Age Group Member Months Capitation Payments FFS Equivalent Leakage 00 - Under Age 1 - - - - 01 - Age 1 to 2 91.00 2,275.00 2,623.83 2578.4 02 - Age 3 to 5 256.00 6,400.00 4,364.65 1919.54 03 - Age 6 to 11 517.00 12,925.00 9,660.31 8845.27 04 - Age 12 to 18 856.00 21,400.00 19,772.27 6389.45 05 - Females age 19 to 24 306.00 7,650.00 2,732.08 4899.9 06 - Males age 19 to 24 259.00 6,475.00 2,526.35 4111.23 07 - Females age 25 to 34 364.00 9,100.00 6,963.47 5642.4 08 - Males age 25 to 34 183.00 4,575.00 2,683.24 2218.89 09 - Age 35 to 44 1,034.00 25,850.00 16,896.40 18331.7 10 - Age 45 to 54 1,702.00 42,550.00 35,499.10 26998.94 11 - Age 55 to 64 1,400.00 35,000.00 32,586.61 28337.93 12 - Age 65 to 74 149.00 3,725.00 3,610.40 3807.84 13 - Age 75+ - - - -

7,117 177,925.00 139,918.71 114,081.49

Capitation Amount 25.00 Practice Risk Score 1.1014 PEIA Risk Score 1.1284

Adjustment Factor 0.9761

Risk Pool PEIA PMPM Practice Claims Practice PMPM Adjusted Target Savings / Loss Hospital 100.18 706,505.90 99.27 97.78 (1.49) Emergency Room 9.46 74,553.26 10.48 9.23 (1.24) Specialist 37.96 249,854.45 35.11 37.05 1.95 Lab 5.57 65,270.15 9.17 5.44 (3.73) Xray 5.90 59,201.94 8.32 5.76 (2.56) Misc 37.88 213,866.69 30.05 36.97 6.92 Pharmacy 63.11 487,650.49 68.52 61.60 (6.92)

Total 260.06 1,856,902.88 260.91 253.84 (7.07)

PMPM Leakage 16.03 PEIA Risk Management 13.00

Net Savings (36.10)

Patient ID Provider ID Provider Name Provider ZIP Provider Specialty Incur Date Primary DX DX Description Bill Type Proc Proc Description Place of Service Units Charge Allow Paid data removed data removed data removed data removed FP 27-JUL-12 2749 GOUT NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 71.00 41.76 26.76 FP 15-JUN-12 78039 OTHER CONVULSIONS 99285 ER EXAM;NEW PT;COMPREHENSIVE 23 1 317.00 186.18 148.94 FP 12-DEC-12 30403 OPIOID DEPENDENCE-REMISS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 56.24 IM 15-NOV-12 2449 HYPOTHYROIDISM NOS 76536 ECHOGRAPHY, SOFT TISSUES OF HE 11 1 120.00 82.13 65.70 FP 06-NOV-12 84500 SPRAIN OF ANKLE NOS 99283 ER EXAM;NEW PT;INTERMEDIATE 23 1 136.00 66.12 52.90 FP 06-NOV-12 4011 BENIGN HYPERTENSION 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 104.05 89.05 FP 06-NOV-12 4011 BENIGN HYPERTENSION 90656 FLU VIR VAC SPLIT PF 3 YR AGE& 11 1 30.00 12.38 12.38 AN 01-NOV-12 25013 DIABETES W/ KETACIDOSIS TYPE I 00740 UPPER GASTROINTESTINAL ENDOSCO 22 6 255.98 210.90 168.72 DR 20-NOV-12 V1083 HX-SKIN MALIGNANCY NEC 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 125.00 107.88 82.88 DR 20-NOV-12 V1083 HX-SKIN MALIGNANCY NEC 17000 DESTRUCTION BY ANY METHOD, INC 11 1 115.00 78.65 - GS 05-DEC-12 78720 DYSPHAGIA, UNSPECIFIED 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 70.30 45.30 GS 12-DEC-12 53019 OTHER ESOPHAGITIS 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 41.76 16.76 IM 30-NOV-12 8470 SPRAIN OF NECK 99283 ER EXAM;NEW PT;INTERMEDIATE 23 1 414.00 66.12 52.90 FP 28-NOV-12 92420 CONTUSION OF FOOT 99202 OFFICE VIS/NEW PT-LIMITED 72 1 89.00 86.03 71.03 FP 04-DEC-12 92420 CONTUSION OF FOOT 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 50.11 35.11 AN 28-NOV-12 42731 ATRIAL FIBRILLATION 00537 ANE/CARDIAC ELECTROPHYSIOLOGIC 22 26 1,950.00 548.34 548.34 AN 28-NOV-12 42731 ATRIAL FIBRILLATION 36620 ARTERIAL CATHETERIZATION OR CA 22 1 225.00 57.42 57.42 AN 28-NOV-12 42731 ATRIAL FIBRILLATION 4048F DOC PROPHYL ANTIBIOTIC PR TO S 22 1 0.01 - - AN 28-NOV-12 42731 ATRIAL FIBRILLATION 4255F DURATION OF GEN OR NEURAXIAL 22 1 0.01 - - AN 28-NOV-12 42731 ATRIAL FIBRILLATION 4250F WARMING USED INTRAOPERATIVELY 22 1 0.01 - - GS 14-NOV-12 56211 DIVERTICULITIS OF COLON 99214 OFFICE VIS/EST PT-INTERMEDIATE 22 1 134.00 80.39 55.39 GS 27-NOV-12 V553 ATTEN TO COLOSTOMY 44626 REPAIR BOWEL OPENING 21 1 4,695.00 1,978.03 1,978.03 FP 08-DEC-12 6822 CELLULITIS OF TRUNK 99213 OFFICE VIS/EST PT-LIMITED 11 1 86.00 70.30 55.30 FP 14-DEC-12 6822 CELLULITIS OF TRUNK 99213 OFFICE VIS/EST PT-LIMITED 11 1 86.00 70.30 55.30 DR 30-NOV-12 7020 ACTINIC KERATOSIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 114.00 70.30 45.30 DR 30-NOV-12 7020 ACTINIC KERATOSIS 17000 DESTRUCTION BY ANY METHOD, INC 11 1 112.00 78.65 - DR 30-NOV-12 7020 ACTINIC KERATOSIS 17003 DESTRUCT.BY ANY METHOD;2ND-14 11 1 11.00 7.31 - GS 17-DEC-12 4548 VAR. VEINS LEG/OTHER COMPLICAT 93970 DUPLEX SCAN OF EXTREMITY VEINS 22 1 50.00 37.93 30.34 FP 02-JAN-12 4619 ACUTE SINUSITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.49 55.49 DR 10-JAN-12 7081 IDIOPATHIC URTICARIA 99213 OFFICE VIS/EST PT-LIMITED 11 1 130.00 70.49 50.49 FP 22-JAN-12 4660 ACUTE BRONCHITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.49 55.49 AN 22-MAY-12 5533 DIAPHRAGMATIC HERNIA 00740 UPPER GASTROINTESTINAL ENDOSCO 22 6 528.00 126.54 101.23 AN 22-MAY-12 5533 DIAPHRAGMATIC HERNIA 00740 UPPER GASTROINTESTINAL ENDOSCO 22 6 282.00 84.36 67.49 GS 18-JUL-12 53081 ESOPHAGEAL REFLUX 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 131.00 104.05 79.05 DR 10-JUL-12 70219 OTHER SEBORRHEIC KERATOSIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 130.00 70.30 45.30 DR 10-JUL-12 70219 OTHER SEBORRHEIC KERATOSIS 17000 DESTRUCTION BY ANY METHOD, INC 11 1 145.00 78.65 - DR 10-JUL-12 70219 OTHER SEBORRHEIC KERATOSIS 17003 DESTRUCT.BY ANY METHOD;2ND-14 11 3 105.00 21.93 - DR 16-JUL-12 7014 KELOID SCAR 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 165.00 107.88 82.88 FP 01-JUN-12 8449 SPRAIN OF KNEE LEG NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 210.00 104.05 89.05 FP 01-JUN-12 8449 SPRAIN OF KNEE LEG NOS 73564 RAD EXAM, KNEE; 11 1 130.00 42.11 33.69 GS 24-APR-12 78903 ABDOMINAL PAIN; RT LOW QUAD 99282 ER EXAM;NEW PT;LIMITED 23 1 85.00 44.20 35.36 FP 19-APR-12 30002 GENERALIZED ANXIETY DIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 101.00 70.30 55.30 AN 12-NOV-12 57450 CALCULUS OF BILE DUCT W/O CHOL 00740 UPPER GASTROINTESTINAL ENDOSCO 22 12 900.00 253.08 22.46 FP 10-NOV-12 57490 CALCULUS OF GALLBLADDER AND BI 99219 INIT OBSERV;PER DAY;MOD SEVERI 22 1 170.00 136.76 109.41 PSY 11-MAY-12 30928 ADJ REACT-MIXED EMOTION 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 - - PSY 09-JAN-12 30928 ADJ REACT-MIXED EMOTION 90804 IND PSYCHOTHERAPY, INSIGHT 11 1 100.00 - - PSY 06-FEB-12 30928 ADJ REACT-MIXED EMOTION 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 27-FEB-12 30928 ADJ REACT-MIXED EMOTION 90804 IND PSYCHOTHERAPY, INSIGHT 11 1 100.00 - - PSY 26-MAR-12 30928 ADJ REACT-MIXED EMOTION 90804 IND PSYCHOTHERAPY, INSIGHT 11 1 100.00 - - PSY 20-APR-12 30928 ADJ REACT-MIXED EMOTION 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 - - PSY 30-APR-12 30928 ADJ REACT-MIXED EMOTION 90804 IND PSYCHOTHERAPY, INSIGHT 11 1 100.00 - - PSY 12-SEP-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 13-SEP-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 19-SEP-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 07-NOV-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 22-AUG-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - FP 29-OCT-12 V0481 VACC/INOC AGAINST INFLUENZA Q2038 FLU VACC SPLIT 3 YRS & > IM FL 11 1 15.00 13.31 13.31 PED 05-DEC-12 4659 ACUTE URI NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 70.30 55.30 PED 05-DEC-12 4659 ACUTE URI NOS 87430 STEPTOCOCCUS, GROUP A; INFECT 11 1 20.00 16.99 - PED 05-DEC-12 4659 ACUTE URI NOS 87070 CULTURE, BACTERIAL, DEFINITIVE 11 1 13.00 12.20 - IM 05-DEC-12 5791 TROPICAL SPRUE 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 146.00 107.88 92.88 AN 27-NOV-12 4404 CHRONIC TOTAL OCCLUSION OF ART 01270 ARTERIES OF UPPER LEG NES 21 21 1,743.00 738.15 738.15 FP 06-NOV-12 V7281 PRE-OPERATIVE CARDIOVASCULAR E 93000 ELECTROCARDIOGRAM, WITH INTERP 11 1 94.00 18.79 15.03 IM 30-APR-12 29620 DEPRESS PSYCHOSIS-UNSPEC 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 41.76 26.76 IM 31-JAN-12 78659 CHEST PAIN NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 74.00 70.49 55.49 FP 30-NOV-12 78650 CHEST PAIN NOS 93016 CARDIOVASC STRESS TREADMILL 22 1 136.25 21.58 17.26 FP 30-NOV-12 78650 CHEST PAIN NOS 93018 CARDIOVASCULAR STRESS TEST USI 22 1 95.50 14.96 11.97 FP 06-DEC-12 9597 LOWER LEG INJURY NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 110.00 70.30 55.30 FP 06-DEC-12 9597 LOWER LEG INJURY NOS 73630 FOOT RAD EXAMINATION 11 1 45.00 21.23 16.98 AN 28-NOV-12 V252 STERILIZATION 00851 TUBAL LIGATION/TRANSECTION 22 12 900.00 253.08 202.46 MG 29-NOV-12 7840 HEADACHE 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 45.30 PED 13-APR-12 V202 ROUTINE CHILD HEALTH EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 120.00 102.31 102.31 FP 26-APR-12 4610 AC MAXILLARY SINUSITIS 99070 SUPPLIES/MATERIALS BY PHYSCIAN 11 1 3.00 - - FP 26-APR-12 4610 AC MAXILLARY SINUSITIS 99070 SUPPLIES/MATERIALS BY PHYSCIAN 11 1 3.00 - - FP 26-APR-12 4610 AC MAXILLARY SINUSITIS 99070 SUPPLIES/MATERIALS BY PHYSCIAN 11 1 3.00 - - FP 26-APR-12 4610 AC MAXILLARY SINUSITIS 99070 SUPPLIES/MATERIALS BY PHYSCIAN 11 1 3.00 - - FP 26-APR-12 4610 AC MAXILLARY SINUSITIS J0696 INJECTION, CEFTRIAXONE SODIUM, 11 1 7.75 0.89 0.71 FP 26-APR-12 4610 AC MAXILLARY SINUSITIS 96372 THER/PROPH/DIAG INJ SC/IM 11 1 16.00 16.00 12.80 FP 26-APR-12 4610 AC MAXILLARY SINUSITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 70.30 55.30 PED 13-APR-12 V202 ROUTINE CHILD HEALTH EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 120.00 102.31 102.31 MG 25-APR-12 7862 COUGH 71020 RADIOLOGIC EXAM, CHEST, 2 VWS 11 1 88.00 18.10 14.48 PED 25-APR-12 4779 ALLERGIC RHINITIS NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 125.00 104.05 89.05 PED 25-APR-12 4779 ALLERGIC RHINITIS NOS 85027 BLOOD COUNT; HEMOGRAM, AUTOMAT 11 1 60.00 9.17 7.34 PED 09-MAY-12 49390 ASTHMA W/O STATUS ASTHM 99212 OFFICE VIS/EST PT-BRIEF 11 1 50.00 41.76 26.76 IM 11-NOV-12 6253 DYSMENORRHEA 99283 ER EXAM;NEW PT;INTERMEDIATE 23 1 345.00 66.12 52.90 FP 09-NOV-12 7862 COUGH 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 120.00 104.05 - GS 05-DEC-12 5758 DIS OF GALLBLADDER NEC 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 340.00 167.39 142.39 FP 07-DEC-12 25000 DIABETES UNCOMPL ADULT 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.30 55.30 DR 24-APR-12 4541 LEG VARICOSITY W INFLAM 99202 OFFICE VIS/NEW PT-LIMITED 11 1 185.00 71.69 51.69 AN 12-OCT-12 2352 UNC BEHAV NEO INTESTINE 00840 INTRAPERITONEAL LOW ABD; NES 21 15 1,440.00 527.25 527.25 PSY 19-APR-12 3149 HYPERKINETIC SYND NOS 90805 IND PSYCHOTHERAPY W/MED EVALU 22 1 214.00 - - PSY 08-MAY-12 29630 RECURR DEPR PSYCHOS-UNSP 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 70.00 57.42 37.42 AN 29-NOV-12 6202 OVARIAN CYST NEC/NOS 00840 INTRAPERITONEAL LOW ABD; NES 22 14 1,232.00 295.26 295.26 AN 29-NOV-12 6202 OVARIAN CYST NEC/NOS 00840 INTRAPERITONEAL LOW ABD; NES 22 14 658.00 196.84 196.84 DR 03-APR-12 2165 BENIGN NEO SKIN TRUNK 99202 OFFICE VIS/NEW PT-LIMITED 11 1 185.00 71.69 51.69 DR 03-APR-12 2165 BENIGN NEO SKIN TRUNK 11100 BIOPSY OF SKIN, SUBCUTANEOUS T 11 1 195.00 101.27 - DR 03-APR-12 17341 BASAL CELL CARCINOMA/SCALP NEC 88305 LEVEL IV - SURGICAL PATHOLOGY, 11 1 200.00 95.00 - IM 09-MAY-12 42732 ATRIAL FLUTTER 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 65.80 8.70 6.96 AN 20-SEP-12 7242 LUMBAGO 99214 OFFICE VIS/EST PT-INTERMEDIATE 22 1 218.00 80.39 55.39 FP 26-NOV-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 84.36 69.36 FP 26-NOV-12 4019 HYPERTENSION NOS 90736 ZOSTER(SHINGLES)VACCINE, LIVE 72 1 354.66 174.42 174.42 FP 26-NOV-12 4019 HYPERTENSION NOS 90471 IMMUNIZATION ADMINISTRATION 72 1 15.00 14.40 14.40 FNSP 09-AUG-12 25002 DIABETES MELLITUS TYPE II 82962 GLUCOSE, BLOOD, BY GLUCOSE MON 11 1 15.00 3.32 2.66 FNSP 09-AUG-12 25002 DIABETES MELLITUS TYPE II 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 252.00 167.39 152.39 FP 24-JUL-12 4779 ALLERGIC RHINITIS NOS 99383 PREVENTIVE; NEW PT; 5-11 YRS 11 1 200.00 115.54 100.54 FP 01-AUG-12 7061 ACNE NEC 99394 PREVENTIVE;EST PT;12-17 YRS 11 1 200.00 - - IM 19-JUL-12 075 INFECTIOUS MONONUCLEOSIS 76705 ECHOGRAPHY, LIMITED - TECH COM 11 1 150.00 69.60 14.38 FP 08-AUG-12 9194 INSECT BITE NEC 99202 OFFICE VIS/NEW PT-LIMITED 11 1 94.00 71.69 56.69 MG 07-JUN-12 79902 HYPOXEMIA 131 94060 BRONCHOSPASM EVALUATION: SPIRO 22 1 589.00 534.89 534.89 MG 07-JUN-12 79902 HYPOXEMIA 131 94729 C02/MEMBANE DIFFUSE CAPACITY 22 1 377.00 301.77 301.77 MG 07-JUN-12 79902 HYPOXEMIA 131 86038 ANTINUCLEAR ANTIBODIES (ANA); 22 1 119.00 64.89 64.89 MG 07-JUN-12 79902 HYPOXEMIA 131 86140 C-REACTIVE PROTEIN 22 1 89.00 34.89 34.89 MG 07-JUN-12 79902 HYPOXEMIA 131 86235 EXTRACTABLE NUCLEAR ANTIGEN, A 22 10 848.00 793.89 793.89 MG 07-JUN-12 79902 HYPOXEMIA 131 86255 FLUORESCENT ANTIBODY; 22 2 275.00 187.89 187.89 MG 07-JUN-12 79902 HYPOXEMIA 131 86431 RHEUMATOID FACTOR; 22 1 72.00 17.89 17.89 MG 07-JUN-12 79902 HYPOXEMIA 131 85652 SEDIMENTATION RATE AUTOMATED 22 1 66.00 11.89 11.89 AN 25-JUL-12 59970 HEMATURIA, UNSPECIFIED 00910 TRANSURETHRAL PROCEDURES NES 22 6 450.00 126.54 - PSY 19-JUL-12 29680 MANIC-DEPRESSIVE NOS 85025 BLOOD COUNT; HEMOGRAM AND PLAT 81 1 18.50 11.02 8.82 PSY 19-JUL-12 29680 MANIC-DEPRESSIVE NOS 80048 BASIC METABOLIC PANEL 81 1 92.80 11.98 9.58 PSY 19-JUL-12 29680 MANIC-DEPRESSIVE NOS 84443 THYROID STIMULATING HORMONE (T 81 1 39.50 23.80 19.04 PSY 19-JUL-12 29680 MANIC-DEPRESSIVE NOS 80076 HEPATIC FUNCTION PANEL 81 1 89.50 11.57 9.26 AN 07-MAY-12 43310 OCCULSION/STENOSIS CAROTID ARE 00350 PROCEDURES MAJOR VESSELS/NECK 21 22 1,650.00 463.98 463.98 AN 07-MAY-12 43310 OCCULSION/STENOSIS CAROTID ARE 36620 ARTERIAL CATHETERIZATION OR CA 21 1 225.00 57.42 57.42 IM 19-JUN-12 311 DEPRESSIVE DISORDER NEC 99223 INIT HSP VISIT;COMPREHENSIVE 21 1 300.00 208.80 167.04 IM 20-JUN-12 311 DEPRESSIVE DISORDER NEC 99232 SUBSEQUENT HSP VISIT;LIMITED 21 1 110.00 72.38 57.90 FP 19-AUG-12 78831 URGE INCONTINENCE 87086 CULTURE, BACTERIAL, URINE; QUA 81 1 19.00 11.43 9.14 FP 19-AUG-12 78831 URGE INCONTINENCE 87491 IAD;CHLAMYDIA TRACHOMATIS,AMPL 81 1 208.00 49.71 39.77 FP 19-AUG-12 78831 URGE INCONTINENCE 87591 NEISSERIA GONORRHOEAE 81 1 208.00 49.71 39.77 FP 19-AUG-12 78831 URGE INCONTINENCE 85025 BLOOD COUNT; HEMOGRAM AND PLAT 81 1 18.50 11.02 8.82 FP 19-AUG-12 78831 URGE INCONTINENCE 80053 COMPREHENSIVE METABOLIC PANEL 81 1 161.00 14.97 11.98 FP 19-AUG-12 78831 URGE INCONTINENCE 81015 URINALYSIS; MICROSCOPIC ONLY 81 1 7.50 4.31 3.45 FP 07-NOV-12 6260 ABSENCE OF MENSTRUATION 99213 OFFICE VIS/EST PT-LIMITED 11 1 98.00 70.30 55.30 FP 07-DEC-12 6260 ABSENCE OF MENSTRUATION 99213 OFFICE VIS/EST PT-LIMITED 11 1 98.00 70.30 55.30 FP 16-NOV-12 7840 HEADACHE 99213 OFFICE VIS/EST PT-LIMITED 11 1 142.00 70.30 55.30 FP 16-NOV-12 7840 HEADACHE J1885 INJECTION, KETOROLAC TROMETHAM 11 4 44.00 1.04 - PSY 18-OCT-12 29690 AFFECTIVE PSYCHOSIS NOS 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 50.10 - - FP 19-JUN-12 311 DEPRESSIVE DISORDER NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 DR 26-JAN-12 70219 OTHER SEBORRHEIC KERATOSIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 130.00 70.49 50.49 FP 15-MAR-12 4660 ACUTE BRONCHITIS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 72 1 131.00 129.46 114.46 AN 30-OCT-12 470 DEVIATED NASAL SEPTUM 00160 PROCEDURES ON NOSE/SINUSES 22 14 1,120.00 - - AN 19-AUG-12 80507 FX C7 VERTEBRA-CLOSED 99291 CRITICAL CARE;1ST HR/DAY 21 1 450.00 220.98 220.98 DR 07-FEB-12 6961 OTHER PSORIASIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 130.00 70.49 50.49 DR 07-FEB-12 6961 OTHER PSORIASIS 11100 BIOPSY OF SKIN, SUBCUTANEOUS T 11 1 195.00 104.38 83.50 DR 14-FEB-12 6953 ROSACEA 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 125.00 108.79 88.79 DR 14-FEB-12 6953 ROSACEA 11311 SHAVING OF EPEDERMAL OR DERMAL 11 1 170.00 110.14 - FP 05-JAN-12 25000 DIABETES UNCOMPL ADULT 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 137.00 104.72 89.72 FP 22-MAY-12 4019 HYPERTENSION NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 134.00 104.05 89.05 FP 04-JUN-12 3004 NEUROTIC DEPRESSION 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 134.00 104.05 89.05 FP 22-MAY-12 70219 OTHER SEBORRHEIC KERATOSIS 11401 EXCISION, BENIGN LESION, EXCEP 11 1 120.00 - - FP 22-MAY-12 70219 OTHER SEBORRHEIC KERATOSIS 88305 LEVEL IV - SURGICAL PATHOLOGY, 11 1 123.00 95.00 76.00 FP 22-MAY-12 70219 OTHER SEBORRHEIC KERATOSIS 11200 REMOVAL OF SKIN TAGS, MULTIPLE 11 1 97.00 - - FNSP 21-AUG-12 7847 EPISTAXIS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 105.00 71.69 56.69 FNSP 21-AUG-12 78904 ABDOMINAL PAIN - LEFT LOWER QU 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 AN 29-JUN-12 6271 POSTMENOPAUSAL BLEEDING 00952 HYSTEROSCOPY 22 7 616.00 146.63 117.30 AN 29-JUN-12 6271 POSTMENOPAUSAL BLEEDING 00952 HYSTEROSCOPY 22 7 329.00 98.42 78.74 FP 13-AUG-12 2724 HYPERLIPIDEMIA NEC/NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 134.00 104.05 89.05 FP 14-AUG-12 2724 HYPERLIPIDEMIA NEC/NOS 85025 BLOOD COUNT; HEMOGRAM AND PLAT 81 1 18.50 11.02 - FP 14-AUG-12 2724 HYPERLIPIDEMIA NEC/NOS 80053 COMPREHENSIVE METABOLIC PANEL 81 1 161.00 14.97 - FP 14-AUG-12 2724 HYPERLIPIDEMIA NEC/NOS 83036 HEMOGLOBIN; 81 1 22.50 13.75 - FP 14-AUG-12 2724 HYPERLIPIDEMIA NEC/NOS 80061 LIPID PANEL 81 1 43.00 18.97 - IM 30-JUL-12 96509 POISONING-OPIATES NEC 99236 OBSERVATION OR INPT HOSP CARE 22 1 276.00 224.46 179.57 FP 06-AUG-12 78650 CHEST PAIN NOS 99283 ER EXAM;NEW PT;INTERMEDIATE 23 1 136.00 66.12 13.82 IM 05-AUG-12 9221 CONTUSION OF CHEST WALL 99284 ER EXAM;NEW PT;EXTENDED 22 1 175.00 128.06 102.45 FP 13-AUG-12 5589 NONINF GASTROENTERIT NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 87.00 70.30 55.30 FP 16-AUG-12 78492 JAW PAIN 99213 OFFICE VIS/EST PT-LIMITED 11 1 87.00 70.30 55.30 GS 03-AUG-12 78079 OTHER MALAISE AND FATIGUE 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 250.00 167.39 142.39 PSY 16-JUL-12 31401 ATTN DEFICIT W HYPERACT 96101 PSYCHOLOGICAL TESTING, PER HR 11 5 625.00 419.35 175.48 GS 24-OCT-12 55320 VENTRAL HERNIA NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 - - FP 08-OCT-12 78650 CHEST PAIN NOS 93018 CARDIOVASCULAR STRESS TEST USI 22 1 38.00 14.96 11.97 PSY 09-NOV-12 30002 GENERALIZED ANXIETY DIS 99215 OFFICE VIS/EST PT-COMPREHENSIV 11 1 170.00 140.59 112.47 PSY 13-NOV-12 30002 GENERALIZED ANXIETY DIS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 110.00 104.05 83.24 GS 31-OCT-12 V6709 FOLLOW-UP EXAM FOLLOWING SURGE 99203 OFFICE VIS/NEW PT-INTERMEDIATE 72 1 131.00 107.88 82.88 PED 08-OCT-12 V059 VACCIN FOR SINGL DIS NOS 90471 IMMUNIZATION ADMINISTRATION 11 1 30.00 12.00 12.00 PED 08-OCT-12 V059 VACCIN FOR SINGL DIS NOS 90658 INFLUENZA VIRUS