 DOOLEY, COLEEN L 2409 N ROOSEVELT BLVD 'STE 6 KEY WEST FL 33040 ADVANCED REGISTERED NURSE PRA', 10 68 $6,495.85 93 XXX XX 1124 MAY, SUSANA 103400 OVERSEAS HWY 241 KEY LARGO FL 33037 PHYSICIAN - M.D. FAMILY PRACTICE 31 118 $6,341.24 94 XXX XX 2986_ AMERICAN AMBULANCE SERVICE __ __ 2570 S PARK RD __ ___ HALLANDALE __ FL 33009_ AMBULANCE SERVICE __ ! ___ __ 10_ 11 ',. $6,241._7 __ C.7.k INSTRUCTIONS There are 5 Tabs in this workbook - this tab of Instructions, plus a tab of benefit changes for 2018, and one tab for each of the 3 Options identified in the RFP. Please address your ability to match each option. Please note that the worksheets include not only coinsurance and copayments, they also Include benefit limitations. Please ensure that you address the limitations as well as the benefit levels. The current plans have varying coinsurance levels that are custom to the County, please ensure that all variations to the plan are addressed. If you can match the benefit exactly, signify by marking an X in the column under "Yes, Can Offer Exact Benefit' If you cannot match the benefit exactly, provide the closest benefit that you offer for the line item. PLEASE NOTE THAT THERE ARE 3 OPTIONS TO QUOTE. THE FOLLOWING ARE MANDATORY: Option 1 - PPO or POS matching current plan 03559 Option 2 - PPO or POS to match the HDHP Option 3 - PPO or POS Retiree Only plan with EGWP (03559) C.7.1,. OPTIONS Monroe County Health Plan Changes adopted 7/25/17 for DESCRIPTION OF CHANGE N/A Add $958,558 from Ad Valorem, Non -Ad Valorem, Enterprise, or Internal Funds to ralth Fund Add $958,558 from Ad Valorem, Non -Ad Valorem, Enterprise, or Internal Funds to Health Fund #2 S ecialist Copayment 50 Your copayment for an office visit with a Specialist will increase from 25 to 50 effective 1/1/18. #2A Urgent Care Copayment $50 Your copayment for a visit at an Urgent Care (for example, Advanced Urgent Care) will increase from $25 to $50 effective 111. #29 PCP, Mental/behavioral health or substance abuse and Pre/Post Natal Care Connyment 830 Your copayment for an office visit with a Primary Care Physicians (PCP), Mental /behavioral health or substance abuse office vi6k 1 P-/P—t Natal Care off cc v sits w 0 11 increase from 525 to 530 effect ve 1/1/18. 430 $10 Copayment for Independent Clinical Lab (Quest) Currently all lab work done through Quest there is zero copayment. Effective 1/1/18 there will be a $10 copayment on all lab (ALL lab work must be sent to Quest for the $10 copayment to work done through Quest. NOTE: apply) ALL PREVENTIVE LAB WORK DONE THROUGH QUEST WILL REMAIN ATA ZERO COPAYMENT. ANY LAB WORK DONE AT AN INDEPENDENT CLINICAL LAB, OTHER THAN QUEST, OR THE OUT - PATIENT HOSPITAL FACILITY YOUR LAB WORK WILL BE SUBJECT TO THE ANNUAL DEDUCTIBLE AND YOU WILL HAVE A 55% COINSURANCE TO PAY. 431 Generic Drug copayment $15 The copayment you are currently paying for Generic Drugs will increase from $10 to $15 effective 1/1/18. No changes were #35 Effective 1/1/18 maintenance medications (for example, You currently have the choice to refill any of your medications monthly or get a 90 -day refill (physician must write prescription medications for diabetes, high blood pressure) will require a 90 -. for a 90 -day supply) at most retail pharmacies. Effective 1/1/18 if you are prescribed any medications that are considered day supply at retail- Walgreens is be the exclusive retail maintenance (for example, diabetes, hypertension medications) your physician must write you a prescription for a 90-day pharmacy you must use for the 90-day maintenance supply that you can only fill at Walgreens Pharmacies. #9 Active Employees Pay $50/75 for Employee