VACCINE,SPLIT 11 1 24.00 11.37 11.37 PED 20-OCT-12 V069 VAC-DIS COMBINATIONS NOS 90472 EACH ADD'L VACCINE, SINGLE OR 11 1 21.00 12.00 12.00 PED 20-OCT-12 V059 VACCIN FOR SINGL DIS NOS 90734 VACCINE;MENINGOCOCAL A,C,Y 11 1 156.00 93.48 93.48 PED 20-OCT-12 V059 VACCIN FOR SINGL DIS NOS 90471 IMMUNIZATION ADMINISTRATION 11 1 30.00 12.00 12.00 PED 20-OCT-12 V059 VACCIN FOR SINGL DIS NOS 90715 TDAP VACC IND 7 YEARS/OLDER IM 11 1 54.00 41.15 41.15 DR 13-NOV-12 7020 ACTINIC KERATOSIS 17000 DESTRUCTION BY ANY METHOD, INC 11 1 129.00 78.65 - DR 13-NOV-12 7020 ACTINIC KERATOSIS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 126.00 71.69 46.69 PED 09-NOV-12 V700 ROUTINE MEDICAL EXAM 99394 PREVENTIVE;EST PT;12-17 YRS 72 1 134.00 111.36 111.36 PED 09-NOV-12 V700 ROUTINE MEDICAL EXAM 92551 SCREENING TEST, PURE TONE, AIR 72 1 13.00 10.79 10.79 FNSP 20-NOV-12 8449 SPRAIN OF KNEE LEG NOS 20610 ARTHROCENTESIS, ASPIRATION AND 23 1 316.00 56.03 - PED 15-OCT-12 4644 CROUP 99212 OFFICE VIS/EST PT-BRIEF 72 1 50.00 41.76 26.76 FP 03-OCT-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 10.00 10.00 AN 03-JAN-12 4548 VAR. VEINS LEG/OTHER COMPLICAT 01260 VEINS OF UPPER LEG 22 8 431.52 177.60 142.08 GS 06-JAN-12 45119 DEEP PHLEBITIS-LEG NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.49 50.49 FP 11-JAN-12 4660 ACUTE BRONCHITIS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 130.00 104.72 89.72 PA 11-JAN-12 82100 FX FEMUR NOS-CLOSED 99213 OFFICE VIS/EST PT-LIMITED 22 1 124.00 52.87 32.87 PED 11-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 115.00 88.79 88.79 IM 06-JAN-12 53550 UNSPEC GASTRITIS & GASTRODUOD G0121 COLOREC CNCR SCR;COLNSCPY NO H 11 1 991.00 417.86 134.29 IM 06-JAN-12 53550 UNSPEC GASTRITIS & GASTRODUOD 43239 ENDOSCOPY UPPER GI W BIOPSY 11 1 532.65 178.26 142.61 DR 22-MAY-12 6953 ROSACEA 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 50.30 FP 14-MAY-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 DR 25-MAY-12 2382 UNC BEHAV NEO SKIN 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 165.00 107.88 87.88 DR 25-MAY-12 2382 UNC BEHAV NEO SKIN 11312 SHAVING OF EPIDERMAL OR DERMAL 11 1 160.00 125.98 100.78 DR 25-MAY-12 2382 UNC BEHAV NEO SKIN 88305 LEVEL IV - SURGICAL PATHOLOGY, 11 1 230.00 95.00 76.00 FP 21-JUN-12 2449 HYPOTHYROIDISM NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 84.36 69.36 GS 05-JUN-12 43310 OCCULSION/STENOSIS CAROTID ARE 93880 DUPLEX SCAN EXTRACRANIAL ARTER 22 1 47.00 31.32 31.32 FP 27-MAY-12 6828 CELLULITIS, SITE NEC 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 130.00 104.05 89.05 FP 27-MAY-12 6828 CELLULITIS, SITE NEC 90715 TDAP VACC IND 7 YEARS/OLDER IM 11 1 45.00 41.15 41.15 FP 27-MAY-12 6828 CELLULITIS, SITE NEC 90471 IMMUNIZATION ADMINISTRATION 11 1 20.00 12.00 12.00 IM 15-MAY-12 2449 HYPOTHYROIDISM NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 125.00 70.30 55.30 IM 15-MAY-12 2449 HYPOTHYROIDISM NOS G8553 AT LEAST ONE RX CREATED DURING 11 1 0.01 - - GS 05-JUN-12 43310 OCCULSION/STENOSIS CAROTID ARE 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.30 50.30 FP 20-JUN-12 9493 3RD DEGREE BURN NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 FP 07-DEC-12 4011 BENIGN HYPERTENSION 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 123.00 104.05 89.05 FP 07-DEC-12 4011 BENIGN HYPERTENSION 93000 ELECTROCARDIOGRAM, WITH INTERP 11 1 96.00 18.79 15.03 FP 07-DEC-12 4011 BENIGN HYPERTENSION 81003 URINALYSIS, BY DIP STICK OR TA 11 1 15.00 3.18 2.54 FP 07-DEC-12 4011 BENIGN HYPERTENSION 90715 TDAP VACC IND 7 YEARS/OLDER IM 11 1 48.00 41.15 41.15 FP 07-DEC-12 4011 BENIGN HYPERTENSION 90471 IMMUNIZATION ADMINISTRATION 11 1 14.00 12.00 12.00 FP 07-DEC-12 4011 BENIGN HYPERTENSION 90658 INFLUENZA VIRUS VACCINE,SPLIT 11 1 24.00 11.37 11.37 FP 07-DEC-12 4011 BENIGN HYPERTENSION 90732 IMM, PNEUMOCOCCUS 11 1 35.00 35.00 35.00 FP 07-DEC-12 4011 BENIGN HYPERTENSION 90472 EACH ADD'L VACCINE, SINGLE OR 11 2 12.00 12.00 12.00 FP 11-DEC-12 6829 CELLULITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 58.00 - - GS 19-JUL-12 7336 TIETZE'S DISEASE 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 150.00 107.88 82.88 PSY 06-FEB-12 311 DEPRESSIVE DISORDER NEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 50.10 50.10 30.10 AN 30-OCT-12 470 DEVIATED NASAL SEPTUM 00160 PROCEDURES ON NOSE/SINUSES 22 14 1,120.00 295.26 236.21 DR 28-JUN-12 6929 DERMATITIS NOS 99201 OFFICE VIS/NEW PATIENT-BRIEF 11 1 65.00 41.76 21.76 GS 15-FEB-12 79381 MAMMOGRAPHIC MICROCALCIFICATIO 99212 OFFICE VIS/EST PT-BRIEF 11 1 65.00 42.02 22.02 DR 16-JAN-12 7018 SKIN HYPERTRO/ATROPH NEC 99202 OFFICE VIS/NEW PT-LIMITED 11 1 140.00 72.52 52.52 DR 20-FEB-12 70909 DYSCHROMIA; OTHER 99213 OFFICE VIS/EST PT-LIMITED 11 1 120.00 70.49 50.49 FP 31-JAN-12 94200 BURN NOS TRUNK-UNSPEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.49 55.49 FP 31-JAN-12 V7231 ROUTINE GYN EXAM 99396 PREVENTIVE; EST PT; 40-64 YRS 11 1 163.00 107.43 97.43 FP 30-JAN-12 34690 MIGRAIN, UNSPECIFIED 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 42.02 27.02 FP 10-JAN-12 71941 JOINT PAIN-SHLDER 73030 RADIOLOGIC EXAM,SHOULDER,COMPL 11 1 37.00 20.00 - FP 03-FEB-12 7273 BURSITIS NEC 99211 OFFICE VIS/EST PT-MINIMAL 11 1 34.00 18.98 3.98 DR 31-JAN-12 6929 DERMATITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 115.00 70.49 50.49 FP 08-FEB-12 V7647 SCREEN-NON-MALIGNANT-VAGINA 99395 PREVENTIVE;EST PT;18-39 YRS 11 1 167.00 96.93 86.93 DR 26-SEP-12 07810 VIRAL WARTS 99212 OFFICE OR OTHER OUTPT VISIT 11 1 75.00 41.76 16.76 DR 26-SEP-12 07810 VIRAL WARTS 17110 DESTRUCTION BY ANY METHOD OF F 11 1 220.00 104.05 9.63 IM 28-JUN-12 V7284 PREOPERATIVE EXAMINATION UNSPE 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 15.00 8.70 6.96 PED 10-FEB-12 4619 ACUTE SINUSITIS NOS J0561 INJECTION PCN G BENZ 100000 UN 11 12 96.00 52.44 41.95 PED 10-FEB-12 4619 ACUTE SINUSITIS NOS 87880 STREPTOCOCUS, GROUP A 11 1 50.00 16.99 13.59 PED 10-FEB-12 4619 ACUTE SINUSITIS NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 140.00 104.72 89.72 PED 13-FEB-12 4619 ACUTE SINUSITIS NOS J0561 INJECTION PCN G BENZ 100000 UN 11 12 96.00 52.44 41.95 PED 13-FEB-12 4619 ACUTE SINUSITIS NOS 81000 UA DIPSTIK/TABLET; NON-AUTO W/ 11 1 30.00 4.48 3.58 PED 13-FEB-12 4619 ACUTE SINUSITIS NOS 87086 CULTURE, BACTERIAL, URINE; QUA 11 1 50.00 11.43 9.14 PED 13-FEB-12 4619 ACUTE SINUSITIS NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 140.00 104.72 89.72 AN 24-JAN-12 5569 ULCERATIVE COLITIS UNSPECIFIED 00810 INTESTINAL ENDOSCOPIC PROCED 22 8 704.00 177.60 142.08 AN 24-JAN-12 5569 ULCERATIVE COLITIS UNSPECIFIED 00810 INTESTINAL ENDOSCOPIC PROCED 22 8 376.00 118.40 94.72 IM 11-SEP-12 2410 NONTOX UNINODULAR GOITER 76536 ECHOGRAPHY, SOFT TISSUES OF HE 11 1 120.00 82.13 - FP 30-JAN-12 8472 SPRAIN LUMBAR REGION 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.49 55.49 FP 30-JAN-12 8472 SPRAIN LUMBAR REGION J1885 INJECTION, KETOROLAC TROMETHAM 11 4 40.00 1.04 0.83 FP 24-JAN-12 4619 ACUTE SINUSITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.49 55.49 FP 17-SEP-12 4510 SUPERFIC PHLEBITIS-LEG 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 55.30 IM 17-SEP-12 7295 PAIN IN LIMB 93971 DUPLEX SCAN OF EXTREMITY VEINS 11 1 250.00 137.81 110.25 IM 14-SEP-12 8911 OPEN WND KNEE/LEG-COMPL 99284 ER EXAM;NEW PT;EXTENDED 23 1 578.00 128.06 102.45 DR 29-AUG-12 7020 ACTINIC KERATOSIS 17000 DESTRUCTION BY ANY METHOD, INC 11 1 129.00 78.65 62.92 DR 29-AUG-12 7020 ACTINIC KERATOSIS 99212 OFFICE OR OTHER OUTPT VISIT 11 1 78.00 41.76 16.76 DR 29-AUG-12 7020 ACTINIC KERATOSIS 17003 DESTRUCT.BY ANY METHOD;2ND-14 11 2 100.00 14.62 11.70 FP 21-SEP-12 30403 OPIOID DEPENDENCE-REMISS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 56.24 FP 27-FEB-12 33829 OTHER CHRONIC PAIN 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 230.00 168.77 153.77 FP 29-FEB-12 25000 DIABETES UNCOMPL ADULT 36415 ROUTINE VENIPUNCTURE 11 1 15.00 3.00 2.40 FP 29-FEB-12 2724 HYPERLIPIDEMIA NEC/NOS 83036 HEMOGLOBIN; 81 1 22.50 13.75 11.00 FP 29-FEB-12 2724 HYPERLIPIDEMIA NEC/NOS 80061 LIPID PANEL 81 1 43.00 18.97 15.18 FP 29-FEB-12 2724 HYPERLIPIDEMIA NEC/NOS G0103 PROSTATE CA SCRN (PSA) TOTAL 81 1 43.00 26.06 20.85 FP 29-FEB-12 2724 HYPERLIPIDEMIA NEC/NOS 80050 GENERAL HEALTH PANEL 81 1 219.00 42.00 33.60 FP 29-FEB-12 2724 HYPERLIPIDEMIA NEC/NOS 82306 CALCIFEDIOL (25-OH VITAMIN D-3 81 1 30.00 30.00 24.00 FNSP 23-FEB-12 920 CONTUSION FACE/SCALP/NCK 99284 ER EXAM;NEW PT;EXTENDED 23 1 200.00 128.78 42.54 FP 27-FEB-12 4619 ACUTE SINUSITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.49 55.49 DR 07-MAR-12 6929 DERMATITIS NOS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 126.00 71.69 51.69 MG 24-FEB-12 7840 HEADACHE 99213 OFFICE VIS/EST PT-LIMITED 22 1 124.00 52.87 32.87 FP 16-FEB-12 7862 COUGH 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 70.49 55.49 FP 09-NOV-12 71947 JOINT PAIN-ANKLE 73610 ANKLE, 3 VIEWS 11 1 50.00 22.62 - PED 23-JUL-12 V700 ROUTINE MEDICAL EXAM 99394 PREVENTIVE;EST PT;12-17 YRS 11 1 97.00 97.00 97.00 PED 23-JUL-12 V700 ROUTINE MEDICAL EXAM 92551 SCREENING TEST, PURE TONE, AIR 11 1 12.00 10.79 10.79 PED 23-JUL-12 V700 ROUTINE MEDICAL EXAM 90734 VACCINE;MENINGOCOCAL A,C,Y 11 1 117.00 93.48 93.48 PED 23-JUL-12 V700 ROUTINE MEDICAL EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 12.00 12.00 12.00 PED 23-JUL-12 V700 ROUTINE MEDICAL EXAM 90715 TDAP VACC IND 7 YEARS/OLDER IM 11 1 46.00 41.15 41.15 PED 23-JUL-12 V700 ROUTINE MEDICAL EXAM 90472 EACH ADD'L VACCINE, SINGLE OR 11 1 12.00 12.00 12.00 FP 25-JUL-12 55090 UNILAT INGUINAL HERNIA 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 70.30 55.30 DR 15-AUG-12 2382 UNC BEHAV NEO SKIN 99202 OFFICE VIS/NEW PT-LIMITED 11 1 126.00 71.69 46.69 GS 12-JUL-12 57420 CHOLELITHIASIS NOS 47563 LAPAROSCOPY; SURG; CHOLECYSTEC 22 1 1,376.00 867.56 686.91 FP 05-JUL-12 84200 SPRAIN OF WRIST NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.30 55.30 FP 05-JUL-12 84200 SPRAIN OF WRIST NOS 73100 XRAY EXAM OF WRIST 11 1 56.00 20.88 - FP 05-JUL-12 84200 SPRAIN OF WRIST NOS L3807 WHFO/AIR SUPPRT W/WO THUMB EXT 11 1 30.00 30.00 - FP 02-AUG-12 7821 NONSPECIF SKIN ERUPT NEC 99202 OFFICE VIS/NEW PT-LIMITED 11 1 94.00 - - MG 17-JUL-12 31400 ATTN DEFIC NONHYPERACT 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 120.00 107.88 - FP 26-JUL-12 DEP DEPENDENT NOT ON FILE 99391 PERIODIC PREVENT MED, UNDER 1 11 1 125.00 - - FP 31-JUL-12 DEP DEPENDENT NOT ON FILE 99391 PERIODIC PREVENT MED, UNDER 1 11 1 125.00 - - GS 14-JUN-12 78906 ABDOMINAL PAIN; EPIGASTRIC 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 56.00 - - FP 02-AUG-12 78052 INSOMNIA NEC 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 148.00 104.05 89.05 GS 08-AUG-12 5770 ACUTE PANCREATITIS 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 41.76 16.76 GS 18-JUL-12 2859 ANEMIA NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 45.30 IM 30-JUL-12 4019 HYPERTENSION NOS 99223 INIT HSP VISIT;COMPREHENSIVE 21 1 345.75 208.80 167.04 IM 31-JUL-12 4019 HYPERTENSION NOS 99232 SUBSEQUENT HSP VISIT;LIMITED 21 1 95.00 72.38 57.90 IM 01-AUG-12 4019 HYPERTENSION NOS 99238 HOSPITAL DISCHARGE DAY MANAGEM 21 1 106.25 70.99 56.79 FP 18-AUG-12 31401 ATTN DEFICIT W HYPERACT 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 FP 28-JUN-12 V700 ROUTINE MEDICAL EXAM 99395 PREVENTIVE;EST PT;18-39 YRS 11 1 144.00 113.80 103.80 FP 18-JUN-12 9953 ALLERGY, UNSPECIFIED 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 FP 18-JUN-12 9953 ALLERGY, UNSPECIFIED J1030 INJECTION, METHYLPREDNISOLONE 11 1 12.00 3.10 2.48 FP 18-JUN-12 9953 ALLERGY, UNSPECIFIED J3301 INJECTION TRIAMCINOLONE ACETON 11 1 12.00 1.69 1.35 DR 30-JUL-12 6929 DERMATITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 115.00 70.30 45.30 PSY 01-NOV-12 3099 ADJUSTMENT REACTION NOS 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 PSY 16-OCT-12 30928 ADJ REACT-MIXED EMOTION 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 01-NOV-12 30928 ADJ REACT-MIXED EMOTION 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 FP 10-OCT-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 99284 ER EXAM;NEW PT;EXTENDED 23 1 415.00 128.06 102.45 FP 10-OCT-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 99284 ER EXAM;NEW PT;EXTENDED 23 1 415.00 - - PSY 06-JAN-12 30928 ADJ REACT-MIXED EMOTION 90804 IND PSYCHOTHERAPY, INSIGHT 11 1 100.00 - - PSY 26-MAR-12 3094 ADJ REACT-EMOTION/CONDUC 90804 IND PSYCHOTHERAPY, INSIGHT 11 1 100.00 61.25 49.00 PSY 11-MAY-12 3094 ADJ REACT-EMOTION/CONDUC 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 AN 22-OCT-12 47400 CHRONIC TONSILLITIS 00170 INTRAORAL PROCEDURES 22 9 792.00 189.81 151.85 AN 22-OCT-12 47400 CHRONIC TONSILLITIS 00170 INTRAORAL PROCEDURES 22 9 423.00 126.54 101.23 PSY 19-SEP-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 17-OCT-12 3094 ADJ REACT-EMOTION/CONDUC 90846 FAMILY PSYCHOTHERAPY 11 2 400.00 168.44 134.75 PSY 16-OCT-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 06-JAN-12 3094 ADJ REACT-EMOTION/CONDUC 90804 IND PSYCHOTHERAPY, INSIGHT 11 1 100.00 - - PSY 09-JAN-12 3094 ADJ REACT-EMOTION/CONDUC 90804 IND PSYCHOTHERAPY, INSIGHT 11 1 100.00 - - PSY 20-JAN-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 01-FEB-12 3094 ADJ REACT-EMOTION/CONDUC 90804 IND PSYCHOTHERAPY, INSIGHT 11 3 300.00 - - PSY 27-FEB-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 06-JAN-12 3094 ADJ REACT-EMOTION/CONDUC 90847 FAMILY PSYCHOTHERAPY 11 2 430.00 - - PSY 17-OCT-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 01-NOV-12 3099 ADJUSTMENT REACTION NOS 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 AN 25-JUL-12 7202 SACROILIITIS NEC 27096 INJ PROC FOR SACROILIAC JOINT 22 1 255.00 87.70 - IM 11-OCT-12 53081 ESOPHAGEAL REFLUX 99213 OFFICE VIS/EST PT-LIMITED 11 1 97.00 70.30 55.30 FP 21-JUN-12 34690 MIGRAIN, UNSPECIFIED 99212 OFFICE VIS/EST PT-BRIEF 72 1 90.00 50.11 35.11 FP 21-JUN-12 34690 MIGRAIN, UNSPECIFIED J2550 INJECTION, PROMETHAZINE HCL, U 72 1 2.00 1.74 1.39 FP 21-JUN-12 34690 MIGRAIN, UNSPECIFIED J1885 INJECTION, KETOROLAC TROMETHAM 72 1 5.51 0.26 0.21 FP 09-JUL-12 25000 DIABETES UNCOMPL ADULT 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 137.00 104.05 89.05 FP 29-OCT-12 25000 DIABETES UNCOMPL ADULT 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 137.00 104.05 89.05 DR 12-NOV-12 17372 SQUAMOUS CELL CARC. LOWER LIMB 17262 DESTRUCTION, MALIGNANT LESION, 11 1 326.00 176.09 140.87 FP 24-OCT-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 - - GS 11-OCT-12 2352 UNC BEHAV NEO INTESTINE 43239 ENDOSCOPY UPPER GI W BIOPSY 21 1 708.00 98.83 98.83 GS 12-OCT-12 2352 UNC BEHAV NEO INTESTINE 44204 COLECTOMY, PARTIAL WITH ANASTO 21 1 3,054.00 1,875.72 1,875.72 GS 11-OCT-12 2352 UNC BEHAV NEO INTESTINE 45380 COLONOSCOPY, FLEXIBLE W/BIOPSY 21 1 954.00 151.03 151.03 AN 11-OCT-12 2352 UNC BEHAV NEO INTESTINE 00810 INTESTINAL ENDOSCOPIC PROCED 21 9 768.00 316.35 316.35 MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 110 ROOM&BOARD/PRIVATE 21 1 524.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 200 INTENSIVE CARE 21 3 2,664.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 250 PHARMACY 21 81 3,495.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 255 DRUGS/INCIDENT RAD 21 1 519.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 259 DRUGS/OTHER 21 14 276.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 270 MEDICAL/SURGICAL SUPPLIES 21 39 1,383.00 1,383.00 1,111.99 MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 272 STERILE SUPPLY 21 23 929.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 300 LABORATORY 21 5 407.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 301 LAB/CHEMISTRY 21 13 455.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 305 LAB/HEMATOLOGY 21 2 146.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 309 LAB/OTHER 21 4 56.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 310 LABORATORY PATHOLOGY 21 1 73.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 350 CT SCAN 21 1 2,015.