Coverage Active employees hired prior to 5/1/12 are currently paying $25 monthly for their coverage. This premium will increase to $50 monthly effective 1/1/18. Active employees hired after 5/1/12 are currently paying $50 monthly for their coverage. This premium will increase to $75 effective 1 /1 /18. These increases are to stay in the traditional insurance plan and not elect the #28 $100 per month smoker surcharge The smoker surcharge is currently $50 and is charged to Active employees hired 1/1/15 or later and Actives who retired after 1/1/15. Effective 1/1/18 the smoker surcharge will increase to $100 for ALL employees, regardless of hire date and ALL retirees on the plan. During this year's Open Enrollment ALL plan participants (actives, retirees, spouses and dependents over the age of 18) must complete, sign and return a Non - Tobacco Attestation Certification Form. The Medicare Part D program offers employers, who keep retirees on their health plan after they are Medicare eligible, a Retiree Drug Subsidy (RDS). The subsidy from RIDS by the County is approximately $150,000 per calendar year, but the County does not receive this susidy for over one year. The Employer Group Waiver Program (EGWP) was introduced several years ago and has become the way employers who offer retiree prescription benefits are going. The EGWP is expected to generate #15 Change Medicare Retiree Drug Subsidy from RIDS to EGWP over $200,00 of subsidy for the County and subsidies through the EGWP are received at time of service. RIDS limits reimbursement to 28% annually. The EGWP has no reimbursement limit. Effective for 2018 calendar year the County will be switching to the EGWP. #36 Over - the - Counter (OTC) medications will no longer be available Effective 1/1/18 Over- the - Counter (OTC) medications will be excluded from being covered under the prescription plan. If you through the prescription plan for just a copayment. have been getting any OTC medications through the prescription plan and just paying the copayment, effective 1/1/18 should your physician give you a prescription for medications that are available OTC, it will be denied. #34 Adopt Envision Select Formulary The Select Formulary is the list of medications that will be covered under our prescription plan effective 1/1/18. Should you happen to be taking any medication that is not covered under the Select Formulary, you will be notified prior to 1/1/18 so that you can discuss an alternative medication with your physician. If a medication is not covered under the Select Formulary, there will be at least (2) two alternative medications that your physician can prescribe. If you elect to receive the non formulary drug, you will have to pay the higher non - preferred copay. C.7.1 *Copayments are fixed dollar amounts (for example, $30) you pay covered health care, usually when you receive the service. Spouses of employees or retirees who have access to coverage Effective 1/1/18 spouses /Domestic Partners of employees and retirees who are eligible for health insurance coverage through through his /her own employer are ineligible for coverage under his /her employer are not eligible for coverage as a dependent on the Monroe County Group Health Plan. Any employee or the Monroe County Group Health Plan. retiree who elects coverage for an employed spouse /Domestic Partner will be required to have an attestation form completed #18A and signed by the spouse or Domestic Partner's employer indicating they offer no health insurance coverage to their employees. Self- employed spouses /Domestic Partners will have to complete and sign attesting that they have no employer sponsored