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 360 OPERATING ROOM SERVICES 21 4 3,953.00 3,953.00 3,953.00 MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 370 ANESTHESIA 21 12 609.00 241.22 241.22 MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 410 RESPIRATORY SERVICES 21 1 66.00 - - MG 24-SEP-12 5778 PANCREATIC DISEASE NEC 111 710 RECOVERY ROOM 21 2 1,160.00 - - GS 24-OCT-12 5778 PANCREATIC DISEASE NEC 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 41.76 16.76 GS 25-SEP-12 5778 PANCREATIC DISEASE NEC 44010 DUODENOTOMY, FOR EXPLORATION, 21 1 1,675.00 1,056.18 1,056.18 GS 25-SEP-12 5778 PANCREATIC DISEASE NEC 49560 REP HERNIA VENTRAL 21 1 1,435.00 445.09 445.09 GS 25-SEP-12 5778 PANCREATIC DISEASE NEC 64680 INJECTION TREATMENT OF NERVE 21 1 500.00 89.79 89.79 MG 23-OCT-12 311 DEPRESSIVE DISORDER NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 56.24 IM 12-SEP-12 V0481 VACC/INOC AGAINST INFLUENZA 90656 FLU VIR VAC SPLIT PF 3 YR AGE& 11 1 19.00 - - IM 12-SEP-12 V0481 VACC/INOC AGAINST INFLUENZA 90472 EACH ADD'L VACCINE, SINGLE OR 11 1 17.00 - - FP 10-NOV-12 V700 ROUTINE MEDICAL EXAM 99384 PREVENTIVE; NEW PT; 12-17 YRS 11 1 204.00 132.24 132.24 FP 10-NOV-12 31401 ATTN DEFICIT W HYPERACT 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 140.00 104.05 89.05 DR 12-OCT-12 7048 HAIR DISEASES NEC 99212 OFFICE VIS/EST PT-BRIEF 11 1 75.00 41.76 16.76 PED 17-OCT-12 6929 DERMATITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 - - PA 18-NOV-12 6202 OVARIAN CYST NEC/NOS 99284 ER EXAM;NEW PT;EXTENDED 23 1 415.00 128.06 102.45 PSY 09-OCT-12 30000 ANXIETY STATE NOS 90801 PSYCHIATRIC DX INTERVIEW/EXAM 11 1 200.00 151.73 121.38 FP 25-OCT-12 2749 GOUT NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 74.00 41.76 26.76 FP 25-OCT-12 2749 GOUT NOS J1030 INJECTION, METHYLPREDNISOLONE 11 1 8.00 3.10 - DR 19-NOV-12 7020 ACTINIC KERATOSIS 17000 DESTRUCTION LESION FACE 11 1 129.00 39.33 6.03 DR 19-NOV-12 7020 ACTINIC KERATOSIS 99212 OFFICE OR OTHER OUTPT VISIT 11 1 78.00 41.76 16.76 DR 19-NOV-12 7020 ACTINIC KERATOSIS 17110 DESTRUCTION BY ANY METHOD OF F 11 1 157.00 104.05 83.24 FP 15-OCT-12 V0481 VACC/INOC AGAINST INFLUENZA Q2038 FLU VACC SPLIT 3 YRS & > IM FL 11 1 15.00 13.31 13.31 FP 15-OCT-12 V0481 VACC/INOC AGAINST INFLUENZA 90471 IMMUNIZATION ADMINISTRATION 11 1 10.00 10.00 10.00 FP 15-OCT-12 78720 DYSPHAGIA, UNSPECIFIED 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.30 55.30 PSY 05-OCT-12 29632 RECURR DEPR PSYCHOS-MOD 90862 RX MANAGEMENT;INCLUDING PRESCR 53 1 47.00 45.24 20.24 FNSP 22-OCT-12 41401 CORONARY ATHEROSCLEROSIS; CORO 99213 OFFICE VIS/EST PT-LIMITED 11 1 88.00 70.30 45.30 FP 25-OCT-12 72611 CALCIF TENDINITIS SHLDER 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.30 55.30 FP 25-OCT-12 72611 CALCIF TENDINITIS SHLDER 73030 RADIOLOGIC EXAM,SHOULDER,COMPL 11 1 73.00 19.14 - FP 25-OCT-12 72611 CALCIF TENDINITIS SHLDER J1040 INJECTION, METHYLPREDNISOLONE 11 1 20.00 7.09 - DR 12-OCT-12 7020 ACTINIC KERATOSIS 99212 OFFICE VIS/EST PT-BRIEF 22 1 48.27 27.14 2.14 DR 31-OCT-12 70219 OTHER SEBORRHEIC KERATOSIS 99212 OFFICE OR OTHER OUTPT VISIT 11 1 100.00 41.76 16.76 DR 31-OCT-12 70219 OTHER SEBORRHEIC KERATOSIS 17311 MOHS 1 STAGE H/N/HF/G 11 1 1,300.00 666.42 533.14 DR 31-OCT-12 70219 OTHER SEBORRHEIC KERATOSIS 17312 MOHS ADDL STAGE 11 2 1,500.00 780.22 624.18 DR 31-OCT-12 70219 OTHER SEBORRHEIC KERATOSIS 13132 REPAIR, COMPLEX, FOREHEAD, CHE 11 1 1,100.00 303.63 242.90 PA 17-OCT-12 7061 ACNE NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 45.30 IM 18-OCT-12 V700 ROUTINE MEDICAL EXAM 99396 PREVENTIVE; EST PT; 40-64 YRS 11 1 185.00 122.84 122.84 FP 10-OCT-12 4619 ACUTE SINUSITIS NOS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 97.00 71.69 56.69 FP 17-OCT-12 4619 ACUTE SINUSITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 50.00 41.76 26.76 FP 08-OCT-12 3829 OTITIS MEDIA NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 50.00 41.76 26.76 FP 17-OCT-12 4619 ACUTE SINUSITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 50.00 41.76 26.76 FP 19-NOV-12 7291 MYALGIA AND MYOSITIS NOS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 20 1 159.00 107.88 82.88 FP 19-NOV-12 7291 MYALGIA AND MYOSITIS NOS 73060 RADIOLOGIC EXAMINATION; HUMERU 20 1 218.00 19.14 15.31 FNSP 15-NOV-12 29690 AFFECTIVE PSYCHOSIS NOS 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 50.10 50.10 35.10 AN 18-OCT-12 650 NORMAL DELIVERY 01967 NEURAXIAL LABOR ANALG/ANESTH F 21 13 2,175.00 456.95 365.56 PED 19-OCT-12 V3000 SINGLE LIVEBORN 99460 INIT NB EM PER DAY HOSP 21 1 123.00 95.00 76.00 PED 20-OCT-12 V3000 SINGLE LIVEBORN 99238 HOSPITAL DISCHARGE DAY MANAGEM 21 1 110.00 70.99 56.79 PED 23-OCT-12 DEP DEPENDENT NOT ON FILE 99213 OFFICE VIS/EST PT-LIMITED 11 1 110.00 - - FP 11-OCT-12 2724 HYPERLIPIDEMIA NEC/NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.30 55.30 DR 09-OCT-12 2382 UNC BEHAV NEO SKIN 11401 EXCISION, BENIGN LESION, EXCEP 11 1 302.00 148.25 118.60 PSY 24-OCT-12 30021 AGORAPHOBIA WITH PANIC 99205 OFFICE VIS/NEW PT-COMPREHENSIV 11 1 275.00 207.06 85.39 IM 11-OCT-12 30001 PANIC DISORDER 99283 ER EXAM;NEW PT;INTERMEDIATE 23 1 371.00 66.12 52.90 PED 19-NOV-12 V0481 VACC/INOC AGAINST INFLUENZA 90655 FLU VIR VAC SPLIT PF 6-35 MO A 11 1 40.00 15.71 15.71 PED 19-NOV-12 V0481 VACC/INOC AGAINST INFLUENZA 90471 IMMUNIZATION ADMINISTRATION 11 1 25.00 12.00 12.00 PED 19-NOV-12 V0481 VACC/INOC AGAINST INFLUENZA 90660 INFLU VIRUS VAC,LIVE, NASAL 11 1 40.00 22.32 22.32 PED 19-NOV-12 V0481 VACC/INOC AGAINST INFLUENZA 90473 IMMU ADMN INTRANASAL/ORAL; 1 V 11 1 30.00 12.00 12.00 FP 12-NOV-12 7962 ELEV BL PRES W/O HYPERTN 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.30 55.30 DR 04-OCT-12 6961 OTHER PSORIASIS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 185.00 71.69 46.69 FP 25-OCT-12 4556 HEMORRHOIDS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 60.00 41.76 26.76 FP 19-MAR-12 4779 ALLERGIC RHINITIS NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 134.00 104.05 89.05 GS 13-FEB-12 5609 INTESTINAL OBSTRUCT NOS 99211 OFFICE VIS/EST PT-MINIMAL 11 1 34.00 18.98 - AN 08-MAR-12 57510 CHOLECYSTITIS,UNSPECIFIED 00790 UPPER ABDOMEN 22 1 809.10 - - FP 06-MAR-12 8470 SPRAIN OF NECK 98925 OMT 1-2 BODY REGIONS 11 1 55.00 30.62 24.50 MG 20-AUG-12 490 BRONCHITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 45.30 MG 20-AUG-12 490 BRONCHITIS NOS J1040 INJECTION, METHYLPREDNISOLONE 11 1 30.00 7.09 - PSY 26-JUL-12 30002 GENERALIZED ANXIETY DIS 90801 PSYCHIATRIC DX INTERVIEW/EXAM 11 1 250.00 151.73 - PSY 09-AUG-12 30002 GENERALIZED ANXIETY DIS 99215 OFFICE VIS/EST PT-COMPREHENSIV 11 1 170.00 140.59 53.86 GS 18-JUL-12 79380 ABNORMAL MAMMOGRAM 99213 OFFICE VIS/EST PT-LIMITED 11 1 87.00 70.30 45.30 IM 13-AUG-12 6271 POSTMENOPAUSAL BLEEDING 76856 ULTRASOUND, PELVIC(NON-OBSTEST 11 1 150.00 80.74 64.59 GS 13-JUL-12 4548 VAR. VEINS LEG/OTHER COMPLICAT 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 45.30 GS 13-JUL-12 4548 VAR. VEINS LEG/OTHER COMPLICAT 93971 DUPLEX SCAN OF EXTREMITY VEINS 11 1 250.00 137.81 - DR 17-AUG-12 7014 KELOID SCAR 99213 OFFICE VIS/EST PT-LIMITED 11 1 114.00 70.30 45.30 AN 12-JUL-12 57420 CHOLELITHIASIS NOS 00790 UPPER ABDOMEN 22 13 701.22 274.17 219.34 GS 12-JUL-12 57410 CHOLELITH W CHOLECYS NEC 47563 LAPAROSCOPY; SURG; CHOLECYSTEC 22 1 3,150.00 867.56 598.55 IM 06-AUG-12 5920 CALCULUS OF KIDNEY 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 210.00 104.05 89.05 PED 30-JUL-12 V068 VAC-DIS COMBINATIONS NEC 90698 DTAP-HIB-IPV FOR INTRAMUSCULAR 11 1 120.00 85.69 85.69 PED 30-JUL-12 V068 VAC-DIS COMBINATIONS NEC 90460 IMM ADMIN THRU 18 VIA ANY RTE 11 1 31.00 12.00 12.00 PED 30-JUL-12 V068 VAC-DIS COMBINATIONS NEC 90633 HEPATITIS A VACCINE,PEDIATRIC 11 1 48.00 23.94 23.94 PED 30-JUL-12 V068 VAC-DIS COMBINATIONS NEC 90460 IMM ADMIN THRU 18 VIA ANY RTE 11 1 21.00 12.00 12.00 PED 30-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 115.00 102.31 102.31 PED 30-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL TESTING 11 1 40.00 8.13 8.13 FP 23-JUL-12 30000 ANXIETY STATE NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 88.00 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 85018 BLOOD COUNT; HEMOGLOBIN 11 1 19.25 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90716 IMMUNIZATION;VARICELLA(CHICKEN 11 1 100.00 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 12.00 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90633 HEPATITIS A VACCINE,PEDIATRIC 11 1 38.00 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90472 EACH ADD'L VACCINE, SINGLE OR 11 1 12.00 - - IM 13-AUG-12 7804 DIZZINESS AND GIDDINESS 93880 DUPLEX SCAN OF EXTRACRANIAL AR 11 1 300.00 220.63 176.50 GS 16-JUL-12 55321 INCISIONAL HERNIA 49656 LAP INC HERNIA REPAIR RECUR 22 1 950.00 875.22 560.43 AN 16-JUL-12 55321 INCISIONAL HERNIA 00752 LUMBAR AND VENTRAL HERNIAS 22 9 928.00 316.35 253.08 GS 10-JUL-12 55320 VENTRAL HERNIA NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 45.30 FP 19-JUL-12 78659 CHEST PAIN NEC 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 50.11 35.11 FP 14-AUG-12 78901 ABDOMINAL PAIN; RT UPPER QUAD 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 84.36 69.36 FP 14-AUG-12 78901 ABDOMINAL PAIN; RT UPPER QUAD 86318 IMMUNOASSAY INFECT AGENT ANTIB 72 1 58.00 18.34 - FP 08-AUG-12 71590 OSTEOARTHROS NOS-UNSPEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 55.30 PED 17-JUL-12 6800 CARBUNCLE OF FACE 99212 OFFICE VIS/EST PT-BRIEF 11 1 39.00 - - PED 11-JUL-12 6809 CARBUNCLE NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 39.00 - - PED 13-JUL-12 6809 CARBUNCLE NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 39.00 - - OSTEO 04-JUL-12 69272 ACUTE DERMATITIIS DUE TO SOLAR 99202 OFFICE VIS/NEW PT-LIMITED 11 1 108.00 108.00 108.00 OSTEO 04-JUL-12 69272 ACUTE DERMATITIIS DUE TO SOLAR J1100 INJECTION, DEXAMETHOSONE SODIU 11 1 16.00 2.00 2.00 OSTEO 04-JUL-12 69272 ACUTE DERMATITIIS DUE TO SOLAR J1030 INJECTION, METHYLPREDNISOLONE 11 1 25.00 25.00 25.00 OSTEO 04-JUL-12 69272 ACUTE DERMATITIIS DUE TO SOLAR 96375 TX/PRO/DX INJ NEW DRUG ADDON 11 1 12.00 12.00 12.00 PSY 30-JUL-12 29630 RECURR DEPR PSYCHOS-UNSP 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 70.00 57.42 32.42 PA 01-AUG-12 7220 CERVICAL DISC DISPLACMNT 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 185.00 107.88 82.88 AN 09-JUL-12 5920 CALCULUS OF KIDNEY 00873 LITHOTRYPSY; W/OUT WATER BATH 22 10 539.40 210.90 168.72 AN 09-JUL-12 5920 CALCULUS OF KIDNEY 00873 LITHOTRYPSY; W/OUT WATER BATH 22 10 330.60 140.60 112.48 FP 15-AUG-12 78659 CHEST PAIN NEC 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 84.36 69.36 FP 17-AUG-12 78650 CHEST PAIN NOS 93306 TTE W/DOPPLER COMPLETE 11 1 1,640.00 190.70 - FP 17-AUG-12 78650 CHEST PAIN NOS 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 300.00 167.39 152.39 FP 17-AUG-12 78650 CHEST PAIN NOS 93000 ELECTROCARDIOGRAM, WITH INTERP 11 1 80.00 18.79 - FP 27-JUL-12 4011 BENIGN HYPERTENSION 99213 OFFICE VIS/EST PT-LIMITED 11 1 98.00 70.30 55.30 PSY 13-JUN-12 29650 BIPOLAR AFF, DEPR-UNSPEC 99222 INIT HSP VISIT;INTERMEDIATE 21 1 235.00 144.07 144.07 FP 05-JUL-12 2724 HYPERLIPIDEMIA NEC/NOS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 151.00 107.88 92.88 AN 18-JUL-12 71887 JT DERANGEMENT NEC-ANKLE 01464 ARTHROSCOPIC PROCEDURES ANKLE 22 1 528.00 - - FP 25-JUL-12 4011 BENIGN HYPERTENSION 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.30 55.30 DR 10-JUL-12 7821 NONSPECIF SKIN ERUPT NEC 11100 BIOPSY OF SKIN, SUBCUTANEOUS T 11 1 212.00 101.27 81.02 DR 10-JUL-12 7821 NONSPECIF SKIN ERUPT NEC 99212 OFFICE OR OTHER OUTPT VISIT 11 1 78.00 41.76 16.76 FP 31-JUL-12 6961 OTHER PSORIASIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 55.30 DR 10-JUL-12 6970 LICHEN PLANUS 88305 LEVEL IV - SURGICAL PATHOLOGY, 11 1 200.00 95.00 76.00 GS 15-OCT-12 99812 HEMATOMA COMPLICATING PROCEDUR 99234 OBSERVATION OR INPT HOSP CARE 22 1 272.00 142.33 113.86 GS 18-JUN-12 V1272 PERSONAL HIST COLONIC POLYPS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 115.00 71.69 51.69 DR 03-OCT-12 2167 BENIGN NEO SKIN LEG 88305 LEVEL IV - SURGICAL PATHOLOGY, 81 1 130.00 95.00 95.00 GS 22-OCT-12 55320 VENTRAL HERNIA NOS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 146.00 107.88 82.88 FP 26-OCT-12 78650 CHEST PAIN NOS 99283 ER EXAM;NEW PT;INTERMEDIATE 23 1 136.00 66.12 52.90 FP 07-DEC-12 490 BRONCHITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.30 55.30 PED 16-NOV-12 DEP DEPENDENT NOT ON FILE 99213 OFFICE VIS/EST PT-LIMITED 11 1 110.00 - - DR 13-DEC-12 6953 ROSACEA 99213 OFFICE VIS/EST PT-LIMITED 11 1 115.00 70.30 45.30 PED 19-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 172.00 102.66 102.66 PED 19-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL SCREENING W/INTP 11 1 87.00 8.13 8.13 PED 19-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 90655 FLU VIR VAC SPLIT PF 6-35 MO A 11 1 47.00 15.71 15.71 PED 19-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 90460 IMM ADMIN THRU 18 VIA ANY RTE 11 1 47.00 12.00 12.00 FP 07-DEC-12 53550 UNSPEC GASTRITIS & GASTRODUOD 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 130.00 107.88 92.88 GS 24-OCT-12 55320 VENTRAL HERNIA NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 41.76 16.76 PSY 17-DEC-12 30002 GENERALIZED ANXIETY DIS 99215 OFFICE VIS/EST PT-COMPREHENSIV 11 1 250.00 140.59 112.47 FP 20-NOV-12 28850 LEUKOCYTOSIS, UNSPECIFIED 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 104.05 89.05 FP 07-DEC-12 4778 ALLERGIC RHINITIS NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.30 55.30 FP 07-NOV-12 2724 HYPERLIPIDEMIA NEC/NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.30 55.30 FP 07-NOV-12 2724 HYPERLIPIDEMIA NEC/NOS 36415 ROUTINE VENIPUNCTURE 11 1 15.00 3.00 - IM 20-NOV-12 4011 BENIGN HYPERTENSION 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 25.00 8.70 - AN 02-NOV-12 72402 SPINAL STENOSIS-LUMBAR 00670 EXTENSIVE SPINE/SPINAL CORD 21 25 1,200.00 527.25 527.25 AN 02-NOV-12 72402 SPINAL STENOSIS-LUMBAR 36620 ARTERIAL CATHETERIZATION OR CA 21 1 151.00 57.42 57.42 PSY 26-NOV-12 30002 GENERALIZED ANXIETY DIS 99215 OFFICE VIS/EST PT-COMPREHENSIV 11 1 170.00 140.59 112.47 IM 25-OCT-12 6100 SOLITARY CYST OF BREAST 76645 ECHOGRAPHY,BREAST - TECH COMP 11 1 150.00 62.29 49.83 GS 03-DEC-12 61172 LUMP OR MASS IN BREAST 99203 OFFICE VIS/NEW PT-INTERMEDIATE 22 1 163.00 82.13 57.13 FP 22-JUN-12 30981 PROLONG POSTTRAUM STRESS 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 50.11 35.11 PA 03-JUL-12 60882 HEMATOSPERMIA 99212 OFFICE VIS/EST PT-BRIEF 11 1 106.00 41.76 16.76 PA 03-JUL-12 60882 HEMATOSPERMIA 81003 URINALYSIS, BY DIP STICK OR TA 11 1 5.75 3.18 - IM 19-JUN-12 78907 OTHER SYMPTOMS INVOLVING ABDOM 76705 ECHOGRAPHY, ABDOMINAL, B-SCAN 11 1 150.00 99.18 99.18 GS 06-JUL-12 72743 GANGLION NOS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 150.00 107.88 82.88 PSY 22-JUN-12 29632 RECURR DEPR PSYCHOS-MOD 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 125.00 104.05 58.63 PSY 11-JUL-12 29632 RECURR DEPR PSYCHOS-MOD 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 125.00 104.05 - FP 08-JUN-12 4011 BENIGN HYPERTENSION 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 - - FP 18-JUN-12 9953 ALLERGY, UNSPECIFIED 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 - - FP 18-JUN-12 9953 ALLERGY, UNSPECIFIED J1030 INJECTION, METHYLPREDNISOLONE 11 1 12.00 - - FP 18-JUN-12 9953 ALLERGY, UNSPECIFIED J3301 INJECTION TRIAMCINOLONE ACETON 11 1 12.00 - - DR 27-JUN-12 7061 ACNE NEC 99212 OFFICE VIS/EST PT-BRIEF 11 1 62.00 41.76 21.76 AN 07-JUN-12 7242 LUMBAGO 99214 OFFICE VIS/EST PT-INTERMEDIATE 22 1 218.00 80.39 60.39 AN 22-JUN-12 7246 DISORDERS OF SACRUM 27096 INJ PROC FOR SACROILIAC JOINT 22 1 255.00 87.70 87.70 AN 11-JUL-12 7242 LUMBAGO 99214 OFFICE VIS/EST PT-INTERMEDIATE 22 1 218.00 80.39 55.39 AN 14-JUN-12 78701 NAUSEA WITH VOMITING 00740 UPPER GASTROINTESTINAL ENDOSCO 22 7 525.00 147.63 118.10 GS 05-JUL-12 61189 OTHER SPEC DISORDER OF BREAST 99212 OFFICE VIS/EST PT-BRIEF 11 1 75.00 41.76 16.76 FP 21-JUN-12 34690 MIGRAIN, UNSPECIFIED J2550 INJECTION, PROMETHAZINE HCL, U 72 1 2.00 - - FP 21-JUN-12 34690 MIGRAIN, UNSPECIFIED J1885 INJECTION, KETOROLAC TROMETHAM 72 1 5.51 - - FP 21-JUN-12 34690 MIGRAIN, UNSPECIFIED 96372 THER/PROPH/DIAG INJ SC/IM 72 2 90.00 - - FNSP 29-OCT-12 5990 URIN TRACT INFECTION NOS 99212 OFFICE OR OTHER OUTPT VISIT 11 1 61.00 41.76 26.76 FNSP 29-OCT-12 5990 URIN TRACT INFECTION NOS 81002 URINALYSIS BY DIPSTICK OR TABL 11 1 5.00 3.33 2.66 FNSP 05-OCT-12 3051 TOBACCO USE DISORDER 99202 OFFICE VIS/NEW PT-LIMITED 11 1 105.00 71.69 56.69 FP 15-NOV-12 7821 NONSPECIF SKIN ERUPT NEC 99284 ER EXAM;NEW PT;EXTENDED 22 1 175.00 128.06 72.17 FP 01-NOV-12 49392 ASTHMA, UNSPECIFIED; 99213 OFFICE VIS/EST PT-LIMITED 11 1 175.00 70.30 55.30 FP 01-NOV-12 49392 ASTHMA, UNSPECIFIED; A7003 ADMIN SET, W/SMALL VOLUME NONF 11 1 15.00 2.11 - FP 01-NOV-12 49392 ASTHMA, UNSPECIFIED; J7611 ALBUTEROL INHALATION SOL 11 1 5.00 0.11 - FP 01-NOV-12 49392 ASTHMA, UNSPECIFIED; J7620 ALBUTEROL, UP TO 2.5MG AND IPR 11 1 5.00 0.28 - FP 01-NOV-12 49392 ASTHMA, UNSPECIFIED; A7016 DOME/MOUTHPIECE USE W/SM VOL U 11 1 15.00 6.54 - MG 19-OCT-12 71949 JOINT PAIN-MULT JTS 86140 C-REACTIVE PROTEIN 81 1 20.00 7.33 5.86 MG 19-OCT-12 71949 JOINT PAIN-MULT JTS 85651 SEDIMENTATION RATE ERYTHROCYTE 81 1 13.00 5.02 4.02 MG 19-OCT-12 71949 JOINT PAIN-MULT JTS 84550 URIC ACID; BLOOD, CHEMICAL 81 1 16.00 6.40 5.12 PSY 28-SEP-12 29680 MANIC-DEPRESSIVE NOS 90862 RX MANAGEMENT;INCLUDING PRESCR 53 1 50.00 45.24 20.24 IM 05-SEP-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 124.00 70.30 55.30 GS 25-OCT-12 78906 ABDOMINAL PAIN; EPIGASTRIC 99213 OFFICE VIS/EST PT-LIMITED 11 1 120.00 70.30 45.30 FNSP 15-NOV-12 4619 ACUTE SINUSITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 87.00 70.30 55.30 DR 09-OCT-12 2165 BENIGN NEO SKIN TRUNK 88305 LEVEL IV - SURGICAL PATHOLOGY, 11 1 200.00 95.00 76.00 GS 01-NOV-12 5780 HEMATEMESIS 43239 UPPER GASTROINTESTINAL ENDOSCO 22 1 643.00 197.66 158.13 PSY 08-OCT-12 29632 RECURR DEPR PSYCHOS-MOD 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 125.00 104.05 - AN 03-JUL-12 2113 BENIGN NEOPLASM LG BOWEL 00810 INTESTINAL ENDOSCOPIC PROCED 24 7 455.00 147.63 118.10 GS 07-NOV-12 11284 CANDIDAL ESOPHAFITIS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 72 1 131.00 107.88 82.88 GS 01-NOV-12 78703 VOMITING ALONE 99225 SUBSEQUENT OBSERVATION CARE 22 1 98.00 72.04 57.63 FP 23-OCT-12 42789 CARDIAC DYSRHYTHMIAS NEC 99231 SUBSEQUENT HSP VISIT;BRIEF 21 3 321.00 120.06 120.06 FP 26-OCT-12 42789 CARDIAC DYSRHYTHMIAS NEC 99239 HOSPITAL DISCHARGE 30 MINUTES+ 21 1 225.00 105.79 105.79 FP 22-OCT-12 42789 CARDIAC DYSRHYTHMIAS NEC 99222 INIT HSP VISIT;INTERMEDIATE 21 1 249.00 144.07 144.07 IM 16-NOV-12 2449 HYPOTHYROIDISM NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 125.00 70.30 55.30 IM 16-NOV-12 2449 HYPOTHYROIDISM NOS G8553 AT LEAST ONE RX CREATED DURING 11 1 0.01 - - AN 04-OCT-12 99812 HEMATOMA COMPLICATING PROCEDUR 00160 PROCEDURES ON NOSE/SINUSES 22 8 664.00 281.20 224.96 AN 01-NOV-12 4279 CARDIAC DYSRHYTHMIA NOS 00537 ANE/CARDIAC ELECTROPHYSIOLOGIC 22 1 2,520.00 2,347.50 2,089.21 PA 14-NOV-12 42741 VENTRICULAR FIBRILLATION 93282 ICD DEVICE PROG EVAL 1 SNGL 11 1 115.00 94.86 94.86 MG 14-NOV-12 4279 CARDIAC DYSRHYTHMIA NOS 93016 CARDIOVASC STRESS TREADMILL 22 1 125.00 48.26 48.26 MG 14-NOV-12 4279 CARDIAC DYSRHYTHMIA NOS 93018 CARDIOVASCULAR STRESS TEST USI 22 1 120.00 31.23 31.23 PSY 19-NOV-12 29680 MANIC-DEPRESSIVE NOS 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 112.00 57.42 32.42 PSY 19-NOV-12 29680 MANIC-DEPRESSIVE NOS G8553 AT LEAST ONE RX CREATED DURING 11 1 - - - PA 22-OCT-12 7140 RHEUMATOID ARTHRITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 130.00 70.30 45.30 PA 22-OCT-12 7140 RHEUMATOID ARTHRITIS 80053 COMPREHENSIVE METABOLIC PANEL 81 1 13.00 - - IM 08-SEP-12 4111 INTERMED CORONARY SYND 99222 INIT HSP VISIT;INTERMEDIATE 21 1 182.00 144.07 144.07 FP 27-JUN-12 78903 ABDOMINAL PAIN; RT LOW QUAD 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 210.00 107.88 92.88 MG 27-JUN-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 85025 BLOOD COUNT; HEMOGRAM AND PLAT 81 1 31.00 11.02 8.82 MG 27-JUN-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 80053 COMPREHENSIVE METABOLIC PANEL 81 1 51.00 14.97 11.98 IM 03-JUL-12 5920 CALCULUS OF KIDNEY 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 65.80 8.70 6.96 FP 05-JUL-12 34690 MIGRAIN, UNSPECIFIED 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 84.36 69.36 IM 12-JUN-12 3009 NEUROTIC DISORDER NOS 99285 ER EXAM;NEW PT;COMPREHENSIVE 23 1 506.00 186.18 186.18 PED 23-MAY-12 38200 AC SUPP OTITIS MEDIA NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 39.00 39.00 24.00 FP 12-JUN-12 311 DEPRESSIVE DISORDER NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.30 55.30 FP 12-JUN-12 311 DEPRESSIVE DISORDER NEC 36415 ROUTINE VENIPUNCTURE 11 1 10.00 3.00 - FP 12-JUN-12 311 DEPRESSIVE DISORDER NEC G8553 AT LEAST ONE RX CREATED DURING 11 1 0.01 - - DR 12-JUN-12 70219 OTHER SEBORRHEIC KERATOSIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 130.00 70.30 50.30 DR 