health care. 419 Conduct an audit to ensure that dependents on the plan are The County will hire an outside firm to perform an audit of all the dependents on the Monroe County Group Health Plan and eligible for coverage ensure that they are eligible for coverage. #32 Effective 1/1/18 the dependent subsidy provided by the County Employees hired 1/1/18 who will want to cover dependents will not receive the same subsidized premiums as current will he reduced to 5o% for employees hired 1 /1 /18 and after. employee receive. Subsidy for dependents of employees hired after 1/1/18 will be reduced to 50%. (PLEASE REFER TO THE ATTACHED RATE SHEET FOR 2018) Effective 1/1/18 the monthly rates for non - Medicare eligible "Rule of 70 Retirees" will change depending on your years of The County subsidy provided to Rule of 70 retirees who are not service with the FRS. Retirees with 25+ YOS will continue to pay current HIS rate. Retires with 20 -24 YOS will ultimately pay over yet eligible far Medicare will be changed over the next 5 years 25% of the "actuarial rate" phased over 5 years and retirees with 10 -19 YOS pay 50% of the "actuarial rate" phased over 5 5 ye 5 years and will vary depending on the years of service with the County. years. (PLEASE REFER TO THE ATTACHED RATE SHEET FOR 2018) Retiree Leaves the Monroe County Health Plan to purchase Medicare Supplement: If the retiree decides to enroll in a Medicare Supplemental Plan effective 1/1/18, the retiree would terminate their coverage under the Monroe County Group Health Plan during the Annual Open Enrollment and beginning 1/1/18 the Medicare Supplemental Plan would become their Secondary Insurance. The County will provide a $250 subsidy to the retiree and the HIS that was being deducted for their coverage with Monroe County will be stopped. The retiree who terminates their coverage under the Monroe County Health The county will begin providing "Rule of 70 Retirees" who are Plan will waive the right to re- enroll and the spouse of the retiree that elects to use the $250 subsidy to purchase a medicare 44A eligible for Medicare a $250 monthly subsidy. This subsidy can supplement will be ineligible to stay on the Monroe County Health Plan. he used by a retiree two different ways: Retiree Remains enrolled on the Monroe County Health Plan: A medicare eligible retiree can use the $250 susidy plus the retirees FRS Health Insurance Subsidy and make up the difference between the County Insurance health premium and these 2 subsidys. For example, for 2018, the monthly actuarial rate is $677. The retiree would use the $250 subsidy from the County, plus the HIS (a 30 year employee would HIS would be $150) toward the $677. The retiree would pay the difference to the County ($677-$250-$150-$277). 441 Establish Acturial Rate (premium) for employees hired 10/1/01 Employees hired 10/01/01 or later are not considered "Rule of 70 Retirees" and are not eligible for the subsidized premium or later and retire with Monroe County that the "Rule of 70 Retirees" have. If you were hired on or after 10/01/01 and retire with Monroe County you have been paying the Department Rate of $1035 for 2017. Effective 1/1/18 the rate paid by these retirees will be the acturial rate. (PLEASE REFER TO THE ATTACHED RATE SHEET FOR 2018) In addition to the County's "Traditional" insurance coverage The Traditional Plan includes a $400 individual deductible; $800 family deductible; Pays 75% coinsurance in Network; Pays plan, employees, dependents, and retirees may elect a High 45°%coinsurance Out of Network; Max out of pocket is $7,150 individual; Max out of pocket is $14,300 family. Deductible Health Plan (HD /HP) with a Health Savings Account 413 (HSA) effective 1/1/18. (A COMPARISON OF THE CURRENT The High Deductible Health plan (HD /HR) includes a $2000 individual deductible; $4000 family deductible (which', must be met "TRADITIONAL PLAN" AND THE "HIGH DEDUCTIBLE HEALTH priorto insurance paying on cc insurance); Pays 80% coinsurance in Network; Pays 50% coinsurance Out of Network; Max out PLAN WITH A HEALTH SAVINGS ACCOUNT WILL BE PROVIDED of pocket Is $6,650 individual; Max out of pocket is AT OPEN ENROLLMENT). $13,300 family, *Copayments are fixed dollar amounts (for example, $30) you pay covered health care, usually when you receive the service. C.7.1,. *Coinsurance is the percentage of the Allowed Amount you pay for covered services. In- Network covered services are paid at 75% of the allowed amount and your *coinsurance is 25% of the allowed amount. (Example: In- network provider bills Florida Blue $1000 for a procedure. When the claim is processed the allowed amount by the plan is $800. Florida Blue will pay the provider $600 which is 75% of the allowed amount. The In- network provider can only bill you $200 which is your coinsurance of 25 %. The difference between the billed and allowed amount, in this case $200 that was not allowed, can not be billed to you. Out -of- network providers are paid at 45% of the allowed amount and you are responsible for a coinsurance of 55 % In addition, Out -of- network providers can bill you for the difference between the billed amount and the allowed amount. EXHIBIT D - BENEFIT COMPARISON MONROE COUNTY BOCC - 2018 BENEFIT GRID OPTION I - PPO Design for EXISTING PLAN 03559 Definitions: DED- annual deductible PAD - per admission deductible PVD - per visit deductible BPM - benefit period maximum LTM - lifetime maximum ENTER PROPOSER INFORMATION IN THIS CELL 1 of 6 I 2 of 6 cult Wellness Office Services In-Network Family Physician $0 In-Network Specialist $0 Out-of-Network 1 55% (No DED) In-Network $0 Out-of-Network $0 nbulance Maximum (per day combined ground, air d water) In-Network DED + 25% Out-of-Network DED + 25% Emergency Room Facility Services Per Visit Deductible (PVD -Waived if Admitted) (also see Professional Provider Services) In-Network $300 PVD + DED + 25% Out-of-Network $300 PVD + DED + 25% nbulatory Surgical Center In-Network DED + 25% Out-of-Network DED + 55% dependent Diagnostic Testing Facility - ays and AIS (includes Physician Services) In-Network - Advanced Imaging Services (AIS) DED + 25% In-Network - Other Diagnostic Services I DED + 25% 3 of 6 I 4 of 6 5 ofs 6 ofs EXHIBIT D - BENEFIT COMPARISON MONROE COUNTY BOCC - 2018 BENEFIT GRID OPTION 2 - HSA COMPATIBLE HDHP - NEW 1/1/18 Definitions: DED- annual deductible PAD - per admission deductible PVD - per visit deductible BPM - benefit period maximum LTM - lifetime maximum ENTER PROPOSER INFORMATION IN THIS CELL 1 of 4 I !a4 I 3 of 4 I 4 of 4 EXHIBIT D - BENEFIT COMPARISON MONROE COUNTY BOCC - 2018 BENEFIT GRID OPTION 5 Medicare Retiree Only PPO with EGWP - BASED ON EXISTING PLAN Definitions: DED- annual deductible PAD - per admission deductible PVD - per visit deductible BPM - benefit period maximum LTM - lifetime maximum ENTER PROPOSER INFORMATION IN THIS CELL 1 of 6 I 2 of 6 cult Wellness Office Services In-Network Family Physician $0 In-Network Specialist $0 Out-of-Network 1 55% (No DED) In-Network $0 Out-of-Network $0 nbulance Maximum (per day combined ground, air d water) In-Network DED + 25% Out-of-Network DED + 25% Emergency Room Facility Services Vi. sit Deductible t ' Per , ible (PVD - Waived if Admitted) (also see Professional Provider Services) In-Network $300 PVD + DED + 25% Out-of-Network $300 