12-JUN-12 70219 OTHER SEBORRHEIC KERATOSIS 11100 BIOPSY OF SKIN, SUBCUTANEOUS T 11 1 195.00 101.27 81.02 FP 10-MAY-12 71941 JOINT PAIN-SHLDER 99213 OFFICE VIS/EST PT-LIMITED 11 1 105.00 70.30 55.30 AN 22-MAY-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 22 1 245.00 82.13 62.13 GS 07-JUN-12 78906 ABDOMINAL PAIN; EPIGASTRIC 43235 UPPER GASTROINTESTINAL ENDOSCO 22 1 627.00 168.78 168.78 GS 04-JUN-12 78703 VOMITING ALONE 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 50.30 PED 15-JUN-12 31400 ATTN DEFIC NONHYPERACT 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 135.00 104.05 89.05 PED 16-MAR-12 V202 ROUTINE CHILD HEALTH EXAM 99383 PREVENTIVE; NEW PT; 5-11 YRS 11 1 161.00 115.54 115.54 PED 16-MAR-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL TESTING 11 1 35.00 8.13 8.13 PED 16-MAR-12 V202 ROUTINE CHILD HEALTH EXAM 92551 SCREENING TEST, PURE TONE, AIR 11 1 15.00 10.79 10.79 PED 14-APR-12 31400 ATTN DEFIC NONHYPERACT 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 135.00 104.05 89.05 PED 15-MAY-12 31400 ATTN DEFIC NONHYPERACT 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 135.00 104.05 89.05 PED 04-JUN-12 37311 HORDEOLUM EXTERNUM 99213 OFFICE VIS/EST PT-LIMITED 11 1 96.00 70.30 55.30 DR 04-JUN-12 7020 ACTINIC KERATOSIS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 22 1 132.00 82.13 62.13 IM 09-MAY-12 35571 CAUSALGIA OF LOWER LIMB 95905 MOTOR/SENS NRVE CONDUCT TEST 11 2 460.00 118.32 118.32 GS 19-SEP-12 78901 ABDOMINAL PAIN; RT UPPER QUAD 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 225.00 167.39 142.39 AN 04-SEP-12 56400 CONSTIPATION, UNSPECIFIED 00810 INTESTINAL ENDOSCOPIC PROCED 22 8 600.00 168.72 134.98 AN 23-AUG-12 7242 LUMBAGO 99214 OFFICE VIS/EST PT-INTERMEDIATE 22 1 218.00 80.39 55.39 AN 07-SEP-12 7244 LUMBOSACRAL NEURITIS NOS 64483 LUMBAR OR SACRAL, SINGLE LEVEL 22 1 343.00 117.62 94.10 AN 07-SEP-12 7244 LUMBOSACRAL NEURITIS NOS 64484 LUMBAR OR SACRAL, SINGLE LEVEL 22 1 230.00 56.38 45.10 PED 14-JUN-12 59972 HEMATURIA/MICROSCOPIC 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 232.00 167.39 152.39 PED 14-JUN-12 59972 HEMATURIA/MICROSCOPIC 80048 BASIC METABOLIC PANEL 11 1 55.00 11.98 9.58 PED 14-JUN-12 59972 HEMATURIA/MICROSCOPIC 85025 BLOOD COUNT; HEMOGRAM AND PLAT 11 1 40.00 11.02 8.82 PED 14-JUN-12 59972 HEMATURIA/MICROSCOPIC 81001 URINALYSIS, AUTOMATED 11 1 18.00 4.48 3.58 FP 19-AUG-12 78831 URGE INCONTINENCE 85025 BLOOD COUNT; HEMOGRAM AND PLAT 81 1 18.50 - - FP 19-AUG-12 78831 URGE INCONTINENCE 80053 COMPREHENSIVE METABOLIC PANEL 81 1 161.00 - - FP 19-AUG-12 78831 URGE INCONTINENCE 81015 URINALYSIS; MICROSCOPIC ONLY 81 1 7.50 - - FP 19-AUG-12 78831 URGE INCONTINENCE 87086 CULTURE, BACTERIAL, URINE; QUA 81 1 19.00 - - FP 19-AUG-12 78831 URGE INCONTINENCE 87491 IAD;CHLAMYDIA TRACHOMATIS,AMPL 81 1 208.00 - - FP 19-AUG-12 78831 URGE INCONTINENCE 87591 NEISSERIA GONORRHOEAE 81 1 208.00 - - FP 22-MAY-12 33829 OTHER CHRONIC PAIN 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 55.30 FP 07-SEP-12 2722 MIXED HYPERLIPIDEMIA 36415 ROUTINE VENIPUNCTURE 11 1 10.00 3.00 - IM 07-SEP-12 78904 ABDOMINAL PAIN - LEFT LOWER QU 76856 ULTRASOUND, PELVIC(NON-OBSTEST 11 1 150.00 80.74 - MG 12-SEP-12 7244 LUMBOSACRAL NEURITIS NOS L0627 LUMB ORTHOS RIGD A&P PANL PREF 12 1 400.00 312.16 249.73 PSY 21-AUG-12 3149 HYPERKINETIC SYND NOS 90805 IND PSYCHOTHERAPY W/MED EVALU 22 1 214.00 - - PSY 10-SEP-12 29630 RECURR DEPR PSYCHOS-UNSP 96101 PSYCHOLOGICAL TESTING, PER HR 11 4 280.00 280.00 224.00 PSY 10-SEP-12 29630 RECURR DEPR PSYCHOS-UNSP 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 70.00 57.42 32.42 FP 30-AUG-12 78791 DIARRHEA 99213 OFFICE VIS/EST PT-LIMITED 11 1 87.00 70.30 55.30 FP 13-SEP-12 31400 ATTN DEFIC NONHYPERACT 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 FP 04-SEP-12 7802 SYNCOPE AND COLLAPSE 99213 OFFICE VIS/EST PT-LIMITED 11 1 115.00 70.30 55.30 FP 09-SEP-12 92410 CONTUSION OF LOWER LEG 29515 APPLICATION OF SHORT LEG SPLIN 22 1 160.00 53.94 - PSY 31-AUG-12 29632 RECURR DEPR PSYCHOS-MOD 90801 PSYCHIATRIC DX INTERVIEW/EXAM 53 1 170.00 124.24 86.77 IM 07-SEP-12 41401 CORONARY ATHEROSCLEROSIS; CORO 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 16.98 8.70 - DR 13-SEP-12 07810 VIRAL WARTS 17110 DESTRUCTION BY ANY METHOD OF F 11 1 220.00 104.05 - DR 13-SEP-12 07810 VIRAL WARTS 99213 OFFICE VIS/EST PT-LIMITED 11 1 115.00 70.30 45.30 GS 14-AUG-12 61172 LUMP OR MASS IN BREAST 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 165.00 107.88 82.88 DR 29-AUG-12 7020 ACTINIC KERATOSIS 17000 DESTRUCTION BY ANY METHOD, INC 11 1 129.00 78.65 - DR 29-AUG-12 7020 ACTINIC KERATOSIS 99212 OFFICE OR OTHER OUTPT VISIT 11 2 78.00 78.00 53.00 DR 29-AUG-12 7020 ACTINIC KERATOSIS 17003 DESTRUCT.BY ANY METHOD;2ND-14 11 1 50.00 7.31 - DR 29-AUG-12 7020 ACTINIC KERATOSIS 17000 DESTRUCTION BY ANY METHOD, INC 11 1 129.00 - - DR 29-AUG-12 7020 ACTINIC KERATOSIS 99212 OFFICE OR OTHER OUTPT VISIT 11 1 78.00 - - DR 29-AUG-12 7020 ACTINIC KERATOSIS 17003 DESTRUCT.BY ANY METHOD;2ND-14 11 2 100.00 - - FP 23-NOV-12 463 ACUTE TONSILLITIS 99212 OFFICE VIS/EST PT-BRIEF 72 1 63.00 41.76 26.76 FNSP 11-DEC-12 4619 ACUTE SINUSITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 70.30 55.30 AN 05-DEC-12 5206 TOOTH ERUPTION DISTURB 00170 INTRAORAL PROCEDURES 22 11 590.50 231.99 128.23 AN 05-DEC-12 5206 TOOTH ERUPTION DISTURB 00170 INTRAORAL PROCEDURES 22 11 590.50 154.66 154.66 PSY 03-DEC-12 3149 HYPERKINETIC SYND NOS 90805 IND PSYCHOTHERAPY W/MED EVALU 22 1 214.00 - - IM 06-DEC-12 78605 SHORTNESS OF BREATH 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 25.00 8.70 6.96 PA 13-DEC-12 7020 ACTINIC KERATOSIS 17000 DESTRUCTION BY ANY METHOD, INC 22 1 220.23 57.42 - PA 13-DEC-12 7020 ACTINIC KERATOSIS 99212 OFFICE OR OTHER OUTPT VISIT 22 1 48.27 27.14 2.14 PA 13-DEC-12 7020 ACTINIC KERATOSIS 17003 DESTRUCT.BY ANY METHOD;2ND-14 22 1 17.44 4.87 - FNSP 17-SEP-12 29690 AFFECTIVE PSYCHOSIS NOS 90801 PSYCHIATRIC DX INTERVIEW/EXAM 11 1 250.00 151.73 121.38 PSY 29-AUG-12 311 DEPRESSIVE DISORDER NEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 50.10 50.10 25.10 PSY 01-NOV-12 311 DEPRESSIVE DISORDER NEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 50.10 50.10 25.10 FP 07-DEC-12 6260 ABSENCE OF MENSTRUATION 99213 OFFICE VIS/EST PT-LIMITED 11 1 98.00 - - IM 29-NOV-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 NSP 28-DEC-12 34690 MIGRAIN, UNSPECIFIED 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 145.00 107.88 82.88 PED 06-DEC-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 128.00 102.66 102.66 PED 06-DEC-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL SCREENING W/INTP 11 1 32.00 8.13 8.13 PED 06-DEC-12 V202 ROUTINE CHILD HEALTH EXAM 90657 INFLUENZA VIRUS VACCINE,SPLIT 11 1 14.00 6.65 6.65 PED 06-DEC-12 V202 ROUTINE CHILD HEALTH EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 33.00 12.00 12.00 FP 11-DEC-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 87.00 70.30 55.30 PED 06-DEC-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 128.00 102.66 102.66 PED 06-DEC-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL SCREENING W/INTP 11 1 32.00 8.13 8.13 PED 06-DEC-12 V202 ROUTINE CHILD HEALTH EXAM 90658 INFLUENZA VIRUS VACCINE,SPLIT 11 1 14.00 11.37 11.37 PED 06-DEC-12 V202 ROUTINE CHILD HEALTH EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 33.00 12.00 12.00 GS 31-DEC-12 72884 DIASTASIS OF MUSCLE 99202 OFFICE VIS/NEW PT-LIMITED 11 1 100.00 71.69 46.69 PSY 30-NOV-12 30002 GENERALIZED ANXIETY DIS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 110.00 104.05 83.24 AN 12-NOV-12 79093 ELEVATED PROSTATE SPECIFIC ANT 00902 ANORECTAL PROCEDURE 22 8 600.00 168.72 134.98 AN 12-NOV-12 79093 ELEVATED PROSTATE SPECIFIC ANT 00910 TRANSURETHRAL PROCEDURES NES 22 6 405.00 84.36 67.49 PED 31-MAY-12 NB NEWBORN PENDING ELIGIBILITY 99460 INIT NB EM PER DAY HOSP 21 1 103.00 - - PED 01-JUN-12 NB NEWBORN PENDING ELIGIBILITY 99238 HOSPITAL DISCHARGE DAY MANAGEM 21 1 95.00 - - PSY 29-MAY-12 30001 PANIC DISORDER 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 125.00 104.05 83.24 FNSP 19-NOV-12 30400 OPIOID DEPENDENCE-UNSPEC 90801 PSYCHIATRIC DX INTERVIEW/EXAM 11 1 250.00 151.73 - FP 27-NOV-12 4619 ACUTE SINUSITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 71.00 41.76 26.76 FP 27-NOV-12 4619 ACUTE SINUSITIS NOS J1040 INJECTION, METHYLPREDNISOLONE 11 1 20.00 7.09 - FP 27-NOV-12 4619 ACUTE SINUSITIS NOS J0696 INJECTION, CEFTRIAXONE SODIUM, 11 4 40.00 3.56 - DR 18-DEC-12 2165 BENIGN NEO SKIN TRUNK 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 210.00 104.05 79.05 DR 18-DEC-12 2165 BENIGN NEO SKIN TRUNK 11100 BIOPSY OF SKIN, SUBCUTANEOUS T 11 1 255.00 101.27 101.27 PED 02-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 123.00 102.66 102.66 PED 02-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 90700 IMMUNIZATION,ACTIVE;DIPTHERIA, 11 1 23.00 17.11 17.11 PED 02-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 90647 HEMOPHILUS INFLUENZA B VACCINE 11 1 25.00 20.37 20.37 PED 02-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 90670 PNEUMOCOCCAL CONJUGATE VACCINE 11 1 140.40 129.28 129.28 PED 02-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 12.00 12.00 12.00 PED 02-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 90657 INFLUENZA VIRUS VACCINE,SPLIT 11 1 18.23 6.65 6.65 PED 02-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 90472 EACH ADD'L VACCINE, SINGLE OR 11 1 12.00 12.00 12.00 PED 02-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 123.00 102.66 102.66 PED 02-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 90658 INFLUENZA VIRUS VACCINE,SPLIT 11 1 19.73 11.37 11.37 PED 02-NOV-12 V202 ROUTINE CHILD HEALTH EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 12.00 12.00 12.00 DR 15-AUG-12 2165 BENIGN NEO SKIN TRUNK 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 210.00 104.05 79.05 PED 05-DEC-12 38870 OTALGIA NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 88.00 70.30 55.30 PED 05-DEC-12 38870 OTALGIA NOS 90657 INFLUENZA VIRUS VACCINE,SPLIT 11 1 25.00 6.65 6.65 PED 05-DEC-12 38870 OTALGIA NOS 90460 IMM ADMIN THRU 18 VIA ANY RTE 11 1 31.00 12.00 12.00 PED 05-DEC-12 920 CONTUSION FACE/SCALP/NCK 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 130.00 104.05 89.05 PED 05-DEC-12 920 CONTUSION FACE/SCALP/NCK 90658 INFLUENZA VIRUS VACCINE,SPLIT 11 1 25.00 11.37 11.37 PED 05-DEC-12 920 CONTUSION FACE/SCALP/NCK 90460 IMM ADMIN THRU 18 VIA ANY RTE 11 1 31.00 12.00 12.00 PED 05-DEC-12 9100 ABRASION HEAD 99213 OFFICE VIS/EST PT-LIMITED 11 1 88.00 70.30 55.30 PED 05-DEC-12 9100 ABRASION HEAD 90658 INFLUENZA VIRUS VACCINE,SPLIT 11 1 25.00 11.37 11.37 PED 05-DEC-12 9100 ABRASION HEAD 90460 IMM ADMIN THRU 18 VIA ANY RTE 11 1 31.00 12.00 12.00 IM 01-OCT-12 V0481 VACC/INOC AGAINST INFLUENZA 90656 FLU VIR VAC SPLIT PF 3 YR AGE& 11 1 19.00 12.38 12.38 IM 01-OCT-12 V0481 VACC/INOC AGAINST INFLUENZA 90471 IMMUNIZATION ADMINISTRATION 11 1 17.00 12.00 12.00 FP 16-NOV-12 2550 CUSHING'S SYNDROME 99202 OFFICE VIS/NEW PT-LIMITED 22 1 96.00 51.85 36.85 GS 10-DEC-12 4548 VAR. VEINS LEG/OTHER COMPLICAT 99212 OFFICE VIS/EST PT-BRIEF 11 1 65.00 41.76 16.76 DR 06-JUN-12 7061 ACNE NEC 17110 DESTRUCTION BY ANY METHOD OF F 11 1 315.00 104.05 104.05 FP 10-DEC-12 78079 OTHER MALAISE AND FATIGUE 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 120.00 104.05 89.05 FP 10-DEC-12 78079 OTHER MALAISE AND FATIGUE 90471 IMMUNIZATION ADMINISTRATION 11 1 20.00 12.00 12.00 FP 10-DEC-12 78079 OTHER MALAISE AND FATIGUE 90736 ZOSTER(SHINGLES)VACCINE, LIVE 11 1 180.00 174.42 174.42 FP 31-DEC-12 7140 RHEUMATOID ARTHRITIS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 120.00 104.05 89.05 FP 31-DEC-12 7140 RHEUMATOID ARTHRITIS J1020 INJECTION, METHYLPREDNISOLONE 11 1 10.00 3.12 - FP 31-DEC-12 7140 RHEUMATOID ARTHRITIS 96372 THER/PROPH/DIAG INJ SC/IM 11 1 20.00 20.00 - FP 31-DEC-12 7140 RHEUMATOID ARTHRITIS 85651 SEDIMENTATION RATE ERYTHROCYTE 11 1 25.00 5.02 - DR 28-FEB-12 69010 SEBORRHEIC DERMATITIS, UNSPEC 99212 OFFICE VIS/EST PT-BRIEF 11 1 100.00 42.02 22.02 PSY 12-MAR-12 29662 BIPOLAR AFFEC, MIXED-MOD 90805 IND PSYCHOTHERAPY W/MED EVALU 11 1 150.00 71.69 57.35 PSY 12-MAR-12 311 DEPRESSIVE DISORDER NEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 50.10 50.10 30.10 MG 09-JAN-12 3518 FACIAL NERVE DIS NEC 99205 OFFICE VIS/NEW PT-COMPREHENSIV 22 1 352.00 176.91 156.91 DR 03-JAN-12 6983 LICHENIFICATION 99202 OFFICE VIS/NEW PT-LIMITED 11 1 126.00 72.52 52.52 PSY 09-JAN-12 311 DEPRESSIVE DISORDER NEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 50.10 50.10 30.10 GS 04-JAN-12 V4589 PRESENCE OF NEUROPACMAKER OR 99212 OFFICE VIS/EST PT-BRIEF 11 1 52.00 42.02 22.02 FP 14-SEP-12 7862 COUGH 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 104.05 89.05 FP 23-FEB-12 83400 DISL FINGER NOS-CLOSED 99202 OFFICE VIS/NEW PT-LIMITED 20 1 127.00 72.52 57.52 FP 23-FEB-12 83400 DISL FINGER NOS-CLOSED 29130 APPLICATION OF FINGER SPLINT; 20 1 72.00 42.36 18.52 FP 23-FEB-12 83400 DISL FINGER NOS-CLOSED 73140 RAD EXAM, FINGERS 2 VIEWS 20 2 184.00 62.36 49.89 FP 29-FEB-12 5289 ORAL SOFT TISSUE DIS NEC 99212 OFFICE VIS/EST PT-BRIEF 11 1 60.00 42.02 27.02 DR 19-MAR-12 6929 DERMATITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 75.00 41.76 21.76 AN 22-AUG-12 7452 TETRALOGY OF FALLOT 01926 INTRACRANIAL, INTRACARDIAC AOR 22 1 3,510.00 1,417.00 1,417.00 PED 08-OCT-12 V202 ROUTINE CHILD HEALTH EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 118.00 102.31 102.31 PSY 30-APR-12 29662 BIPOLAR AFFEC, MIXED-MOD 80101 DRUG, SCREEN; 11 9 315.00 177.48 141.98 PSY 30-APR-12 29662 BIPOLAR AFFEC, MIXED-MOD 82055 ALCOHOL (ETHANOL); 11 1 75.00 14.01 11.21 PSY 30-APR-12 29651 BIPOLAR AFFEC, DEPR-MILD 90805 IND PSYCHOTHERAPY W/MED EVALU 11 1 150.00 71.69 57.35 GS 25-JAN-12 7856 ENLARGEMENT LYMPH NODES 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 204.00 168.77 148.77 GS 02-FEB-12 7856 ENLARGEMENT LYMPH NODES 38500 BIOPSY OR EXCISION OF LYMPH NO 22 1 610.00 299.93 299.93 IM 10-JAN-12 7842 SWELLING IN HEAD NECK 76881 US XTR NON-VASC COMPLETE 11 1 150.00 79.64 79.64 PED 08-OCT-12 V202 ROUTINE CHILD HEALTH EXAM 99394 PREVENTIVE;EST PT;12-17 YRS 11 1 129.00 111.36 111.36 PED 08-OCT-12 V202 ROUTINE CHILD HEALTH EXAM 85025 BLOOD COUNT; HEMOGRAM AND PLAT 11 1 27.00 11.02 11.02 PED 08-OCT-12 V059 VACCIN FOR SINGL DIS NOS 90471 IMMUNIZATION ADMINISTRATION 11 1 30.00 12.00 12.00 PED 08-OCT-12 V059 VACCIN FOR SINGL DIS NOS 90658 INFLUENZA VIRUS VACCINE,SPLIT 11 1 24.00 11.37 11.37 FP 03-APR-12 7260 ADHESIVE CAPSULIT SHLDER 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 32.36 17.36 FP 15-MAY-12 7831 ABNORMAL WEIGHT GAIN 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 FP 11-DEC-12 6829 CELLULITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 58.00 41.76 26.76 GS 18-APR-12 7062 SEBACEOUS CYST 99202 OFFICE VIS/NEW PT-LIMITED 11 1 89.00 71.69 51.69 FP 21-APR-12 78909 ABDOMINAL PAIN OTHER SPEC SITE 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 137.00 104.05 89.05 FP 21-APR-12 78909 ABDOMINAL PAIN OTHER SPEC SITE 81002 URINALYSIS BY DIPSTICK OR TABL 11 1 6.00 3.33 2.66 FP 12-MAY-12 7828 CHANGES IN SKIN TEXTURE 99213 OFFICE VIS/EST PT-LIMITED 11 1 80.00 70.30 55.30 AN 26-JAN-12 5920 CALCULUS OF KIDNEY 00910 TRANSURETHRAL PROCEDURES NES 22 6 450.00 133.20 106.56 DR 30-JAN-12 07810 VIRAL WARTS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 165.00 108.79 88.79 DR 30-JAN-12 07810 VIRAL WARTS 17110 DESTRUCTION BY ANY METHOD OF F 11 1 138.00 107.09 85.67 IM 30-JAN-12 53085 BARRET'S ESOPHAGUS 99213 OFFICE VIS/EST PT-LIMITED 11 1 67.00 67.00 52.00 GS 03-JAN-12 4548 VAR. VEINS LEG/OTHER COMPLICAT 36475 ENDOVENOUS ABLATION THERAPY OF 22 1 4,600.00 235.03 188.02 GS 03-JAN-12 4548 VAR. VEINS LEG/OTHER COMPLICAT 37765 STAB PHLEBECT VV 1 EXT; 10-20 22 1 1,100.00 582.23 465.78 GS 03-JAN-12 4548 VAR. VEINS LEG/OTHER COMPLICAT 36470 INJECTION OF SCLEROSING SOLUTI 22 1 300.00 87.44 69.95 PED 06-FEB-12 V202 ROUTINE CHILD HEALTH EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 115.00 88.79 88.79 PED 25-JAN-12 4659 ACUTE URI NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.49 55.49 GS 09-JAN-12 53081 ESOPHAGEAL REFLUX 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 131.00 104.72 84.72 GS 06-FEB-12 25000 DIABETES UNCOMPL ADULT 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 131.00 104.72 84.72 AN 18-JAN-12 V5869 LONG TERM(CURRENT) USE OTH MED 80101 DRUG, SCREEN; 22 12 960.00 236.64 236.64 AN 18-JAN-12 7295 PAIN IN LIMB 99203 OFFICE VIS/NEW PT-INTERMEDIATE 22 1 200.00 82.69 62.69 PED 16-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 99391 PERIODIC PREVENT MED, UNDER 1 11 1 78.00 78.00 78.00 PED 16-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 90744 HEPATITIS B VACCINE IMMUNIZATI 11 1 21.00 21.00 21.00 PED 16-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 12.00 12.00 12.00 PED 16-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 90655 FLU VIR VAC SPLIT PF 6-35 MO A 11 1 18.23 15.71 15.71 PED 16-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 90698 DTAP-HIB-IPV FOR INTRAMUSCULAR 11 1 82.20 82.20 82.20 PED 16-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 90472 EACH ADD'L VACCINE, SINGLE OR 11 1 12.00 12.00 12.00 PED 16-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 90670 PNEUMOCOCCAL CONJUGATE VACCINE 11 1 140.40 129.28 129.28 PED 16-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 90680 ROTAVIRUS VACCINE,PENTAVALENT 11 1 92.00 74.24 74.24 AN 22-OCT-12 59972 HEMATURIA/MICROSCOPIC 00910 TRANSURETHRAL PROCEDURES NES 22 6 287.25 84.36 67.49 AN 22-OCT-12 59972 HEMATURIA/MICROSCOPIC 00910 TRANSURETHRAL PROCEDURES NES 22 6 287.25 126.54 101.23 PA 14-NOV-12 4271 PAROX VENTRIC TACHYCARD 99213 OFFICE VIS/EST PT-LIMITED 11 1 146.00 121.79 121.79 IM 14-NOV-12 79431 ABNORM ELECTROCARDIOGRAM 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 30.00 17.09 17.09 FP 08-NOV-12 6869 LOCAL SKIN INFECTION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 100.00 85.00 FP 08-NOV-12 6869 LOCAL SKIN INFECTION NOS 36415 ROUTINE VENIPUNCTURE 11 1 15.00 3.00 - FP 07-NOV-12 78079 OTHER MALAISE AND FATIGUE 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 104.05 89.05 IM 12-NOV-12 57450 CALCULUS OF BILE DUCT W/O CHOL 00740 UPPER GASTROINTESTINAL ENDOSCO 22 1 747.00 - - GS 07-DEC-12 1542 MALIG NEOPL ANAL CANAL 99212 OFFICE OR OTHER OUTPT VISIT 11 1 65.00 41.76 16.76 GS 07-DEC-12 1542 MALIG NEOPL ANAL CANAL 46600 ANOSCOPY; DIAGNOSTIC (SEPARATE 11 1 150.00 83.17 83.17 AN 11-DEC-12 53010 ESOPHAGITIS, UNSPECIFIED 00740 UPPER GASTROINTESTINAL ENDOSCO 22 6 450.00 126.54 101.23 IM 10-DEC-12 4019 HYPERTENSION NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 202.48 104.05 89.05 PSY 12-DEC-12 30928 ADJ REACT-MIXED EMOTION 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 06-DEC-12 3094 ADJ REACT-EMOTION/CONDUC 90846 FAMILY PSYCHOTHERAPY 11 1 215.00 - - PSY 06-DEC-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 19-DEC-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 22-AUG-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 28-NOV-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 DR 11-DEC-12 1101 DERMATOPHYTOSIS OF NAIL 99213 OFFICE VIS/EST PT-LIMITED 11 1 130.00 70.30 45.30 PA 30-NOV-12 4659 ACUTE URI NOS 99213 OFFICE VIS/EST PT-LIMITED 20 1 124.00 70.30 45.30 PA 30-NOV-12 4659 ACUTE URI NOS 87880 STREPTOCOCUS, GROUP A 20 1 47.00 16.99 - FP 14-DEC-12 5990 URIN TRACT INFECTION NOS 87086 CULTURE, BACTERIAL, URINE; QUA 81 1 19.00 11.43 - FP 14-DEC-12 5990 URIN TRACT INFECTION NOS 87186 SENSITIVITY STUDIES, ANTIBIOTI 81 1 19.33 12.25 - FP 14-DEC-12 5990 URIN TRACT INFECTION NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 20 1 184.00 104.05 79.05 FP 14-DEC-12 5990 URIN TRACT INFECTION NOS 81003 URINALYSIS, BY DIP STICK OR TA 20 1 13.00 3.18 - FP 14-DEC-12 5990 URIN TRACT INFECTION NOS 81025 URINE PREGNANCY TEST, BY VISUA 20 1 22.00 8.96 - GS 20-NOV-12 5771 CHRONIC PANCREATITIS 99243 CONSULTATION; EXTENDED 22 1 415.00 332.00 317.00 GS 20-DEC-12 5771 CHRONIC PANCREATITIS 43235 UPPER GASTROINTESTINAL ENDOSCO 22 1 761.00 168.78 168.78 GS 20-DEC-12 5771 CHRONIC PANCREATITIS 99238 HOSPITAL DISCHARGE DAY MANAGEM 22 1 219.00 70.99 70.99 FP 18-DEC-12 31400 ATTN DEFIC NONHYPERACT 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 55.30 FP 29-NOV-12 7840 HEADACHE 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 10.00 10.00 GS 13-DEC-12 5758 DIS OF GALLBLADDER NEC 47562 LAPAROSCOPY; CHOLECYSTECTOMY 22 1 3,474.00 899.93 719.94 GS 13-DEC-12 5758 DIS OF GALLBLADDER NEC 47001 BIPSY OF LIVER, W OTH MAJOR PR 22 1 580.00 128.76 103.01 FP 16-JUL-12 33829 OTHER CHRONIC PAIN 99214 OFFICE VIS/EST PT-INTERMEDIATE 72 1 125.00 104.05 89.05 FP 12-JAN-12 V7231 ROUTINE GYN EXAM 99396 PREVENTIVE; EST PT; 40-64 YRS 72 1 137.00 128.92 118.92 FP 12-JAN-12 V7231 ROUTINE GYN EXAM 82270 BLOOD; OCCULT, FECES, SCREENIN 72 1 24.00 4.61 3.69 FP 12-JAN-12 V7231 ROUTINE GYN EXAM 86580 SKIN TEST; TUBERCULOSIS, INTRA 72 1 13.00 9.35 7.48 IM 04-FEB-12 78650 CHEST PAIN NOS 99220 INIT OBSERV;PER DAY;HIGH SEVER 22 1 212.00 159.96 127.97 IM 05-FEB-12 78650 CHEST PAIN NOS 99217 OBSERVATION CARE DISCHARGE 22 1 95.00 72.52 58.02 FP 14-FEB-12 4011 BENIGN HYPERTENSION 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.49 55.49 GS 07-DEC-12 5693 RECTAL ANAL HEMORRHAGE 99202 OFFICE VIS/NEW PT-LIMITED 11 1 115.00 71.69 46.69 FP 28-NOV-12 7881 DYSURIA 81002 URINALYSIS BY DIPSTICK OR TABL 11 1 5.00 3.33 2.66 FNSP 05-DEC-12 78079 OTHER MALAISE AND FATIGUE 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 PA 19-OCT-12 71651 POLYARTHRITIS NOS-SHLDER 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 300.00 167.39 142.39 PA 19-OCT-12 71651 POLYARTHRITIS NOS-SHLDER 20610 ARTHROCENTESIS, ASPIRATION AND 11 1 150.00 73.08 58.46 PA 19-OCT-12 71651 POLYARTHRITIS NOS-SHLDER J1040 INJECTION, METHYLPREDNISOLONE 11 1 40.00 7.09 5.67 PA 19-OCT-12 71651 POLYARTHRITIS NOS-SHLDER 84550 URIC ACID; BLOOD, CHEMICAL 81 1 13.00 - - PA 19-OCT-12 71651 POLYARTHRITIS NOS-SHLDER 20610 ARTHROCENTESIS, ASPIRATION AND 11 1 150.00 36.54 29.23 PA 06-NOV-12 71654 POLYARTHRITIS NOS-HAND 99213 OFFICE VIS/EST PT-LIMITED 11 1 130.00 70.30 45.30 PA 06-NOV-12 71654 POLYARTHRITIS NOS-HAND 36415 ROUTINE VENIPUNCTURE 11 1 13.00 3.00 2.40 PA 19-NOV-12 6960 PSORIATIC ARTHROPATHY 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 210.00 104.05 79.05 FNSP 16-NOV-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B G0008 ADMINISTRATION OF INFLUENZA VI 11 1 5.00 5.00 5.00 FNSP 16-NOV-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B Q2038 FLU VACC SPLIT 3 YRS & > IM FL 11 1 10.00 10.00 10.00 FP 23-NOV-12 3559 MONONEURITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 63.00 41.76 26.76 FNSP 16-NOV-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B G0008 ADMINISTRATION OF INFLUENZA VI 11 1 5.00 5.00 5.00 FNSP 16-NOV-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B Q2038 FLU VACC SPLIT 3 YRS & > IM FL 11 1 10.00 10.00 10.00 PSY 09-NOV-12 3149 HYPERKINETIC SYND NOS 90805 IND PSYCHOTHERAPY W/MED EVALU 22 1 214.00 - - PSY 29-NOV-12 30000 ANXIETY STATE NOS 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 105.00 57.42 32.42 AN 09-NOV-12 V252 STERILIZATION 00921 VASECTOMY, UNILATERAL/BILATERA 22 9 675.00 189.81 151.85 PSY 04-DEC-12 29651 BIPOLAR AFFEC, DEPR-MILD 90805 IND PSYCHOTHERAPY W/MED EVALU 11 1 150.00 71.69 29.27 PSY 26-NOV-12 311 DEPRESSIVE DISORDER NEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 50.10 50.10 25.10 PSY 25-JUL-12 311 DEPRESSIVE DISORDER NEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 50.10 50.10 25.10 FP 07-NOV-12 6260 ABSENCE OF MENSTRUATION 99213 OFFICE VIS/EST PT-LIMITED 11 1 98.00 - - FP 14-NOV-12 8470 SPRAIN OF NECK 98926 OMT 3-4 BODY REGIONS 22 1 77.00 35.50 - FP 14-NOV-12 8470 SPRAIN OF NECK 97124 MASSAGE,INC EFFLEURAGE PETRI 22 1 46.00 23.66 - FP 16-NOV-12 7840 HEADACHE 99213 OFFICE VIS/EST PT-LIMITED 11 1 98.00 - - FP 16-NOV-12 7840 HEADACHE J1885 INJECTION, KETOROLAC TROMETHAM 11 4 44.00 - - FP 16-NOV-12 7840 HEADACHE 96372 THER/PROPH/DIAG INJ SC/IM 11 1 44.00 - - IM 15-NOV-12 78650 CHEST PAIN NOS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 22 1 146.00 82.13 67.13 IM 27-NOV-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 IM 09-DEC-12 DEP DEPENDENT NOT ON FILE 93010 ELECTROCARDIOGRAM,INTERP & REP 21 1 46.00 - - FP 04-JUN-12 4619 ACUTE SINUSITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 71.00 41.76 26.76 FP 04-JUN-12 4619 ACUTE SINUSITIS NOS G8553 AT LEAST ONE RX CREATED DURING 11 1 0.01 - - FP 04-JUN-12 4619 ACUTE SINUSITIS NOS J1040 INJECTION, METHYLPREDNISOLONE 11 1 20.00 7.09 5.67 FP 04-JUN-12 4619 ACUTE SINUSITIS NOS J0696 INJECTION, CEFTRIAXONE SODIUM, 11 4 40.00 3.56 2.85 GS 13-JUN-12 57410 CHOLELITH W CHOLECYS NEC 99202 OFFICE VIS/NEW PT-LIMITED 11 1 115.00 71.69 51.69 GS 07-MAR-12 43310 OCCULSION/STENOSIS CAROTID ARE 35301 THROMBOENDARTERECTOMY, WITH OR 21 1 2,139.00 1,428.89 1,428.89 PSY 06-MAR-12 29661 BIPOLAR AFF, MIXED-MILD 90805 IND PSYCHOTHERAPY W/MED EVALU 11 1 150.00 71.69 - IM 05-JAN-12 78651 PRECORDIAL PAIN 99232 SUBSEQUENT HSP VISIT;LIMITED 21 2 210.00 - - PED 13-JUN-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 113.00 102.66 102.66 PED 13-JUN-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL TESTING 11 1 40.00 8.13 8.13 PED 11-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 113.00 66.89 66.89 PED 11-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 12.00 12.00 12.00 PED 11-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 90472 EACH ADD'L VACCINE, SINGLE OR 11 4 48.00 48.00 48.00 PED 11-JAN-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL TESTING 11 1 40.00 5.73 5.73 PSY 29-MAY-12 29636 RECUR DEPR PSYC-FULL REM 99205 OFFICE VIS/NEW PT-COMPREHENSIV 11 1 250.00 207.06 165.65 GS 14-JUN-12 53081 ESOPHAGEAL REFLUX 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 131.00 104.05 84.05 FNSP 10-FEB-12 34690 MIGRAIN, UNSPECIFIED 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 150.00 108.79 93.79 PED 28-FEB-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 99222 INIT HSP VISIT;INTERMEDIATE 21 1 235.00 144.03 115.22 AN 27-FEB-12 4555 EXT HEMRRHOID W COMP NEC 00810 INTESTINAL ENDOSCOPIC PROCED 22 7 525.00 155.40 124.32 GS 17-MAY-12 61172 LUMP OR MASS IN BREAST 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 50.30 GS 11-JUN-12 61172 LUMP OR MASS IN BREAST 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 230.00 167.39 147.39 GS 11-JUN-12 61172 LUMP OR MASS IN BREAST G8427 WRITTEN PROV DOC CURR MEDS VER 11 1 - - - FP 13-JUN-12 71946 JOINT PAIN-L/LEG 73565 RAD EXAM, KNEE; 11 1 41.00 23.32 18.66 FP 29-MAR-12 4660 ACUTE BRONCHITIS 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 50.11 35.11 FP 19-APR-12 4019 HYPERTENSION NOS 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 50.11 35.11 AN 27-JUL-12 3540 CARPAL TUNNEL SYNDROME 01710 NERVES,MUSCLES,TENDONS,FASCIA 22 6 345.00 126.54 101.23 DR 01-MAR-12 69010 SEBORRHEIC DERMATITIS, UNSPEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 130.00 70.30 50.30 DR 01-MAR-12 69010 SEBORRHEIC DERMATITIS, UNSPEC 17000 DESTRUCTION LESION FACE 11 1 145.00 39.33 31.46 DR 01-MAR-12 69010 SEBORRHEIC DERMATITIS, UNSPEC 17003 DESTRUCT.BY ANY METHOD;2ND-14 11 4 140.00 29.24 23.39 DR 01-MAR-12 69010 SEBORRHEIC DERMATITIS, UNSPEC 11100 BIOPSY OF SKIN 11 1 195.00 101.27 81.02 DR 01-MAR-12 70219 OTHER SEBORRHEIC KERATOSIS 88305 LEVEL IV - SURGICAL PATHOLOGY, 11 1 200.00 95.00 76.00 GS 22-FEB-12 2409 GOITER NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 42.02 22.02 MG 14-FEB-12 59970 HEMATURIA, UNSPECIFIED 81001 URINALYSIS, AUTOMATED 81 1 7.00 4.48 3.58 MG 14-FEB-12 59970 HEMATURIA, UNSPECIFIED 81025 URINE PREGNANCY TEST, BY VISUA 81 1 12.00 8.96 7.17 MG 14-FEB-12 59970 HEMATURIA, UNSPECIFIED 87086 CULTURE, BACTERIAL, URINE; QUA 81 1 25.00 11.43 9.14 MG 22-FEB-12 59970 HEMATURIA, UNSPECIFIED 81001 URINALYSIS, AUTOMATED 81 1 7.00 4.48 3.58 FP 14-FEB-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 111.00 104.72 89.72 FP 22-FEB-12 5920 CALCULUS OF KIDNEY 99213 OFFICE VIS/EST PT-LIMITED 11 1 82.00 70.49 55.49 PED 10-FEB-12 V202 ROUTINE CHILD HEALTH EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 147.00 88.79 88.79 PED 10-FEB-12 V202 ROUTINE CHILD HEALTH EXAM 92587 EVOKED OTOACOUSTIC EMISSIONS 11 1 55.00 35.58 35.58 PED 10-FEB-12 V202 ROUTINE CHILD HEALTH EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 130.00 88.79 88.79 PED 10-FEB-12 V202 ROUTINE CHILD HEALTH EXAM 92587 EVOKED OTOACOUSTIC EMISSIONS 11 1 55.00 35.58 35.58 PED 10-FEB-12 V202 ROUTINE CHILD HEALTH EXAM 92015 DETERMINATION OF REFRACTIVE ST 11 1 45.00 - - PED 10-FEB-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL TESTING 11 1 20.00 8.13 8.13 DR 01-AUG-12 6953 ROSACEA 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.30 45.30 DR 01-AUG-12 7062 SEBACEOUS CYST 99202 OFFICE VIS/NEW PT-LIMITED 11 1 126.00 71.69 46.69 GS 13-JUL-12 61172 LUMP OR MASS IN BREAST 19120 EXCISION OF CYST, FIBROADENOMA 22 1 800.00 480.24 204.19 GS 13-JUL-12 61172 LUMP OR MASS IN BREAST 11426 EXC BEN LES SCALP HANDS OVER 4 22 1 657.00 155.56 124.45 GS 23-JUL-12 5531 UMBILICAL HERNIA 99213 OFFICE VIS/EST PT-LIMITED 11 1 114.00 70.30 45.30 FP 25-MAY-12 7242 LUMBAGO 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 137.00 104.05 89.05 FP 12-JUL-12 7242 LUMBAGO 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 91.00 91.00 76.00 AN 19-JUN-12 65681 FET/PLAC PROB NEC-DELIV 01967 NEURAXIAL LABOR ANALG/ANESTH F 21 7 560.00 246.05 196.84 PED 19-JUL-12 V700 ROUTINE MEDICAL EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 88.00 88.00 88.00 PED 19-JUL-12 V700 ROUTINE MEDICAL EXAM 92551 SCREENING TEST, PURE TONE, AIR 11 1 12.00 10.79 10.79 FNSP 05-OCT-12 71949 JOINT PAIN-MULT JTS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 105.00 71.69 56.69 FNSP 05-OCT-12 71949 JOINT PAIN-MULT JTS 90658 INFLUENZA VIRUS VACCINE,SPLIT 11 1 35.00 11.37 11.37 FNSP 05-OCT-12 71949 JOINT PAIN-MULT JTS 90471 IMMUNIZATION ADMINISTRATION 11 1 38.00 12.00 12.00 FNSP 28-SEP-12 7089 URTICARIA NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 GS 11-JUL-12 5693 RECTAL ANAL HEMORRHAGE 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 131.00 107.88 82.88 GS 26-JUL-12 5693 RECTAL ANAL HEMORRHAGE 45385 COLONOSCOPY, FIBEROPTIC, BEYON 22 1 1,006.00 359.14 133.10 GS 08-AUG-12 2113 BENIGN NEOPLASM LG BOWEL 99212 OFFICE VIS/EST PT-BRIEF 11 1 52.00 41.76 16.76 FP 18-JUL-12 30403 OPIOID DEPENDENCE-REMISS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 MG 14-AUG-12 7242 LUMBAGO 131 72100 SPINE, RADIOLOGICAL EXAM 22 1 248.00 22.97 - PSY 21-JUN-12 311 DEPRESSIVE DISORDER NEC 99221 INITIAL HOSP VISIT;BRIEF 21 1 200.00 107.88 107.88 PSY 22-JUN-12 311 DEPRESSIVE DISORDER NEC 99232 SUBSEQUENT HSP VISIT;LIMITED 21 1 100.00 72.38 72.38 PSY 23-JUN-12 311 DEPRESSIVE DISORDER NEC 99231 SUBSEQUENT HSP VISIT;BRIEF 21 1 75.00 40.02 40.02 PSY 24-JUN-12 311 DEPRESSIVE DISORDER NEC 99231 SUBSEQUENT HSP VISIT;BRIEF 21 1 75.00 40.02 40.02 PSY 25-JUN-12 311 DEPRESSIVE DISORDER NEC 99231 SUBSEQUENT HSP VISIT;BRIEF 21 1 75.00 40.02 40.02 PSY 26-JUN-12 311 DEPRESSIVE DISORDER NEC 99239 HOSPITAL DISCHARGE 30 MINUTES+ 21 1 150.00 105.79 105.79 FNSP 14-AUG-12 7242 LUMBAGO 99213 OFFICE VIS/EST PT-LIMITED 72 1 100.00 84.36 69.36 GS 19-SEP-12 56949 RECTAL ANAL DIS NEC 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 41.76 16.76 AN 18-JUL-12 V1271 PEPTIC ULCER DISEASES 00740 UPPER GASTROINTESTINAL ENDOSCO 24 8 520.00 168.72 134.98 PSY 27-JUL-12 29680 MANIC-DEPRESSIVE NOS 90801 PSYCHIATRIC DX INTERVIEW/EXAM 53 1 225.00 124.24 99.39 PSY 17-AUG-12 29680 MANIC-DEPRESSIVE NOS 90801 PSYCHIATRIC DX INTERVIEW/EXAM 53 1 210.00 124.24 99.39 IM 23-JUL-12 41400 CORONARY ATHEROSCLEROSIS; UNSP 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 184.00 104.05 89.05 AN 27-JUL-12 3540 CARPAL TUNNEL SYNDROME 01710 NERVES,MUSCLES,TENDONS,FASCIA 22 1 345.00 - - GS 03-OCT-12 78904 ABDOMINAL PAIN - LEFT LOWER QU 99213 OFFICE VIS/EST PT-LIMITED 11 1 120.00 70.30 45.30 FP 09-OCT-12 40210 BEN HYPERTEN HRT DIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 GS 10-OCT-12 V7651 SPECIAL SCREENING; COLON 45385 COLONOSCOPY, FIBEROPTIC, BEYON 11 1 2,982.00 551.93 551.93 FP 26-SEP-12 5589 NONINF GASTROENTERIT NEC 99217 OBSERVATION CARE DISCHARGE 22 1 104.00 72.38 57.90 FP 24-SEP-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 87.00 70.30 55.30 GS 15-OCT-12 78906 ABDOMINAL PAIN; EPIGASTRIC 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 200.00 104.05 79.05 FP 12-SEP-12 4659 ACUTE URI NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 87.00 70.30 55.30 FP 05-MAR-12 31400 ATTN DEFIC NONHYPERACT 99213 OFFICE VIS/EST PT-LIMITED 11 1 105.00 - - FP 20-JUL-12 V700 ROUTINE MEDICAL EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 94.12 94.12 94.12 FP 20-JUL-12 V700 ROUTINE MEDICAL EXAM 96110 DEVELOPMENTAL TESTING 11 1 29.40 8.13 8.13 FP 20-JUL-12 V700 ROUTINE MEDICAL EXAM 92552 PURE TONE AUDIOMETRY (THRESHOL 11 1 25.00 25.00 25.00 FP 05-MAR-12 31400 ATTN DEFIC NONHYPERACT 99213 OFFICE VIS/EST PT-LIMITED 11 1 105.00 70.30 55.30 FP 16-OCT-12 31400 ATTN DEFIC NONHYPERACT 99213 OFFICE VIS/EST PT-LIMITED 11 1 115.00 70.30 55.30 FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 66.72 - - FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL TESTING 11 1 29.40 - - FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 92552 PURE TONE AUDIOMETRY (THRESHOL 11 1 25.00 - - FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 90707 IMMUN;MEASLES,MUMPS & RUBELLA 11 1 - - - FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 90700 IMMUNIZATION,ACTIVE;DIPTHERIA, 11 1 - - - FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 90670 PNEUMOCOCCAL CONJUGATE VACCINE 11 1 - - - FP 09-AUG-12 V040 VACCIN FOR POLIOMYELITIS 90713 IMMUNIZATION;POLIOMYELITIS VAC 11 1 - - - FP 09-AUG-12 V040 VACCIN FOR POLIOMYELITIS 90471 IMMUNIZATION ADMINISTRATION 11 1 35.00 - - FP 09-AUG-12 V040 VACCIN FOR POLIOMYELITIS 90472 EACH ADD'L VACCINE, SINGLE OR 11 3 30.00 - - DR 27-JUN-12 7821 NONSPECIF SKIN ERUPT NEC 99202 OFFICE VIS/NEW PT-LIMITED 11 1 126.00 71.69 51.69 DR 09-JUL-12 2165 BENIGN NEO SKIN TRUNK 99202 OFFICE VIS/NEW PT-LIMITED 11 1 128.00 71.69 46.69 IM 22-JUN-12 78720 DYSPHAGIA, UNSPECIFIED 76536 ECHOGRAPHY, SOFT TISSUES OF HE 11 1 120.00 82.13 65.70 AN 22-MAY-12 5990 URIN TRACT INFECTION NOS 00910 TRANSURETHRAL PROCEDURES NES 24 5 325.00 105.45 84.36 FP 26-JUN-12 V202 ROUTINE CHILD HEALTH EXAM 99394 PREVENTIVE;EST PT;12-17 YRS 11 1 150.00 111.36 111.36 FP 22-MAY-12 70219 OTHER SEBORRHEIC KERATOSIS 11401 EXCISION, BENIGN LESION, EXCEP 11 1 120.00 120.00 119.68 FP 22-MAY-12 70219 OTHER SEBORRHEIC KERATOSIS 88305 LEVEL IV - SURGICAL PATHOLOGY, 11 1 123.00 - - FP 22-MAY-12 70219 OTHER SEBORRHEIC KERATOSIS 11200 REMOVAL OF SKIN TAGS, MULTIPLE 11 1 97.00 - - FP 13-SEP-12 4619 ACUTE SINUSITIS NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 104.05 89.05 PSY 14-AUG-12 29650 BIPOLAR AFF, DEPR-UNSPEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 100.00 57.42 32.42 FP 01-AUG-12 V703 MED EXAM NEC-ADMIN PURP 99213 OFFICE VIS/EST PT-LIMITED 11 1 102.00 - - MG 22-OCT-12 7140 RHEUMATOID ARTHRITIS 85025 BLOOD COUNT; HEMOGRAM AND PLAT 81 1 31.00 11.02 11.02 MG 22-OCT-12 7140 RHEUMATOID ARTHRITIS 80053 COMPREHENSIVE METABOLIC PANEL 81 1 38.00 14.97 14.97 MG 22-OCT-12 7140 RHEUMATOID ARTHRITIS 85651 SEDIMENTATION RATE ERYTHROCYTE 81 1 13.00 5.02 5.02 MG 22-OCT-12 7140 RHEUMATOID ARTHRITIS 86140 C-REACTIVE PROTEIN 81 1 20.00 7.33 7.33 FP 04-NOV-12 4619 ACUTE SINUSITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.30 55.30 FP 04-NOV-12 4619 ACUTE SINUSITIS NOS 87880 STREPTOCOCUS, GROUP A 11 1 27.00 16.99 - PED 21-SEP-12 V198 FAMILY HX-CONDITION NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 70.30 55.30 FP 18-JUL-12 6828 CELLULITIS, SITE NEC 99202 OFFICE VIS/NEW PT-LIMITED 11 1 87.00 71.69 56.69 PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 88.00 88.00 88.00 PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 92551 SCREENING TEST, PURE TONE, AIR 11 1 12.00 10.79 10.79 PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 90696 DTAP-IPV VACCINE AGES 4-6 11 1 62.00 42.75 42.75 PSY 30-MAY-12 3090 ADJ REACTION W/BRIEF DEPRESSIV 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 12.00 12.00 12.00 PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 90707 IMMUN;MEASLES,MUMPS & RUBELLA 11 1 62.00 48.24 48.24 PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 90716 IMMUNIZATION;VARICELLA(CHICKEN 11 1 100.00 81.75 81.75 PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 90472 EACH ADD'L VACCINE, SINGLE OR 11 1 12.00 12.00 12.00 GS 03-JUL-12 57510 CHOLECYSTITIS,UNSPECIFIED 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 136.00 107.88 82.88 DR 12-JUN-12 70909 DYSCHROMIA; OTHER 88305 LEVEL IV - SURGICAL PATHOLOGY, 11 1 200.00 95.00 76.00 GS 12-JUN-12 6089 MALE GENITAL DIS NOS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 128.00 71.69 51.69 FP 14-JUN-12 4019 HYPERTENSION NOS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 146.00 107.88 92.88 GS 09-JUL-12 78906 ABDOMINAL PAIN; EPIGASTRIC 