PVD + DED + 25% nbulatory Surgical Center In-Network DED + 25% Out-of-Network DED + 55% dependent Diagnostic Testing Facility - ays and AIS (includes Physician Services) In-Network - Advanced Imaging Services (AIS) DED + 25% In-Network - Other Diagnostic Services I DED + 25% 3 of 6 I 4 of 6 5 ofs 6 ofs EXHIBIT E CPT CODE WORKSH MONROE COUNTY BOARD OF COUNTY COMMISSIONERS Gallagher Benefit Services Network Evaluation Model Sample Physician Fee Schedules Average Negotiated CPT4 Allowable Fee Code Description PPO Global Fees R &C 11100 Biopsy Skin Lesion 17000 Destruct Premalg Lesion - - 17311 Mohs 1 Stage H /N /Hf/G - - 19081 Bx Breast 1 St Lesion Strtctc - - 19303 Mast Simple Complete - - 19350 Breast Reconstruction - - 20550 lnj Tendon Sheath/Ligament - - 20610 Drain/Inj Joint /Bursa W/O Us - - 27130 Total Hip Arthroplasty - - 27447 Total Knee Arthroplasty - - 29876 Knee Arthroscopy /Surgery - - 31237 Nasal /Sinus Endoseopy Surg - - 31295 Sinus Endo W /Balloon Dil - - 45378 Diagnostic Colonoscopy - - 45380 Colonoscopy And Biopsy - - 50590 Fragmenting Of Kidney Stone - - 58661 Laparoscopy Remove Adnexa - - 59400 Vaginal Delivery - - 59510 Cesarean Delivery - - 64450 N Block Other Peripheral - - 64483 lnj Foramen Epidural L/S - - 64721 Carpal Tunnel Surgery - - 66984 Cataract Surg W /Iol 1 Stage - - 73221 Mri Joint Upr Extrem W/O Dye - - 73564 X -Ray Exam Knee 4 Or More - - 73630 X -Ray Exam Of Foot - - 73718 Mri Lower Extremity W/O Dye - - 76641 Ultrasound Breast Complete - - 76819 Fetal Biophys Profil W/O Nst - - 76856 Us Exam Pelvic Complete - - 78815 Pet Image W /Ct Skull -Thigh - - 81211 Brcal &2 Seq & Com Dup /Del - - 92507 Speech/Hearing Therapy - - 95004 Percut Allergy Skin Tests - - 95165 Antigen Therapy Services - - 97001 Pt Evaluation - - 97110 Therapeutic Exercises - - CPT /HPCS Codes - Page 1 of 2 Pages EXHIBIT E CPT CODE WORKSH Gallagher Benefit Services Network Evaluation Model Sample Physician Fee Schedules Average Negotiates CPT4 Allowable Fee Code Description PP( R &C 97140 Manual Therapy 1/> Regions - - 99202 Office /Outpatient Visit New - - 99203 Office /Outpatient Visit New - - 99204 Office /Outpatient Visit New - - 99205 Office /Outpatient Visit New - - 99212 Office /Outpatient Visit Est - - 99213 Office /Outpatient Visit Est - - 99214 Office /Outpatient Visit Est - - 99215 Office /Outpatient Visit Est - - CPT /HPCS Codes - Page 2 of 2 Pages EXHIBIT E CPT CODE WORKSH Gallagher Benefit Services Network Evaluation Model Sample Physician Fee Schedules Average Negotiates CPT4 Allowable Fee Code Description PP( R &C 99222 99223 99232 99233 99243 Initial Hospital Care Initial Hospital Care Subsequent Hospital Care Subsequent Hospital Care Office Consultation - - - - - - - - - - 99244 Office Consultation - - 99245 Office Consultation - - 99283 Emergency Dept Visit - - 99284 Emergency Dept Visit - - 99285 Emergency Dept Visit - - 99291 Critical Care First Hour - - 99385 Prev Visit New Age 18 -39 - - 99386 Prev Visit New Age 40 -64 - - 99391 Per Pm Reeval Est Pat Infant - - 99393 Prev Visit Est Age 5 -11 - - 99394 Prev Visit Est Age 12 -17 - - 99395 Prev Visit Est Age 18 -39 - - 99396 1 Prev Visit Est Age 40 -64 - I I - rroiessionai q- 70450 74177 76641 88305 88307 Ancillary (HC A0427 A0429 A4230 J7302 S3854 Q2048 omponent Ct Head /Brain W/O Dye - - Ct Abd & Pely W /Contrast - - Ultrasound Breast Complete - - Tissue Exam By Pathologist - - Tissue Exam By Pathologist - I I - rc:a) Amb Srvc Als Emerg Transport Levl 1 - Amb Service Bls Emergency Transport - Infus Set Ext Insulin Pump Nonndle - Levonorgestrel Intrautern Cntracpt - Gene Expression Profiling Panel - Injection, doxorubicin HCL, liposomal, Doxil, 