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 45.30 FP 05-JUL-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 AN 02-FEB-12 7856 ENLARGEMENT LYMPH NODES 00300 PROCEDURES/INTEGUMENTARY NECK 22 9 306.98 306.98 306.98 FP 05-MAR-12 462 ACUTE PHARYNGITIS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 153.00 104.05 89.05 IM 11-APR-12 78901 ABDOMINAL PAIN; RT UPPER QUAD 76705 ECHOGRAPHY, LIMITED - TECH COM 11 1 150.00 69.60 55.68 IM 02-FEB-12 7842 SWELLING IN HEAD NECK 76998 US GUIDE INTRAOP 11 1 150.00 97.11 97.11 IM 30-APR-12 7802 SYNCOPE AND COLLAPSE 93880 DUPLEX SCAN OF EXTRACRANIAL AR 11 1 300.00 220.63 176.50 IM 30-APR-12 7295 PAIN IN LIMB 93923 NONINVASIVE PHYSIOLOGIC STUDIE 11 1 250.00 143.03 114.42 GS 30-APR-12 27801 MORBID OBESITY 99213 OFFICE VIS/EST PT-LIMITED 22 1 89.00 - - GS 09-APR-12 53081 ESOPHAGEAL REFLUX 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 131.00 104.05 84.05 GS 07-MAY-12 53081 ESOPHAGEAL REFLUX 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 131.00 104.05 84.05 FP 10-MAR-12 71946 JOINT PAIN-L/LEG 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 130.00 104.05 89.05 PED 03-MAY-12 7856 ENLARGEMENT LYMPH NODES 99213 OFFICE VIS/EST PT-LIMITED 11 1 65.00 65.00 50.00 IM 18-APR-12 78605 SHORTNESS OF BREATH 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 25.00 8.70 6.96 PSY 01-FEB-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - FP 16-FEB-12 2449 HYPOTHYROIDISM NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.49 55.49 FP 13-MAR-12 37230 CONJUNCTIVITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 71.00 41.76 26.76 FP 13-MAR-12 37230 CONJUNCTIVITIS NOS G8553 AT LEAST ONE RX CREATED DURING 11 1 0.01 - - GS 07-FEB-12 78906 ABDOMINAL PAIN; EPIGASTRIC 43235 UPPER GASTROINTESTINAL ENDOSCO 22 1 627.00 171.48 171.48 GS 08-FEB-12 78906 ABDOMINAL PAIN; EPIGASTRIC 99217 OBSERVATION CARE DISCHARGE 22 1 141.00 72.52 72.52 GS 07-FEB-12 78906 ABDOMINAL PAIN; EPIGASTRIC 99218 INIT OBSERV;PER DAY;LOW SEVERI 22 1 134.00 68.12 68.12 GS 15-FEB-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 42.02 22.02 AN 07-MAR-12 2189 UTERINE LEIOMYOMA NOS 00840 INTRAPERITONEAL LOW ABD; NES 22 12 1,056.00 253.08 202.46 AN 07-MAR-12 2189 UTERINE LEIOMYOMA NOS 00840 INTRAPERITONEAL LOW ABD; NES 22 12 564.00 168.72 134.98 PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 99395 PREVENTIVE;EST PT;18-39 YRS 11 1 98.00 98.00 88.00 PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 92551 SCREENING TEST, PURE TONE, AIR 11 1 12.00 - - PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 90649 HPV VACCINE, TYPES 6,11,16,8 11 1 166.00 144.00 144.00 PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 12.00 12.00 12.00 PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 90715 TDAP VACC IND 7 YEARS/OLDER IM 11 1 46.00 41.15 41.15 PED 20-JUN-12 V700 ROUTINE MEDICAL EXAM 90472 EACH ADD'L VACCINE, SINGLE OR 11 1 12.00 12.00 12.00 FP 02-JUL-12 9493 3RD DEGREE BURN NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 FP 24-MAY-12 72871 PLANTAR FIBROMATOSIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 FP 16-AUG-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 84.36 69.36 FP 13-FEB-12 4659 ACUTE URI NOS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 108.00 72.52 57.52 FP 13-FEB-12 4659 ACUTE URI NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 114.00 70.49 55.49 FP 13-FEB-12 4659 ACUTE URI NOS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 108.00 72.52 57.52 FP 13-JAN-12 2724 HYPERLIPIDEMIA NEC/NOS 80061 LIPID PANEL 11 1 10.00 - - FP 13-JAN-12 2724 HYPERLIPIDEMIA NEC/NOS 84436 THYROXINE; 11 1 10.00 - - FP 13-JAN-12 2724 HYPERLIPIDEMIA NEC/NOS 84479 TRIDOTHYRONINE (T-3) 11 1 15.00 - - FP 13-JAN-12 2724 HYPERLIPIDEMIA NEC/NOS 80050 GENERAL HEALTH PANEL 11 1 30.00 - - FP 13-JAN-12 2724 HYPERLIPIDEMIA NEC/NOS 80050 GENERAL HEALTH PANEL 11 1 8.00 - - FP 04-JUN-12 4611 AC FRONTAL SINUSITIS J0696 INJECTION, CEFTRIAXONE SODIUM, 11 1 7.75 0.89 0.71 FP 04-JUN-12 4611 AC FRONTAL SINUSITIS 96372 THER/PROPH/DIAG INJ SC/IM 11 1 16.00 - - FP 04-JUN-12 4611 AC FRONTAL SINUSITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 96.00 70.30 55.30 FP 31-DEC-12 5990 URIN TRACT INFECTION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 FP 31-DEC-12 5990 URIN TRACT INFECTION NOS 81003 URINALYSIS, BY DIP STICK OR TA 11 1 20.00 3.18 3.18 DR 27-NOV-12 2169 BENIGN NEOPLASM SKIN NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 92.00 70.30 45.30 PSY 19-DEC-12 30001 PANIC DISORDER 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 125.00 104.05 79.05 FP 03-APR-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 84.36 69.36 DR 26-MAR-12 07810 VIRAL WARTS 99213 OFFICE VIS/EST PT-LIMITED 11 1 114.00 70.30 50.30 FP 04-APR-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 114.00 70.30 55.30 AN 23-MAR-12 V252 STERILIZATION 00851 TUBAL LIGATION/TRANSECTION 22 15 809.10 316.35 253.08 PSY 09-APR-12 316 PSYCHIC FACTOR W OTH DIS 90801 PSYCHIATRIC DX INTERVIEW/EXAM 22 1 254.00 124.24 124.24 PSY 09-APR-12 316 PSYCHIC FACTOR W OTH DIS 96101 PSYCHOLOGICAL TESTING, PER HR 22 3 441.00 238.02 238.02 AN 12-MAR-12 7295 PAIN IN LIMB 99213 OFFICE VIS/EST PT-LIMITED 22 1 125.00 52.55 32.55 PSY 02-APR-12 30981 PROLONG POSTTRAUM STRESS 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 90.00 57.42 37.42 IM 17-MAR-12 78650 CHEST PAIN NOS 99285 ER EXAM;NEW PT;COMPREHENSIVE 23 1 892.00 186.18 186.18 PED 13-APR-12 V202 ROUTINE CHILD HEALTH EXAM 99391 PERIODIC PREVENT MED, UNDER 1 11 1 78.00 78.00 78.00 PED 29-MAR-12 46619 ACUTE BRONCHIOLITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 PED 13-APR-12 3829 OTITIS MEDIA NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 PED 13-APR-12 4770 RHINITIS DUE TO POLLEN 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 DR 18-APR-12 2165 BENIGN NEO SKIN TRUNK 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 180.00 107.88 87.88 IM 10-APR-12 78600 RESPIRATORY ABNORM NOS 94016 SPIROMETRIC/PHYS REVIEW & INTE 22 1 50.00 23.32 18.66 AN 06-APR-12 V7651 SPECIAL SCREENING; COLON 00810 INTESTINAL ENDOSCOPIC PROCED 24 7 455.00 147.63 147.63 DR 31-JAN-12 6953 ROSACEA 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.49 50.49 GS 04-JAN-12 5778 PANCREATIC DISEASE NEC 99211 OFFICE VIS/EST PT-MINIMAL 11 1 34.00 18.98 - IM 29-MAR-12 79389 OTHER ABNORMAL FINDINGS ON RAD 76645 ECHOGRAPHY,BREAST - TECH COMP 11 1 100.00 62.29 49.83 GS 15-MAY-12 78901 ABDOMINAL PAIN; RT UPPER QUAD 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 160.00 107.88 87.88 GS 14-DEC-12 V1272 PERSONAL HIST COLONIC POLYPS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 115.00 71.69 46.69 FP 07-FEB-12 4610 AC MAXILLARY SINUSITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 70.49 55.49 FP 23-JAN-12 31400 ATTN DEFIC NONHYPERACT 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.49 55.49 DR 23-JAN-12 7062 SEBACEOUS CYST 11401 EXCISION, BENIGN LESION, EXCEP 11 1 302.00 150.13 2.17 GS 23-JAN-12 V7651 SPECIAL SCREENING; COLON 45385 COLONOSCOPY, FIBEROPTIC, BEYON 22 1 1,024.00 365.00 365.00 GS 23-MAR-12 4556 HEMORRHOIDS NOS 45378 COLONOSCOPY, FLEXIBLE TO SPLEN 22 1 750.00 255.08 204.06 PSY 16-JAN-12 29630 RECURR DEPR PSYCHOS-UNSP 99239 HOSPITAL DISCHARGE 30 MINUTES+ 21 1 150.00 105.40 84.32 PSY 11-JAN-12 29630 RECURR DEPR PSYCHOS-UNSP 99232 SUBSEQUENT HSP VISIT;LIMITED 21 1 100.00 72.86 58.29 PSY 12-JAN-12 29630 RECURR DEPR PSYCHOS-UNSP 99232 SUBSEQUENT HSP VISIT;LIMITED 21 1 100.00 72.86 58.29 PSY 13-JAN-12 29630 RECURR DEPR PSYCHOS-UNSP 99232 SUBSEQUENT HSP VISIT;LIMITED 21 1 100.00 72.86 58.29 PSY 14-JAN-12 29630 RECURR DEPR PSYCHOS-UNSP 99231 SUBSEQUENT HSP VISIT;BRIEF 21 1 75.00 40.67 32.54 PSY 15-JAN-12 29630 RECURR DEPR PSYCHOS-UNSP 99231 SUBSEQUENT HSP VISIT;BRIEF 21 1 75.00 40.67 32.54 FP 21-MAR-12 30403 OPIOID DEPENDENCE-REMISS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 AN 02-APR-12 5921 CALCULUS OF URETER 00910 TRANSURETHRAL PROCEDURES NES 22 7 392.25 147.63 118.10 DR 29-MAR-12 7020 ACTINIC KERATOSIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 110.00 70.30 50.30 DR 29-MAR-12 7020 ACTINIC KERATOSIS 17000 DESTRUCTION BY ANY METHOD, INC 11 1 150.00 78.65 - DR 29-MAR-12 7020 ACTINIC KERATOSIS 17003 DESTRUCT.BY ANY METHOD;2ND-14 11 2 50.00 14.62 - PED 04-APR-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 140.00 102.66 102.66 PED 04-APR-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B 90633 HEPATITIS A VACCINE,PEDIATRIC 11 1 40.00 21.17 21.17 PED 04-APR-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B 90460 IMM ADMIN THRU 18 VIA ANY RTE 11 1 32.00 12.00 12.00 PED 04-APR-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B 90645 HEMOPHILUS INFLENZA B VACCINE 11 1 45.00 20.37 20.37 PED 04-APR-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B 90460 IMM ADMIN THRU 18 VIA ANY RTE 11 1 32.00 12.00 12.00 PED 04-APR-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B 90700 IMMUNIZATION,ACTIVE;DIPTHERIA, 11 1 40.00 17.11 17.11 PED 04-APR-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B 90460 IMM ADMIN THRU 18 VIA ANY RTE 11 1 32.00 12.00 12.00 PED 04-APR-12 V0381 VAC-HEMOPHILUS INFLUENZA,TYP B 90461 IMM ADMIN THRU 18 VIA ANY RTE 11 2 24.00 24.00 24.00 PED 20-APR-12 37200 ACUTE CONJUNCTIVITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 55.30 DR 27-MAR-12 6953 ROSACEA 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 50.30 DR 14-FEB-12 6953 ROSACEA 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 125.00 - - DR 14-FEB-12 6953 ROSACEA 11311 SHAVE LESION; SINGLE; .6-1 CM 11 1 170.00 - - GS 19-DEC-12 4439 PERIPH VASCULAR DIS NOS 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 300.00 167.39 142.39 FNSP 28-DEC-12 7881 DYSURIA 99212 OFFICE OR OTHER OUTPT VISIT 11 1 61.00 41.76 26.76 FNSP 28-DEC-12 7881 DYSURIA 81002 URINALYSIS BY DIPSTICK OR TABL 11 1 5.00 3.33 2.66 GS 21-DEC-12 78906 ABDOMINAL PAIN; EPIGASTRIC 45378 COLONOSCOPY, FLEXIBLE TO SPLEN 22 1 1,025.00 255.08 104.86 GS 21-DEC-12 78906 ABDOMINAL PAIN; EPIGASTRIC 43239 ENDOSCOPY UPPER GI W BIOPSY 22 1 975.00 98.83 79.06 PSY 01-FEB-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 87.10 69.68 FP 17-JAN-12 7295 PAIN IN LIMB 73630 FOOT RAD EXAMINATION 11 1 41.00 22.03 - FNSP 08-FEB-12 41401 CORONARY ATHEROSCLEROSIS; CORO 99214 OFFICE VIS/EST PT-INTERMEDIATE 22 1 104.00 80.32 65.32 PSY 26-JAN-12 29631 RECURR DEPR PSYCHOS-MILD 90801 PSYCHIATRIC DX INTERVIEW/EXAM 11 1 200.00 154.88 123.90 IM 31-JAN-12 78609 RESPIRATORY ABNORM NEC 93016 CARDIOVASC STRESS TREADMILL 22 1 130.00 22.71 22.71 IM 31-JAN-12 78609 RESPIRATORY ABNORM NEC 93018 CARDIOVASCULAR STRESS TEST USI 22 1 150.00 15.59 15.59 IM 24-FEB-12 42611 ATRIOVENT BLOCK-1ST DEGR 93010 ELECTROCARDIOGRAM,INTERP & REP 23 1 46.00 9.15 9.15 GS 16-FEB-12 43310 OCCULSION/STENOSIS CAROTID ARE 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 137.00 104.72 84.72 FP 10-APR-12 25003 DIABETES MELITUS TYPE I 99232 SUBSEQUENT HSP VISIT;LIMITED 21 1 117.00 72.38 57.90 FP 11-APR-12 25003 DIABETES MELITUS TYPE I 99238 HOSPITAL DISCHARGE DAY MANAGEM 21 1 133.00 70.99 56.79 FP 25-SEP-12 42789 CARDIAC DYSRHYTHMIAS NEC 99231 SUBSEQUENT HSP VISIT;BRIEF 21 2 214.00 80.04 64.03 FP 24-SEP-12 78650 CHEST PAIN NOS 93016 CARDIOVASC STRESS TREADMILL 21 1 103.00 21.58 17.26 FP 24-SEP-12 78650 CHEST PAIN NOS 93018 CARDIOVASCULAR STRESS TEST USI 21 1 172.00 14.96 11.97 FP 23-SEP-12 42789 CARDIAC DYSRHYTHMIAS NEC 99231 SUBSEQUENT HSP VISIT;BRIEF 21 1 107.00 40.02 32.02 FP 04-OCT-12 42731 ATRIAL FIBRILLATION 99213 OFFICE VIS/EST PT-LIMITED 11 1 150.00 70.30 55.30 FP 04-OCT-12 42731 ATRIAL FIBRILLATION 93000 ELECTROCARDIOGRAM, WITH INTERP 11 1 85.00 18.79 15.03 FP 17-OCT-12 42731 ATRIAL FIBRILLATION 99213 OFFICE VIS/EST PT-LIMITED 11 1 150.00 70.30 55.30 FP 17-OCT-12 42731 ATRIAL FIBRILLATION 93000 ELECTROCARDIOGRAM, WITH INTERP 11 1 85.00 18.79 15.03 IM 11-OCT-12 4011 BENIGN HYPERTENSION 99213 OFFICE VIS/EST PT-LIMITED 11 1 125.00 70.30 55.30 IM 11-OCT-12 4011 BENIGN HYPERTENSION G8553 AT LEAST ONE RX CREATED DURING 11 1 0.01 - - GS 17-OCT-12 56211 DIVERTICULITIS OF COLON 99213 OFFICE VIS/EST PT-LIMITED 22 1 88.00 52.55 27.55 IM 12-DEC-12 49300 EXT ASTHMA W/O STAT ASTH 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 440.00 167.39 152.39 IM 12-DEC-12 49300 EXT ASTHMA W/O STAT ASTH 94060 BRONCHOSPASM EVALUATION: SPIRO 11 1 350.00 54.64 1.98 IM 12-DEC-12 49300 EXT ASTHMA W/O STAT ASTH 94727 PULM FUNCTION TEST BY GAS 11 1 175.00 38.63 30.90 IM 12-DEC-12 49300 EXT ASTHMA W/O STAT ASTH 94729 C02/MEMBANE DIFFUSE CAPACITY 11 1 225.00 47.68 38.14 IM 19-DEC-12 79311 SOLITARY PULMONARY NODULE 99212 OFFICE OR OTHER OUTPT VISIT 11 1 80.00 41.76 26.76 FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 99173 SCREENING TEST OF VISUAL ACUIT 11 1 10.00 - - FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 66.72 66.72 66.72 FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL SCREENING W/INTP 11 1 29.40 8.13 8.13 FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 92552 PURE TONE AUDIOMETRY (THRESHOL 11 1 25.00 25.00 25.00 FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 90707 IMMUN;MEASLES,MUMPS & RUBELLA 11 1 - - - FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 90700 IMMUNIZATION,ACTIVE;DIPTHERIA, 11 1 - - - FP 09-AUG-12 V202 ROUTINE CHILD HEALTH EXAM 90670 PNEUMOCOCCAL CONJUGATE VACCINE 11 1 - - - FP 09-AUG-12 V040 VACCIN FOR POLIOMYELITIS 90713 IMMUNIZATION;POLIOMYELITIS VAC 11 1 - - - FP 09-AUG-12 V040 VACCIN FOR POLIOMYELITIS 90471 IMMUNIZATION ADMINISTRATION 11 1 35.00 12.00 12.00 FP 09-AUG-12 V040 VACCIN FOR POLIOMYELITIS 90472 EACH ADD'L VACCINE, SINGLE OR 11 3 30.00 30.00 30.00 AN 01-NOV-12 4279 CARDIAC DYSRHYTHMIA NOS 00537 ANE/CARDIAC ELECTROPHYSIOLOGIC 22 1 2,520.00 2,347.50 2,089.21 PSY 14-DEC-12 29650 BIPOLAR AFF, DEPR-UNSPEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 100.00 57.42 32.42 PSY 22-AUG-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 12-DEC-12 30928 ADJ REACT-MIXED EMOTION 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 04-OCT-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 06-DEC-12 3094 ADJ REACT-EMOTION/CONDUC 90846 FAMILY PSYCHOTHERAPY 11 1 215.00 84.22 67.38 PSY 06-DEC-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 19-DEC-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 24-FEB-12 29650 BIPOLAR AFF, DEPR-UNSPEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 100.00 57.95 37.95 FP 24-FEB-12 490 BRONCHITIS NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 104.72 89.72 FP 06-NOV-12 2819 DEFICIENCY ANEMIA NOS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 159.00 107.88 92.88 IM 25-JUN-12 32723 OBSTRUCTIVE SLEEP APNEA 99213 OFFICE VIS/EST PT-LIMITED 11 1 147.00 70.30 55.30 PSY 20-JUN-12 29630 RECURR DEPR PSYCHOS-UNSP 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 70.00 57.42 32.42 FP 08-JUN-12 34690 MIGRAIN, UNSPECIFIED 99283 ER EXAM;NEW PT;INTERMEDIATE 23 1 267.00 66.12 66.12 GS 06-JUN-12 61171 MASTODYNIA 99201 OFFICE VIS/NEW PATIENT-BRIEF 11 1 75.00 41.76 21.76 AN 09-MAY-12 42732 ATRIAL FLUTTER 00410 ELECTRICAL CONVERS/ARRHYTHMIAS 22 5 323.64 105.45 84.36 AN 08-MAR-12 57510 CHOLECYSTITIS,UNSPECIFIED 00790 UPPER ABDOMEN 22 15 809.10 316.35 312.46 AN 27-NOV-12 V553 ATTEN TO COLOSTOMY 00840 INTRAPERITONEAL LOW ABD; NES 21 27 1,296.00 569.43 569.43 AN 01-NOV-12 4279 CARDIAC DYSRHYTHMIA NOS 00537 ANE/CARDIAC ELECTROPHYSIOLOGIC 22 1 (2,520.00) (2,347.50) (2,089.21) FP 11-DEC-12 683 ACUTE LYMPHADENITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 75.00 70.30 55.30 AN 03-MAY-12 81342 FX DISTAL RADIUS NEC-CL 01830 OPEN PROC ON RADIUS/ULNA/WRIST 22 10 750.00 210.90 168.72 PSY 30-APR-12 29662 BIPOLAR AFFEC, MIXED-MOD 80101 DRUG, SCREEN; 11 9 315.00 - - PSY 30-APR-12 29662 BIPOLAR AFFEC, MIXED-MOD 82055 ALCOHOL (ETHANOL); 11 1 75.00 - - PSY 30-APR-12 29651 BIPOLAR AFFEC, DEPR-MILD 90805 IND PSYCHOTHERAPY W/MED EVALU 11 1 150.00 - - PSY 11-JUN-12 29652 BIPOLAR AFFEC, DEPR-MOD 90805 IND PSYCHOTHERAPY W/MED EVALU 11 1 150.00 71.69 71.69 PSY 11-JUN-12 29652 BIPOLAR AFFEC, DEPR-MOD 81001 URINALYSIS, AUTOMATED 11 1 36.00 4.48 4.48 PSY 11-JUN-12 29652 BIPOLAR AFFEC, DEPR-MOD 80101 DRUG, SCREEN; 11 9 315.00 177.48 177.48 GS 12-JUN-12 79381 MAMMOGRAPHIC MICROCALCIFICATIO 99212 OFFICE VIS/EST PT-BRIEF 11 1 65.00 41.76 21.76 AN 14-MAY-12 2189 UTERINE LEIOMYOMA NOS 00840 INTRAPERITONEAL LOW ABD; NES 21 18 1,260.00 379.62 298.99 AN 14-MAY-12 2189 UTERINE LEIOMYOMA NOS 00840 INTRAPERITONEAL LOW ABD; NES 21 18 720.00 253.08 202.46 PA 13-JAN-12 V1272 COLONIC POLYPS 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 380.85 168.77 148.77 FP 06-JAN-12 7862 COUGH 71020 RADIOLOGIC EXAM, CHEST, 2 VWS 11 1 37.00 19.32 15.46 FP 03-JAN-12 8728 OPEN WOUND OF EAR NOS 99211 OFFICE VIS/EST PT-MINIMAL 72 1 27.00 25.06 10.06 PSY 25-NOV-12 30500 ALCOHOL ABUSE-UNSPEC 99232 SUBSEQUENT HSP VISIT;LIMITED 21 1 123.00 72.38 57.90 FP 05-MAR-12 53081 ESOPHAGEAL REFLUX 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 FP 18-APR-12 6929 DERMATITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 84.36 69.36 FP 18-APR-12 6929 DERMATITIS NOS J2930 INJECTION, METHYLPREDISOLONE S 72 1 21.26 2.58 2.06 FP 18-APR-12 6929 DERMATITIS NOS 96372 THER/PROPH/DIAG INJ SC/IM 72 1 19.00 - - FP 26-APR-12 5589 NONINF GASTROENTERIT NEC 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 136.00 107.88 92.88 PSY 10-MAY-12 29661 BIPOLAR AFF, MIXED-MILD 80050 GENERAL HEALTH PANEL 11 1 174.00 42.00 31.62 PSY 10-MAY-12 29661 BIPOLAR AFF, MIXED-MILD 80156 CARBAMAZEPINE 11 1 112.00 20.62 16.50 PSY 10-MAY-12 29661 BIPOLAR AFF, MIXED-MILD 90805 IND PSYCHOTHERAPY W/MED EVALU 11 1 150.00 71.69 57.35 MG 12-MAR-12 30000 ANXIETY STATE NOS 99285 ER EXAM;NEW PT;COMPREHENSIVE 23 1 411.00 332.75 332.75 DR 18-MAY-12 2165 BENIGN NEO SKIN TRUNK 99213 OFFICE VIS/EST PT-LIMITED 11 1 115.00 70.30 50.30 FP 01-AUG-12 V705 HEALTH EXAM-GROUP SURVEY 99213 OFFICE VIS/EST PT-LIMITED 11 1 102.00 - - FP 25-JUN-12 V705 HEALTH EXAM-GROUP SURVEY 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 70.30 55.30 FP 24-AUG-12 3051 TOBACCO USE DISORDER 71020 RADIOLOGIC EXAMINATION, CHEST, 11 1 37.00 28.88 23.10 PSY 12-SEP-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 400.00 84.22 - AN 21-AUG-12 650 NORMAL DELIVERY 01967 NEURAXIAL LABOR ANALG/ANESTH F 21 13 1,275.00 456.95 365.56 PED 22-AUG-12 NB NEWBORN PENDING ELIGIBILITY 99460 INIT NB EM PER DAY HOSP 21 1 175.00 - - PED 25-AUG-12 DEP DEPENDENT NOT ON FILE 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 120.00 - - PED 28-AUG-12 DEP DEPENDENT NOT ON FILE 99391 PERIODIC PREVENT MED, UNDER 1 11 1 125.00 - - DR 04-SEP-12 17372 SQUAMOUS CELL CARC. LOWER LIMB 88305 LEVEL IV - SURGICAL PATHOLOGY, 11 2 400.00 190.00 - PED 04-SEP-12 NB NEWBORN PENDING ELIGIBILITY 99391 PERIODIC PREVENT MED, UNDER 1 11 1 125.00 - - PED 23-AUG-12 V3000 SINGLE LIVEBORN 99238 HOSPITAL DISCHARGE DAY MANAGEM 21 1 97.00 70.99 - DR 28-AUG-12 7140 RHEUMATOID ARTHRITIS 85025 BLOOD COUNT; HEMOGRAM AND PLAT 81 1 31.00 11.02 - DR 28-AUG-12 7140 RHEUMATOID ARTHRITIS 85651 SEDIMENTATION RATE ERYTHROCYTE 81 1 13.00 5.02 - DR 28-AUG-12 7140 RHEUMATOID ARTHRITIS 80053 COMPREHENSIVE METABOLIC PANEL 81 1 38.00 11.97 - DR 28-AUG-12 7140 RHEUMATOID ARTHRITIS 86140 C-REACTIVE PROTEIN 81 1 20.00 7.33 - IM 23-AUG-12 53081 ESOPHAGEAL REFLUX 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 226.00 167.39 152.39 GS 13-SEP-12 5758 DIS OF GALLBLADDER NEC 99202 OFFICE VIS/NEW PT-LIMITED 11 1 100.00 71.69 46.69 DR 15-AUG-12 2165 BENIGN NEO SKIN TRUNK 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 210.00 - - FP 05-SEP-12 311 DEPRESSIVE DISORDER NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 GS 10-SEP-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 41.76 16.76 FP 30-AUG-12 33720 REFLEX SYMPATHETIC DYSTROPHY 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 146.00 107.88 92.88 FP 13-SEP-12 2859 ANEMIA NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 148.00 104.05 89.05 MG 28-AUG-12 311 DEPRESSIVE DISORDER NEC 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 130.00 107.88 86.30 FP 28-AUG-12 DEP DEPENDENT NOT ON FILE 99391 PERIODIC PREVENT MED, UNDER 1 11 1 125.00 - - FP 28-AUG-12 DEP DEPENDENT NOT ON FILE 90723 IMMUNIZE;DIPHTHERIA,TETANUS TO 11 1 120.00 - - FP 28-AUG-12 DEP DEPENDENT NOT ON FILE 90471 IMMUNIZATION ADMINISTRATION 11 1 25.00 - - FP 28-AUG-12 DEP DEPENDENT NOT ON FILE 90647 HEMOPHILUS INFLUENZA B VACCINE 11 1 30.00 - - FP 28-AUG-12 DEP DEPENDENT NOT ON FILE 90670 PNEUMOCOCCAL CONJUGATE VACCINE 11 1 140.00 - - FP 28-AUG-12 DEP DEPENDENT NOT ON FILE 90680 ROTAVIRUS VACCINE,PENTAVALENT 11 1 90.00 - - FP 28-AUG-12 DEP DEPENDENT NOT ON FILE 90472 EACH ADD'L VACCINE, SINGLE OR 11 3 60.00 - - FP 24-AUG-12 4660 ACUTE BRONCHITIS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 136.00 - - FP 24-AUG-12 4660 ACUTE BRONCHITIS 90718 IMMUN;TETANUS/DIPHTHERIA;ADULT 11 1 38.00 - - FP 24-AUG-12 4660 ACUTE BRONCHITIS 90471 IMMUNIZATION ADMINISTRATION 11 1 30.00 - - FP 11-AUG-12 7821 NONSPECIF SKIN ERUPT NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 126.00 - - FP 11-AUG-12 7821 NONSPECIF SKIN ERUPT NEC J3301 INJECTION TRIAMCINOLONE ACETON 11 2 30.00 - - FP 11-AUG-12 7821 NONSPECIF SKIN ERUPT NEC J1020 INJECTION, METHYLPREDNISOLONE 11 1 15.00 - - FP 24-AUG-12 4660 ACUTE BRONCHITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 - - FP 11-AUG-12 6918 OTHER ATOPIC DERMATITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 - - IM 12-SEP-12 V0481 VACC/INOC AGAINST INFLUENZA 90656 FLU VIR VAC SPLIT PF 3 YR AGE& 11 1 19.00 12.38 12.38 IM 12-SEP-12 V0481 VACC/INOC AGAINST INFLUENZA 90471 IMMUNIZATION ADMINISTRATION 11 1 17.00 12.00 12.00 FP 03-APR-12 6929 DERMATITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 74.00 70.30 55.30 GS 17-MAR-12 78906 ABDOMINAL PAIN; EPIGASTRIC 99224 SUBSEQUENT OBSERVATION CARE 22 1 65.00 41.76 41.76 GS 18-MAR-12 78906 ABDOMINAL PAIN; EPIGASTRIC 99217 OBSERVATION CARE DISCHARGE 22 1 141.00 72.38 72.38 GS 16-MAR-12 78906 ABDOMINAL PAIN; EPIGASTRIC 99218 INIT OBSERV;PER DAY;LOW SEVERI 22 1 134.00 99.18 99.18 GS 20-MAR-12 5650 ANAL FISSURE 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 244.00 167.39 147.39 GS 21-MAR-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 131.00 107.88 87.88 GS 22-MAR-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 99212 OFFICE VIS/EST PT-BRIEF 11 1 52.00 41.76 21.76 AN 20-APR-12 V7651 SPECIAL SCREENING; COLON 00810 INTESTINAL ENDOSCOPIC PROCED 24 8 480.00 112.48 112.48 AN 20-APR-12 V7651 SPECIAL SCREENING; COLON 00810 INTESTINAL ENDOSCOPIC PROCED 24 8 520.00 168.72 168.72 DR 25-APR-12 7061 ACNE NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 120.00 70.30 50.30 FP 01-MAY-12 84500 SPRAIN OF ANKLE NOS 99201 OFFICE VIS/NEW PATIENT-BRIEF 72 1 52.00 50.11 35.11 IM 04-MAY-12 41071 SUBENDOCARDIAL INFARCTION-INIT 99238 HOSPITAL DISCHARGE DAY MANAGEM 21 1 150.00 70.99 56.79 IM 03-MAY-12 41071 SUBENDOCARDIAL INFARCTION-INIT 99232 SUBSEQUENT HSP VISIT;LIMITED 21 1 123.00 72.38 57.90 IM 02-MAY-12 41071 SUBENDOCARDIAL INFARCTION-INIT 99222 INIT HSP VISIT;INTERMEDIATE 21 1 235.00 144.07 115.26 FP 08-MAY-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 76.72 76.72 76.72 FP 08-MAY-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL TESTING 11 1 29.40 8.13 8.13 DR 14-FEB-12 7020 ACTINIC KERATOSIS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 185.00 72.52 52.52 DR 14-FEB-12 7020 ACTINIC KERATOSIS 17000 DESTRUCTION LESION FACE 11 1 145.00 40.16 - DR 14-FEB-12 7020 ACTINIC KERATOSIS 11100 BIOPSY OF SKIN 11 1 195.00 104.38 56.76 DR 14-FEB-12 2163 BENIGN NEO SKIN FACE NEC 88305 LEVEL IV - SURGICAL PATHOLOGY, 11 1 200.00 99.64 79.71 PED 30-APR-12 71946 JOINT PAIN-L/LEG 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 55.30 AN 04-MAY-12 73399 BONE CARTILAGE DIS NEC 01400 OPEN PROCED KNEE JOINT; NES 22 10 880.00 210.90 210.90 AN 04-MAY-12 73399 BONE CARTILAGE DIS NEC 01400 OPEN PROCED KNEE JOINT; NES 22 10 470.00 140.60 140.60 DR 07-FEB-12 2167 BENIGN NEO SKIN LEG 88305 LEVEL IV - SURGICAL PATHOLOGY, 11 1 200.00 99.64 79.71 IM 01-MAR-12 2449 HYPOTHYROIDISM NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 125.00 104.05 89.05 IM 01-MAR-12 2449 HYPOTHYROIDISM NOS 82270 BLOOD; OCCULT, FECES, SCREENIN 11 1 15.00 4.61 3.69 GS 05-MAR-12 V5875 AFTERCARE-TEETH,DIGESTIVE,ORAL 99212 OFFICE VIS/EST PT-BRIEF 22 1 66.00 27.14 7.14 PED 06-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 140.00 102.66 102.66 PED 06-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 96110 DEVELOPMENTAL TESTING 11 1 15.00 8.13 8.13 AN 13-JUN-12 71698 ARTHROPATHY NOS-OTH SITE 99213 OFFICE VIS/EST PT-LIMITED 22 1 125.00 52.55 32.55 PED 23-AUG-12 7452 TETRALOGY OF FALLOT 93303 TRANSTHORACIC ECHOCARDIOGRAPHY 22 1 499.00 169.24 135.39 PED 23-AUG-12 7452 TETRALOGY OF FALLOT 93320 DOPPLER ECHOCARDIOGRAPHY 22 1 330.00 50.41 40.33 PED 23-AUG-12 7452 TETRALOGY OF FALLOT 93325 DOPPLER COLOR FLOW VELOCITY 22 1 211.00 9.92 7.94 FP 08-JUN-12 4011 BENIGN HYPERTENSION 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 104.05 89.05 GS 30-JUL-12 311 DEPRESSIVE DISORDER NEC 99212 OFFICE VIS/EST PT-BRIEF 11 1 106.00 41.76 - AN 27-AUG-12 5920 CALCULUS OF KIDNEY 00918 TUR W/FRAGMENTATION; REMOVAL 22 14 1,050.00 295.26 236.21 DR 27-JUN-12 17331 BASAL CELL CARCINOMA OF SKIN O 17311 MOHS 1 STAGE H/N/HF/G 22 1 1,124.00 214.20 171.36 DR 27-JUN-12 17331 BASAL CELL CARCINOMA OF SKIN O 14040 ADJACENT TISSUE TRANSFER OR RE 22 1 1,902.00 702.96 562.37 DR 14-AUG-12 17331 BASAL CELL CARCINOMA OF SKIN O 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 45.30 PSY 30-AUG-12 30002 GENERALIZED ANXIETY DIS 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 85.00 57.42 32.42 PA 18-AUG-12 49121 OBSTRUCT CHR BRONCH/ACUTE EXAC 99232 SUBSEQUENT HSP VISIT;LIMITED 21 1 83.00 72.38 57.90 PA 19-AUG-12 49121 OBSTRUCT CHR BRONCH/ACUTE EXAC 99238 HOSPITAL DISCHARGE DAY MANAGEM 21 1 82.00 70.99 56.79 GS 05-AUG-12 5990 URIN TRACT INFECTION NOS 99283 ER EXAM;NEW PT;INTERMEDIATE 23 1 202.00 199.98 199.98 FP 08-AUG-12 56983 PERFORATION OF INTESTINE 99283 ER EXAM;NEW PT;INTERMEDIATE 23 1 202.00 187.86 187.86 IM 08-AUG-12 2411 NONTOX MULTINODUL GOITER 99213 OFFICE VIS/EST PT-LIMITED 11 1 125.00 70.30 55.30 IM 08-AUG-12 2411 NONTOX MULTINODUL GOITER G8553 AT LEAST ONE RX CREATED DURING 11 1 0.01 - - FP 20-JUL-12 2724 HYPERLIPIDEMIA NEC/NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 60.30 FP 20-JUL-12 V700 ROUTINE MEDICAL EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 94.12 - - FP 20-JUL-12 V700 ROUTINE MEDICAL EXAM 96110 DEVELOPMENTAL TESTING 11 1 29.40 - - FP 20-JUL-12 V700 ROUTINE MEDICAL EXAM 92552 PURE TONE AUDIOMETRY (THRESHOL 11 1 25.00 - - FNSP 19-JUL-12 78904 ABDOMINAL PAIN - LEFT LOWER QU 99202 OFFICE VIS/NEW PT-LIMITED 11 1 105.00 71.69 56.69 FNSP 19-JUL-12 78904 ABDOMINAL PAIN - LEFT LOWER QU 81002 URINALYSIS BY DIPSTICK OR TABL 11 1 5.00 3.33 - PSY 20-APR-12 29650 BIPOLAR AFF, DEPR-UNSPEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 100.00 57.42 45.94 PSY 18-JUN-12 29650 BIPOLAR AFF, DEPR-UNSPEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 100.00 57.42 37.42 FP 17-SEP-12 2859 ANEMIA NOS 85025 BLOOD COUNT; HEMOGRAM AND PLAT 11 1 23.00 11.02 8.82 FP 17-SEP-12 2859 ANEMIA NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 80.00 70.30 55.30 FP 17-SEP-12 V202 ROUTINE CHILD HEALTH EXAM 99393 PREVENTIVE;EST PT; 5-11 YEARS 11 1 85.00 85.00 85.00 FP 17-SEP-12 V202 ROUTINE CHILD HEALTH EXAM 90633 HEPATITIS A VACCINE,PEDIATRIC 11 1 47.00 23.94 23.94 FP 17-SEP-12 V202 ROUTINE CHILD HEALTH EXAM 90669 PNEUMOCOCCAL CONJUGATE VACCINE 11 1 102.00 95.48 95.48 FP 17-SEP-12 V202 ROUTINE CHILD HEALTH EXAM 90700 IMMUNIZATION,ACTIVE;DIPTHERIA, 11 1 30.00 17.11 17.11 FP 17-SEP-12 V202 ROUTINE CHILD HEALTH EXAM 90713 IMMUNIZATION;POLIOMYELITIS VAC 11 1 35.00 28.29 28.29 FP 17-SEP-12 V202 ROUTINE CHILD HEALTH EXAM 90707 IMMUN;MEASLES,MUMPS & RUBELLA 11 1 63.00 48.24 48.24 FP 17-SEP-12 V202 ROUTINE CHILD HEALTH EXAM 90716 IMMUNIZATION;VARICELLA(CHICKEN 11 1 90.00 81.75 81.75 IM 21-AUG-12 6271 POSTMENOPAUSAL BLEEDING 76830 ULTRASOUND, TRANSVAGINAL 11 1 180.00 81.43 65.14 FP 21-AUG-12 1330 SCABIES 99212 OFFICE VIS/EST PT-BRIEF 20 1 106.00 41.76 16.76 AN 30-AUG-12 5921 CALCULUS OF URETER 00918 TUR W/FRAGMENTATION; REMOVAL 22 11 647.28 231.99 185.59 GS 13-SEP-12 V1272 COLONIC POLYPS 45380 COLONOSCOPY, FLEXIBLE W/BIOPSY 22 1 1,150.00 302.06 302.06 PED 06-SEP-12 6929 DERMATITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 52.00 41.76 26.76 PED 18-SEP-12 4619 ACUTE SINUSITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 88.00 70.30 55.30 DR 17-AUG-12 07810 VIRAL WARTS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 165.00 107.88 82.88 DR 17-AUG-12 07810 VIRAL WARTS 17110 DESTRUCTION BY ANY METHOD OF F 11 1 153.00 104.05 83.24 FP 25-JUN-12 6110 INFLAM DISEASE OF BREAST 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 50.11 35.11 FP 23-JUL-12 30000 ANXIETY STATE NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 - - GS 31-AUG-12 5693 RECTAL ANAL HEMORRHAGE 45378 COLONOSCOPY, FLEXIBLE TO SPLEN 22 1 750.00 255.08 204.06 GS 31-AUG-12 5693 RECTAL ANAL HEMORRHAGE 43239 ENDOSCOPY UPPER GI W BIOPSY 22 1 550.00 98.83 79.06 GS 01-OCT-12 53550 UNSPEC GASTRITIS & GASTRODUOD 99212 OFFICE VIS/EST PT-BRIEF 11 1 90.00 41.76 16.76 PED 14-SEP-12 4659 ACUTE URI NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 70.30 55.30 PSY 30-MAY-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 21-MAR-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 18-APR-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 02-MAY-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 11-MAY-12 3099 ADJUSTMENT REACTION NOS 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 PSY 16-MAY-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 28-JUN-12 3099 ADJUSTMENT REACTION NOS 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 PSY 03-JUL-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 215.00 84.22 67.38 PSY 30-AUG-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 23-MAY-12 30928 ADJ REACT-MIXED EMOTION 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 07-JUN-12 30928 ADJ REACT-MIXED EMOTION 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 27-JUN-12 30928 ADJ REACT-MIXED EMOTION 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 PSY 20-SEP-12 30928 ADJ REACT-MIXED EMOTION 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 11-JUL-12 3094 ADJ REACT-EMOTION/CONDUC 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 30.34 PSY 26-JUL-12 3094 ADJ REACT-EMOTION/CONDUC 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 PSY 22-AUG-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 16-MAY-12 3094 ADJ REACT-EMOTION/CONDUC 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 PSY 17-MAY-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 23-MAY-12 3094 ADJ REACT-EMOTION/CONDUC 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 PSY 10-MAY-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 07-JUN-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 27-JUN-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 26-SEP-12 3094 ADJ REACT-EMOTION/CONDUC 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 IM 28-SEP-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 43239 ENDOSCOPY UPPER GI W BIOPSY 22 1 575.00 98.83 79.06 IM 28-SEP-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 45384 COLONOSCOPY,W/REMOVAL TUMOR(S) 22 1 2,605.00 318.07 254.46 GS 01-OCT-12 5758 DIS OF GALLBLADDER NEC 47562 LAPAROSCOPY; CHOLECYSTECTOMY 22 1 2,784.00 899.93 719.94 PSY 21-MAR-12 3099 ADJUSTMENT REACTION NOS 90804 IND PSYCHOTHERAPY, INSIGHT 11 1 100.00 - - PSY 18-APR-12 3099 ADJUSTMENT REACTION NOS 90804 IND PSYCHOTHERAPY, INSIGHT 11 1 100.00 61.25 49.00 PSY 09-MAY-12 3099 ADJUSTMENT REACTION NOS 90804 IND PSYCHOTHERAPY, INSIGHT 11 1 100.00 61.25 49.00 PSY 09-MAY-12 3099 ADJUSTMENT REACTION NOS 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 PSY 22-AUG-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 - PSY 11-JUL-12 30928 ADJ REACT-MIXED EMOTION 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 30.34 PSY 26-JUL-12 30928 ADJ REACT-MIXED EMOTION 90847 FAMILY PSYCHOTHERAPY 11 1 215.00 103.70 82.96 PSY 29-AUG-12 30928 ADJ REACT-MIXED EMOTION 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 19-SEP-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 PSY 03-OCT-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 DR 04-SEP-12 2382 UNC BEHAV NEO SKIN 11302 SHAVING OF EPIDERMAL OR DERMAL 11 1 184.00 111.36 61.09 DR 04-SEP-12 2382 UNC BEHAV NEO SKIN 11100 BIOPSY SKIN/SUBCUTAN 1 LESION 11 1 212.00 50.64 40.51 PED 02-OCT-12 V053 IMM VIRAL HEPATITIS 99391 PERIODIC PREVENT MED, UNDER 1 11 1 125.00 95.35 95.35 PED 02-OCT-12 V053 IMM VIRAL HEPATITIS 90744 HEP B VACC PED/ADOL-3 DOSE SCH 11 1 45.00 24.22 24.22 PED 02-OCT-12 V053 IMM VIRAL HEPATITIS 90460 IMM ADMIN THRU 18 VIA ANY RTE 11 1 32.00 12.00 12.00 FP 11-SEP-12 3829 OTITIS MEDIA NOS 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 195.00 - - GS 10-OCT-12 78900 SYMPTOMS OF ABDOMEN AND PELVIS 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 170.00 167.39 142.39 FP 01-OCT-12 25000 DIABETES UNCOMPL ADULT 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 165.00 107.88 92.88 FP 08-OCT-12 25000 DIABETES UNCOMPL ADULT 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 FP 13-OCT-12 V700 ROUTINE MEDICAL EXAM 99396 PREVENTIVE; EST PT; 40-64 YRS 11 1 185.00 122.84 122.84 FP 13-OCT-12 V700 ROUTINE MEDICAL EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 25.00 12.00 12.00 FP 13-OCT-12 V700 ROUTINE MEDICAL EXAM 90732 IMM, PNEUMOCOCCUS 11 1 55.00 55.00 55.00 FP 08-OCT-12 59970 HEMATURIA, UNSPECIFIED 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 165.00 107.88 92.88 FP 08-OCT-12 59970 HEMATURIA, UNSPECIFIED 73562 RADIOLOGIC EXAM; ANTEROPOSTERI 11 1 55.00 24.71 19.77 FP 08-OCT-12 59970 HEMATURIA, UNSPECIFIED 81003 URINALYSIS, BY DIP STICK OR TA 11 1 20.00 3.18 2.54 FP 13-OCT-12 5990 URIN TRACT INFECTION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 FP 13-OCT-12 5990 URIN TRACT INFECTION NOS 81003 URINALYSIS, BY DIP STICK OR TA 11 1 20.00 3.18 2.54 FP 26-JUL-12 DEP DEPENDENT NOT ON FILE 99391 PERIODIC PREVENT MED, UNDER 1 11 1 125.00 - - GS 24-SEP-12 5778 PANCREATIC DISEASE NEC 99222 INIT HSP VISIT;INTERMEDIATE 21 1 262.00 144.07 115.26 FP 03-OCT-12 78052 INSOMNIA NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 GS 14-JUN-12 78906 ABDOMINAL PAIN; EPIGASTRIC 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 41.76 21.76 GS 20-SEP-12 2859 ANEMIA NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 45.30 IM 01-OCT-12 78053 HYPERSOMNI W SLEEP APNEA 95810 POLYSOMNOGRAPHY, SLEEP STAGING 11 1 400.00 123.19 63.64 IM 26-SEP-12 7842 SWELLING IN HEAD NECK 76881 US XTR NON-VASC COMPLETE 11 1 200.00 79.69 63.75 AN 26-SEP-12 57420 CHOLELITHIASIS NOS 00790 UPPER ABDOMEN 22 12 900.00 253.08 253.08 AN 26-SEP-12 57420 CHOLELITHIASIS NOS 00790 UPPER ABDOMEN 22 12 801.00 168.72 168.72 GS 26-SEP-12 57510 CHOLECYSTITIS,UNSPECIFIED 47562 LAPAROSCOPY; CHOLECYSTECTOMY 22 1 2,300.00 899.93 899.93 AN 07-SEP-12 5559 REGIONAL ENTERITIS NOS 00740 UPPER GASTROINTESTINAL ENDOSCO 22 8 704.00 168.72 134.98 AN 07-SEP-12 5559 REGIONAL ENTERITIS NOS 00740 UPPER GASTROINTESTINAL ENDOSCO 22 8 376.00 112.48 89.98 GS 02-OCT-12 9583 POSTTRAUM WND INFEC NEC 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 146.00 107.88 82.88 GS 04-OCT-12 8830 OPEN WOUND OF FINGER 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 45.30 IM 10-SEP-12 59970 HEMATURIA, UNSPECIFIED 76857 ULTRASOUND, PELVIC(NON-OBSTETR 11 1 80.00 70.64 - FP 10-OCT-12 2724 HYPERLIPIDEMIA NEC/NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.30 55.30 FP 10-OCT-12 2724 HYPERLIPIDEMIA NEC/NOS 36415 ROUTINE VENIPUNCTURE 11 1 15.00 3.00 - AN 18-JUL-12 71887 JT DERANGEMENT NEC-ANKLE 01464 ARTHROSCOPIC PROCEDURES ANKLE 22 11 528.00 231.99 185.59 IM 06-JUL-12 V7284 PREOPERATIVE EXAMINATION UNSPE 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 46.00 8.70 6.96 DR 17-SEP-12 1725 MALIG MELANOMA TRUNK 11602 EXCISION, MALIGNANT LESION, TR 11 1 494.00 249.52 199.62 GS 01-OCT-12 79380 ABNORMAL MAMMOGRAM 99203 OFFICE VIS/NEW PT-INTERMEDIATE 22 1 150.00 82.13 57.13 GS 01-OCT-12 79380 ABNORMAL MAMMOGRAM 19000 PUNCTURE ASPIRATION OF CYST; 22 1 300.00 50.46 - GS 01-OCT-12 79380 ABNORMAL MAMMOGRAM 76942 GUIDE, NEEDLE BIOPSY-SUPERVISI 22 1 300.00 34.45 - PSY 28-NOV-12 29680 MANIC-DEPRESSIVE NOS 99224 SUBSEQUENT OBSERVATION CARE 22 1 68.00 41.76 41.76 IM 15-NOV-12 2449 HYPOTHYROIDISM NOS 76536 ECHOGRAPHY, SOFT TISSUES OF HE 11 1 120.00 - - FP 04-DEC-12 2689 VITAMIN D DEFICIENCY NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 104.05 89.05 IM 06-SEP-12 7840 HEADACHE 99284 ER EXAM;NEW PT;EXTENDED 23 1 578.00 128.06 102.45 NSP 09-AUG-12 4019 HYPERTENSION NOS 83970 PARATHORMONE (PARATHYROID HORM 81 1 97.00 58.46 46.77 NSP 09-AUG-12 4019 HYPERTENSION NOS 82570 CREATININE; URINE 81 1 16.80 7.33 5.86 NSP 09-AUG-12 4019 HYPERTENSION NOS 84156 PROT TOTAL NO REFRACTOMETRY; U 81 1 10.00 5.19 4.15 FP 20-SEP-12 78079 OTHER MALAISE AND FATIGUE 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 