10 mg - CPT /HPCS Codes - Page 3 of 2 Pages C.7 n EXHIBIT F - PRICING EXHIBIT Complete the exhibit by entering the PEPM Cost for each separate component listed. If the component is included in the overall Administration fee, please indicate. If the component is not provided, please indicate NA in the cell. — ALL SERVICES PROPOSED MUST BE INCLUDED AS A PACKAGE IN THIS PRICING EXHIBIT AND MUST TOTAL TO THE FINAL PEPM CHARGE FOR THE PROPOSAL. IF YOU ARE OFFERING VARYING LEVELS OF SERVICE PLEASE PREPARE A SEPARATE PRICING EXHIBIT TO REFLECT EACH PACKAGE YOU ARE OFFERING. Please enter the total PEPM charge for all services quoted in line 74. Enter your monthly estimated enrollment in line 72. CLAIMS ADMINISTRATION SERVICES {Enter Vendor blame Here} CLAIMS ADMINISTRATION 2019 2020 2021 Administration Fee $$$ $$$ $$$ Hospital Bill Audit $$$ $$$ $$$ s Network Access Fees $$$ $$$ $$$ Network Access Fees - Out of Area $$$ $$$ $$$ Subrogation Services $$$ $$$ $$$ Fraud Investigation Services/Recovery $$$ $$$ $$$ Repricing Fees $$$ $$$ $$$ Coordination of Benefits $$$ $$$ $$$ Grievance /Appeals Administration $$$ $$$ $$$ Independent Review Organization Reviews $$$ $$$ $$$ C CL State Report Filings or Fee Remittances $$$ $$$ $$$ CL Other (State & show PEPM cost) SET UP FEES - INCLUDE ALL SET UP FEES FOR ALL SERVICES IN THIS SECTION Cr Client Set Up $$$ $$$ $$$ Enrollment Assistance - Materials, Meetings $$$ $$$ $$$ Plan Document - Original $$$ $$$ $$$ Booklet fee (each) $$$ $$$ $$$ �— Renewal fee if an $$$ $$$ $$$ — ID Cards, Claim Forms, Enrollment Manual, etc. $$$ $$$ $$$ Other (State & show PEPM cost) Other (State & show PEPM cost) OTHER SERVICES Claim Fiduciary $$$ $$$ $$$ — 24/7 Nurse Hotline $$$ $$$ $$$ Disease Management Fees $$$ $$$ $$$ LL Utilization Review $$$ $$$ $$$ COBRA Notifications $$$ $$$ $$$ — Customer Service Line $$$ $$$ $$$ PBM Interface Fees (PEPM) $$$ $$$ $$$ Disease Management Interface Fees $$$ $$$ $$$ COBRA / HIPAA $$$ $$$ $$$ Run -Out Fees $$$ $$$ $$$ Reporting - month) $$$ $$$ $$$ c: Reporting -Ad Hoc $$$ $$$ $$$ Other State & show PEPM cost WELLNESS PROGRAMS -> PRICING SHOULD BE BASED ON THE FREQUENCIES SHOWN Base Fee $$$ $$$ $ Packet Pg. 1002 Wellness Consultant - actively participating with County $$$ $$$ $$$ Biornetric Screenings - Annual for all participants $$$ $$$ $$$ Health Risk Assessments (HRA's) - Annually for all $$$ $$$ $$$ Health Fairs - Minimum 4 per year $$$ $$$ $$$ Incentives and Incentive Administration $$$ $$$ $$$ Other (State & show PEPM cost) Web /Phone Based Programs Weight loss - Nutrition $$$ $$$ $$$ Walking $$$ $$$ $$$ Stress Reduction $$$ $$$ $$$ Smoking Cessation $$$ $$$ $$$ Physical Activity $$$ $$$ $$$ Health Coaching one - one $$$ $$$ $$$ Other (State & show PEPM cost) On-Site Components Offered Weight loss - Nutrition $$$ $$$ $$$ Walking $$$ $$$ $$$ Stress Reduction $$$ $$$ $$$ Smoking Cessation $$$ $$$ $$$ Physical Activity $$$ $$$ $$$ On-Site Coordinator $$$ $$$ $$$ Other (State & show PEPM cost) WELLNESS REPORTING Quarterly and Annual Participation & R01 $$$ $$$ $$$ Ad hoc Reports $$$ $$$ $$$ ADDITIONAL FEES NOT REPORTED DATA INTEGRATION SET UP FEES FOR PBM ACCUMULATORS Other (State & show PEPM cost) TOTAL ADMINISTRATION FEES PEPM* 1621 TOTAL ESTIMATED ANNUAL ADMIN FEES $0 $0 $0 USE THE LINES BELOW TO DEMONSTRATE ANY OFFSETS TO ADMINISTRATION FEES Offsets: define and state amount and unit (eg. PEPM, Quarterly, Annual) Offsets: define and state amount and unit (eg. PEPM, Quarterly, Annual) Offsets: define and state amount and unit (eg. PEPM, Quarterly, Annual) Offsets: define and state amount and unit (eg. PEPM, Quarterly, Annual) C.7.n I u- F- x C 0) E