169.00 107.88 92.88 FP 27-JUN-12 78903 ABDOMINAL PAIN; RT LOW QUAD 74022 RADIOLOGIC EXAMINATION, ABDOME 11 1 159.00 29.23 23.38 IM 13-SEP-12 5990 URIN TRACT INFECTION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 FP 10-APR-12 4611 AC FRONTAL SINUSITIS 99204 OFFICE VISIT/NEW PT-EXTENDED 20 1 195.00 195.00 195.00 AN 07-MAY-12 43310 OCCULSION/STENOSIS CAROTID ARE 00350 PROCEDURES MAJOR VESSELS/NECK 21 1 1,650.00 - - AN 07-MAY-12 43310 OCCULSION/STENOSIS CAROTID ARE 36620 ARTERIAL CATHETERIZATION OR CA 21 1 225.00 - - AN 07-MAY-12 78009 UNCONSCIOUSNESS-OTHER 31500 INTUBATION, ENDOTRACHEAL, EMER 21 1 560.00 131.20 131.20 AN 07-MAY-12 43310 OCCULSION/STENOSIS CAROTID ARE 00350 PROCEDURES MAJOR VESSELS/NECK 21 22 1,458.00 309.32 309.32 MG 02-MAR-12 7262 SHOULDER REGION DIS NEC 73030 RADIOLOGIC EXAM,SHOULDER,COMPL 11 1 74.00 19.14 15.31 FP 20-NOV-12 2724 HYPERLIPIDEMIA NEC/NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 - - FP 28-DEC-12 28850 LEUKOCYTOSIS, UNSPECIFIED 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.30 55.30 FP 28-DEC-12 28850 LEUKOCYTOSIS, UNSPECIFIED 36415 ROUTINE VENIPUNCTURE 11 1 15.00 3.00 - GS 04-DEC-12 V6709 FOLLOW-UP EXAM FOLLOWING SURGE 45378 COLONOSCOPY, FLEXIBLE TO SPLEN 22 1 744.00 255.08 146.02 GS 19-DEC-12 56210 DIVERTICULOSIS OF COLON 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 41.76 16.76 AN 18-DEC-12 7452 TETRALOGY OF FALLOT 01920 CARDIAC CATHETERIZATION 22 1 2,028.00 - - AN 18-DEC-12 7452 TETRALOGY OF FALLOT 01920 CARDIAC CATHETERIZATION 22 1 2,028.00 1,675.00 1,675.00 FP 11-OCT-12 33989 OTHER HEADACHE SYNDROMES 99213 OFFICE VIS/EST PT-LIMITED 11 1 80.00 70.30 55.30 FP 02-APR-12 7295 PAIN IN LIMB 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 134.00 104.05 89.05 FP 28-DEC-12 462 ACUTE PHARYNGITIS 87804 INF AGENT DETECTION; INFLUENZA 11 1 27.00 16.99 - FP 28-DEC-12 462 ACUTE PHARYNGITIS 87880 STREPTOCOCUS, GROUP A 11 1 27.00 16.99 - FP 28-DEC-12 462 ACUTE PHARYNGITIS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 137.00 104.05 89.05 FP 05-APR-12 30002 GENERALIZED ANXIETY DIS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 150.00 107.88 92.88 FP 06-APR-12 4739 CHRONIC SINUSITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 108.00 70.30 55.30 DR 27-FEB-12 07810 VIRAL WARTS 99213 OFFICE VIS/EST PT-LIMITED 11 1 114.00 70.49 50.49 DR 27-FEB-12 07810 VIRAL WARTS 17110 DESTRUCTION BY ANY METHOD OF F 11 1 138.00 107.09 85.67 PED 15-FEB-12 78841 URINARY FREQUENCY 99212 OFFICE OR OTHER OUTPT VISIT 11 1 65.00 42.02 27.02 PED 15-FEB-12 78841 URINARY FREQUENCY 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 135.00 89.13 89.13 PED 15-FEB-12 78841 URINARY FREQUENCY 96110 DEVELOPMENTAL TESTING 11 1 20.00 8.13 8.13 GS 12-DEC-12 7289 MUSCLE/LIGAMENT DIS NOS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 150.00 107.88 82.88 GS 05-MAR-12 4019 HYPERTENSION NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 131.00 104.05 84.05 PSY 05-MAR-12 30981 PROLONG POSTTRAUM STRESS 90801 PSYCHIATRIC DX INTERVIEW/EXAM 11 1 200.00 151.73 151.73 PSY 12-MAR-12 30981 PROLONG POSTTRAUM STRESS 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 90.00 57.42 37.42 IM 17-MAR-12 78659 CHEST PAIN NEC 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 25.00 8.70 8.70 PSY 12-MAR-12 30981 PROLONG POSTTRAUM STRESS 80104 DRUG SCREEN, MULTIPLE DRUG CLA 11 1 25.00 12.36 12.36 FP 13-FEB-12 4659 ACUTE URI NOS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 108.00 72.52 57.52 GS 20-MAR-12 4552 INT HEMRRHOID W COMP NEC 99212 OFFICE VIS/EST PT-BRIEF 11 1 65.00 41.76 21.76 FP 24-AUG-12 4660 ACUTE BRONCHITIS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 136.00 107.88 92.88 FP 24-AUG-12 4660 ACUTE BRONCHITIS 90718 IMMUN;TETANUS/DIPHTHERIA;ADULT 11 1 38.00 17.85 17.85 FP 24-AUG-12 4660 ACUTE BRONCHITIS 90471 IMMUNIZATION ADMINISTRATION 11 1 30.00 12.00 12.00 FP 11-SEP-12 3829 OTITIS MEDIA NOS 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 195.00 167.39 152.39 FP 24-AUG-12 4660 ACUTE BRONCHITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.30 55.30 FP 11-AUG-12 7821 NONSPECIF SKIN ERUPT NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 126.00 70.30 55.30 FP 11-AUG-12 7821 NONSPECIF SKIN ERUPT NEC J3301 INJECTION TRIAMCINOLONE ACETON 11 2 30.00 3.38 - FP 11-AUG-12 7821 NONSPECIF SKIN ERUPT NEC J1020 INJECTION, METHYLPREDNISOLONE 11 1 15.00 3.12 - FP 02-AUG-12 7821 NONSPECIF SKIN ERUPT NEC 99202 OFFICE VIS/NEW PT-LIMITED 11 1 94.00 71.69 56.69 FP 11-AUG-12 6918 OTHER ATOPIC DERMATITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.30 55.30 FP 11-SEP-12 4619 ACUTE SINUSITIS NOS 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 195.00 167.39 152.39 GS 20-FEB-12 5693 RECTAL ANAL HEMORRHAGE 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 230.00 168.77 148.77 DR 02-OCT-12 7048 HAIR DISEASES NEC 11100 BIOPSY OF SKIN, SUBCUTANEOUS T 11 1 225.00 101.27 81.02 DR 02-OCT-12 7048 HAIR DISEASES NEC 99000 HANDLING/CONVEY SPEC;OV TO LAB 11 1 12.00 - - FP 04-SEP-12 4619 ACUTE SINUSITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 50.11 35.11 IM 22-AUG-12 78901 ABDOMINAL PAIN; RT UPPER QUAD 76705 ECHOGRAPHY, LIMITED - TECH COM 11 1 150.00 69.60 55.68 NSP 09-AUG-12 5854 CHRNC KIDNEY DISEASE STAGE IV 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 184.00 104.05 79.05 PA 29-AUG-12 V7231 ROUTINE GYN EXAM 98925 OMT 1-2 BODY REGIONS 11 1 55.00 30.62 - PA 29-AUG-12 V7231 ROUTINE GYN EXAM 99395 PREVENTIVE;EST PT;18-39 YRS 11 1 144.00 113.80 113.80 IM 09-AUG-12 4660 ACUTE BRONCHITIS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 225.00 107.88 92.88 IM 09-AUG-12 4660 ACUTE BRONCHITIS 71020 RADIOLOGIC EXAM, CHEST, 2 VWS 11 1 127.40 18.10 - IM 15-AUG-12 78659 CHEST PAIN NEC 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 25.00 8.70 6.96 FP 08-AUG-12 9953 ALLERGY, UNSPECIFIED 99212 OFFICE VIS/EST PT-BRIEF 11 1 50.00 41.76 26.76 IM 13-SEP-12 V0481 VACC/INOC AGAINST INFLUENZA 90656 FLU VIR VAC SPLIT PF 3 YR AGE& 11 1 19.00 12.38 12.38 IM 13-SEP-12 V0481 VACC/INOC AGAINST INFLUENZA 90471 IMMUNIZATION ADMINISTRATION 11 1 17.00 12.00 12.00 IM 04-SEP-12 24290 THYROTOX NOS NO CRISIS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 11 1 146.00 107.88 92.88 FP 29-JUN-12 78079 OTHER MALAISE AND FATIGUE 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.30 55.30 FNSP 30-AUG-12 62570 VULVODYNIA, UNSPECIFIED 99202 OFFICE VIS/NEW PT-LIMITED 11 1 105.00 71.69 56.69 DR 30-JUL-12 1725 MALIG MELANOMA TRUNK 11601 EXCISION, MALIGNANT LESION, TR 11 1 403.00 228.64 174.91 DR 30-JUL-12 1725 MALIG MELANOMA TRUNK 11300 SHAVING LESION 0.5 CM OR LESS 11 1 173.00 33.76 27.01 IM 17-JUN-12 34580 OTHER FORMS OF EPILEPSY 95816 ELECTROENCEPHALOGRAM 21 1 68.43 55.68 44.54 FP 21-AUG-12 7962 ELEV BL PRES W/O HYPERTN 99202 OFFICE VIS/NEW PT-LIMITED 11 1 94.00 71.69 56.69 FP 21-AUG-12 79029 OTHER ABNORMAL GLUCOSE 36415 ROUTINE VENIPUNCTURE 11 1 10.00 3.00 - GS 17-SEP-12 61172 LUMP OR MASS IN BREAST 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 90.00 90.00 65.00 IM 06-SEP-12 79380 ABNORMAL MAMMOGRAM 76645 ECHOGRAPHY,BREAST - TECH COMP 11 1 150.00 62.29 - FP 29-AUG-12 462 ACUTE PHARYNGITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.30 55.30 FP 01-AUG-12 7061 ACNE NEC 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 - - FP 29-AUG-12 462 ACUTE PHARYNGITIS 99213 OFFICE VIS/EST PT-LIMITED 11 1 100.00 70.30 55.30 FP 11-SEP-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 55.30 DR 30-AUG-12 7062 SEBACEOUS CYST 99202 OFFICE VIS/NEW PT-LIMITED 11 1 126.00 71.69 46.69 PSY 28-AUG-12 29632 RECURR DEPR PSYCHOS-MOD 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 125.00 104.05 - GS 18-AUG-12 80507 FX C7 VERTEBRA-CLOSED 99222 INIT HSP VISIT;INTERMEDIATE 21 1 235.00 144.07 115.26 GS 20-AUG-12 80507 FX C7 VERTEBRA-CLOSED 99238 HOSPITAL DISCHARGE DAY MANAGEM 21 1 150.00 70.99 56.79 FP 25-AUG-12 7242 LUMBAGO 99203 OFFICE VIS/NEW PT-INTERMEDIATE 20 1 159.00 107.88 82.88 FP 25-AUG-12 7242 LUMBAGO 96372 THER/PROPH/DIAG INJ SC/IM 20 1 33.50 - - FP 25-AUG-12 7242 LUMBAGO J3301 INJECTION TRIAMCINOLONE ACETON 20 4 12.00 6.76 5.41 FP 25-AUG-12 7242 LUMBAGO J1100 INJECTION, DEXAMETHOSONE SODIU 20 4 16.00 0.44 0.35 FP 01-SEP-12 4619 ACUTE SINUSITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 FP 01-SEP-12 4619 ACUTE SINUSITIS NOS 96372 THER/PROPH/DIAG INJ SC/IM 11 1 30.00 - - FP 01-SEP-12 4619 ACUTE SINUSITIS NOS J2930 INJECTION, METHYLPREDISOLONE S 11 1 30.00 2.58 - FP 06-AUG-12 3558 MONONEURITIS LEG NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 55.30 FP 05-SEP-12 340 MULTIPLE SCLEROSIS 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 41.76 26.76 FP 18-SEP-12 34690 MIGRAIN, UNSPECIFIED 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 84.36 69.36 AN 12-AUG-12 33818 OTHER ACUTE POSTOPERATIVE PAIN 01996 DAILY HSP MANAGE EPIDURAL/DRUG 21 1 195.00 187.20 149.76 AN 09-AUG-12 56211 DIVERTICULITIS OF COLON 00790 UPPER ABDOMEN 21 1 1,300.00 1,248.00 883.46 AN 09-AUG-12 56211 DIVERTICULITIS OF COLON 99140 EMERGENCY ANESTHESIA 21 1 130.00 124.80 99.84 AN 10-AUG-12 33818 OTHER ACUTE POSTOPERATIVE PAIN 01996 DAILY HSP MANAGE EPIDURAL/DRUG 21 1 195.00 187.20 149.76 AN 11-AUG-12 33818 OTHER ACUTE POSTOPERATIVE PAIN 01996 DAILY HSP MANAGE EPIDURAL/DRUG 21 1 195.00 187.20 149.76 AN 13-AUG-12 33818 OTHER ACUTE POSTOPERATIVE PAIN 01996 DAILY HSP MANAGE EPIDURAL/DRUG 21 1 195.00 187.20 156.51 AN 14-AUG-12 33818 OTHER ACUTE POSTOPERATIVE PAIN 01996 DAILY HSP MANAGE EPIDURAL/DRUG 21 3 195.00 195.00 156.00 FP 08-AUG-12 56983 PERFORATION OF INTESTINE 99283 ER EXAM;NEW PT;INTERMEDIATE 23 1 202.00 - - GS 09-AUG-12 56211 DIVERTICULITIS OF COLON 99223 INITIAL HOSP VISIT 21 1 342.00 328.32 328.32 GS 09-AUG-12 56211 DIVERTICULITIS OF COLON 44143 COLECTOMY, PARTIAL; WITH END C 21 1 3,773.00 3,622.08 3,622.08 GS 23-AUG-12 56210 DIVERTICULOSIS OF COLON 99203 OFFICE VIS/NEW PT-INTERMEDIATE 22 1 132.00 82.13 57.13 FP 09-AUG-12 DEP DEPENDENT NOT ON FILE 99173 SCREENING TEST OF VISUAL ACUIT 11 1 10.00 - - FP 20-JUL-12 V7231 ROUTINE GYN EXAM 99396 PREVENTIVE; EST PT; 40-64 YRS 11 1 95.00 95.00 95.00 FP 15-AUG-12 53011 DISEASES OF ESOPHAGUS-REFLUX E 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 150.00 104.05 89.05 PSY 02-AUG-12 31400 ATTN DEFIC NONHYPERACT 96101 PSYCHOLOGICAL TESTING, PER HR 11 8 1,248.00 670.96 - MG 18-JUL-12 V5869 LONG TERM(CURRENT) USE OTH MED 85025 BLOOD COUNT; HEMOGRAM AND PLAT 81 1 31.00 11.02 8.82 MG 18-JUL-12 V5869 LONG TERM(CURRENT) USE OTH MED 85651 SEDIMENTATION RATE ERYTHROCYTE 81 1 13.00 5.02 4.02 MG 18-JUL-12 V5869 LONG TERM(CURRENT) USE OTH MED 80053 COMPREHENSIVE METABOLIC PANEL 81 1 38.00 11.97 9.58 MG 18-JUL-12 V5869 LONG TERM(CURRENT) USE OTH MED 86140 C-REACTIVE PROTEIN 81 1 20.00 7.33 5.86 GS 14-MAY-12 5693 RECTAL ANAL HEMORRHAGE 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 230.00 167.39 147.39 GS 14-MAY-12 V7651 SPECIAL SCREENING; COLON 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 230.00 167.39 157.39 DR 08-MAY-12 70219 OTHER SEBORRHEIC KERATOSIS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 185.00 71.69 51.69 DR 08-MAY-12 70219 OTHER SEBORRHEIC KERATOSIS 17000 DESTRUCTION BY ANY METHOD, INC 11 1 145.00 78.65 - DR 08-MAY-12 70219 OTHER SEBORRHEIC KERATOSIS 17003 DESTRUCT.BY ANY METHOD;2ND-14 11 1 35.00 7.31 - FP 19-APR-12 4619 ACUTE SINUSITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 71.00 41.76 26.76 FP 19-APR-12 4619 ACUTE SINUSITIS NOS G8553 AT LEAST ONE RX CREATED DURING 11 1 0.01 - - FP 19-APR-12 4619 ACUTE SINUSITIS NOS J1040 INJECTION, METHYLPREDNISOLONE 11 1 20.00 7.09 - FP 19-APR-12 4619 ACUTE SINUSITIS NOS J0696 INJECTION, CEFTRIAXONE SODIUM, 11 4 40.00 3.56 - FP 26-APR-12 4619 ACUTE SINUSITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 71.00 41.76 26.76 FP 26-APR-12 4619 ACUTE SINUSITIS NOS G8553 AT LEAST ONE RX CREATED DURING 11 1 0.01 - - PSY 17-APR-12 3090 ADJ REACTION W/BRIEF DEPRESSIV 90846 FAMILY PSYCHOTHERAPY 11 1 145.00 - - FP 26-APR-12 4619 ACUTE SINUSITIS NOS J1885 INJECTION, KETOROLAC TROMETHAM 11 4 10.00 1.04 0.83 FP 26-APR-12 4619 ACUTE SINUSITIS NOS J0696 INJECTION, CEFTRIAXONE SODIUM, 11 4 40.00 3.56 2.85 DR 01-MAY-12 1101 DERMATOPHYTOSIS OF NAIL 88312 SPECIAL STAINS (LIST SEPARATEL 11 1 200.00 83.52 66.82 DR 01-MAY-12 1101 DERMATOPHYTOSIS OF NAIL 88302 LEVEL II - SURGICAL PATHOLOGY, 11 1 85.00 49.76 39.81 DR 01-MAY-12 70219 OTHER SEBORRHEIC KERATOSIS 99202 OFFICE VIS/NEW PT-LIMITED 11 1 185.00 71.69 51.69 GS 13-APR-12 56400 CONSTIPATION, UNSPECIFIED 45378 COLONOSCOPY, FLEXIBLE TO SPLEN 22 1 872.00 255.08 204.06 GS 26-APR-12 56210 DIVERTICULOSIS OF COLON 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 41.76 21.76 AN 13-APR-12 V5883 THERAPUTIC DRUG MONITORING 00740 UPPER GASTROINTESTINAL ENDOSCO 22 1 729.00 - - GS 30-APR-12 5778 PANCREATIC DISEASE NEC 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 41.76 21.76 IM 01-MAY-12 7891 HEPATOMEGALY 76705 ECHOGRAPHY, LIMITED - TECH COM 11 1 150.00 69.60 55.68 IM 25-MAY-12 2411 NONTOX MULTINODUL GOITER 76536 ECHOGRAPHY, SOFT TISSUES OF HE 11 1 120.00 82.13 65.70 IM 09-MAY-12 44021 ATHEROSCLEROSIS-OF ARTERIES OF 93923 NONINVASIVE PHYSIOLOGIC STUDIE 11 1 250.00 143.03 114.42 IM 11-JUN-12 7295 PAIN IN LIMB 93971 DUPLEX SCAN OF EXTREMITY VEINS 11 1 250.00 137.81 110.25 FP 14-JUN-12 6926 DERMATITIS DUE TO PLANT J1030 INJECTION, METHYLPREDNISOLONE 11 1 21.00 3.10 2.48 FP 14-JUN-12 6926 DERMATITIS DUE TO PLANT J1030 INJECTION, METHYLPREDNISOLONE 11 1 41.00 3.10 2.48 FP 14-JUN-12 6926 DERMATITIS DUE TO PLANT 96372 THER/PROPH/DIAG INJ SC/IM 11 1 16.00 - - FP 14-JUN-12 6926 DERMATITIS DUE TO PLANT 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 70.30 55.30 FP 26-JUN-12 4739 CHRONIC SINUSITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 70.30 55.30 FP 25-JUN-12 78659 CHEST PAIN NEC 99203 OFFICE VIS/NEW PT-INTERMEDIATE 72 1 131.00 129.46 114.46 DR 02-OCT-12 17332 SQUAMOUS CELL CARCINOMA OF SKI 99213 OFFICE VIS/EST PT-LIMITED 11 1 130.00 70.30 45.30 DR 02-OCT-12 17332 SQUAMOUS CELL CARCINOMA OF SKI 17000 DESTRUCTION BY ANY METHOD, INC 11 1 145.00 78.65 - DR 02-OCT-12 17332 SQUAMOUS CELL CARCINOMA OF SKI 17003 DESTRUCT.BY ANY METHOD;2ND-14 11 6 210.00 43.86 - GS 24-SEP-12 55320 VENTRAL HERNIA NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 95.00 70.30 45.30 FP 04-OCT-12 8738 OPEN WOUND OF HEAD NEC 12011 SIMPLE REPAIR OF SUPERFICIAL W 11 1 285.00 116.58 - FP 04-OCT-12 8738 OPEN WOUND OF HEAD NEC 99201 OFFICE VIS/NEW PATIENT-BRIEF 11 1 60.00 41.76 26.76 PSY 18-JAN-12 29632 RECURR DEPR PSYCHOS-MOD 90801 PSYCHIATRIC DX INTERVIEW/EXAM 11 1 250.00 154.88 123.90 FP 05-JAN-12 4019 HYPERTENSION NOS 99203 OFFICE VIS/NEW PT-INTERMEDIATE 72 1 131.00 126.06 111.06 PSY 29-MAY-12 29680 MANIC-DEPRESSIVE NOS 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 105.00 57.42 37.42 PSY 21-MAY-12 29689 MANIC-DEPRESSIVE NEC 90862 RX MANAGEMENT;INCLUDING PRESCR 11 1 112.00 57.42 37.42 AN 18-MAY-12 53190 STOMACH ULCER NOS 00740 UPPER GASTROINTESTINAL ENDOSCO 24 7 455.00 147.63 147.63 GS 26-MAY-12 95912 OTHER INJURY OF ABDOMEN 99221 INITIAL HOSP VISIT;BRIEF 21 1 192.00 107.88 86.30 GS 27-MAY-12 95912 OTHER INJURY OF ABDOMEN 99238 HOSPITAL DISCHARGE DAY MANAGEM 21 1 140.00 70.99 56.79 IM 10-MAY-12 4019 HYPERTENSION NOS 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 54.74 8.70 6.96 IM 03-MAY-12 41071 SUBENDOCARDIAL INFARCTION-INIT 92980 TRANSCATHETER PLACE INTRACOR 21 1 2,412.00 987.28 987.28 IM 03-MAY-12 41071 SUBENDOCARDIAL INFARCTION-INIT 93458 L HRT ARTERY/VENTRICLE ANGIO 21 1 909.00 203.41 203.41 FP 25-SEP-12 490 BRONCHITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 55.30 DR 08-OCT-12 2382 UNC BEHAV NEO SKIN 99212 OFFICE VIS/EST PT-BRIEF 11 1 78.00 41.76 16.76 PED 27-SEP-12 4644 CROUP 99213 OFFICE VIS/EST PT-LIMITED 72 1 84.00 70.30 55.30 FP 29-SEP-12 462 ACUTE PHARYNGITIS 99283 ER EXAM;NEW PT;INTERMEDIATE 23 1 267.00 66.12 - PED 01-OCT-12 4644 CROUP 99213 OFFICE VIS/EST PT-LIMITED 72 1 84.00 70.30 55.30 IM 13-JUN-12 37200 ACUTE CONJUNCTIVITIS NOS 99212 OFFICE VIS/EST PT-BRIEF 11 1 56.00 41.76 26.76 PSY 25-NOV-12 30500 ALCOHOL ABUSE-UNSPEC 99232 SUBSEQUENT HSP VISIT;LIMITED 21 1 123.00 - - FP 20-AUG-12 490 BRONCHITIS NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 10.00 10.00 FP 20-AUG-12 490 BRONCHITIS NOS J1040 INJECTION, METHYLPREDNISOLONE 11 1 30.00 - - MG 03-OCT-12 4019 HYPERTENSION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 90.00 70.30 45.30 PA 11-OCT-12 4779 ALLERGIC RHINITIS NOS 99204 OFFICE VISIT/NEW PT-EXTENDED 11 1 330.00 167.39 142.39 AN 17-SEP-12 53081 ESOPHAGEAL REFLUX 00740 UPPER GASTROINTESTINAL ENDOSCO 24 7 455.00 147.63 147.63 FNSP 10-OCT-12 42789 CARDIAC DYSRHYTHMIAS NEC 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 174.00 104.05 89.05 FNSP 10-OCT-12 42789 CARDIAC DYSRHYTHMIAS NEC 93000 ELECTROCARDIOGRAM, WITH INTERP 11 1 65.00 18.79 15.03 AN 18-SEP-12 6271 POSTMENOPAUSAL BLEEDING 00952 HYSTEROSCOPY 22 10 750.00 210.90 168.72 AN 12-NOV-12 79093 ELEVATED PROSTATE SPECIFIC ANT 00910 TRANSURETHRAL PROCEDURES NES 22 4 225.00 - - AN 12-NOV-12 79093 ELEVATED PROSTATE SPECIFIC ANT 00400 ANTERIOR INTEGUMENTARY CHEST 22 6 180.00 - - IM 29-AUG-12 5921 CALCULUS OF URETER 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 65.80 8.70 8.70 FP 29-JUN-12 59970 HEMATURIA, UNSPECIFIED 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 210.00 104.05 89.05 FP 29-JUN-12 59970 HEMATURIA, UNSPECIFIED 74000 RADIOLOGIC EXAMINATION, ABDOME 11 1 113.00 14.62 11.70 FP 29-JUN-12 59970 HEMATURIA, UNSPECIFIED 96372 THER/PROPH/DIAG INJ SC/IM 11 1 40.00 - - FP 29-JUN-12 59970 HEMATURIA, UNSPECIFIED J1885 INJECTION, KETOROLAC TROMETHAM 11 4 140.00 1.04 0.83 FP 29-JUN-12 59970 HEMATURIA, UNSPECIFIED 85025 BLOOD COUNT; HEMOGRAM AND PLAT 11 1 35.00 11.02 8.82 FP 29-JUN-12 59970 HEMATURIA, UNSPECIFIED 80048 BASIC METABOLIC PANEL 11 1 75.00 11.98 9.58 DR 03-OCT-12 2382 UNC BEHAV NEO SKIN 11100 BIOPSY OF SKIN, SUBCUTANEOUS T 11 1 155.00 101.27 - DR 03-OCT-12 2382 UNC BEHAV NEO SKIN 99202 OFFICE VIS/NEW PT-LIMITED 11 1 75.00 71.69 46.69 FP 19-SEP-12 30000 ANXIETY STATE NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 - - FP 23-JUL-12 30000 ANXIETY STATE NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 - - PED 21-SEP-12 52100 DENTAL CARIES, UNSPECIFIED 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 - - AN 28-SEP-12 52100 DENTAL CARIES, UNSPECIFIED 00170 INTRAORAL PROCEDURES 22 16 863.04 337.44 - AN 28-SEP-12 52100 DENTAL CARIES, UNSPECIFIED 00170 INTRAORAL PROCEDURES 22 1 528.96 - - GS 10-OCT-12 2113 BENIGN NEOPLASM LG BOWEL 99212 OFFICE VIS/EST PT-BRIEF 11 1 75.00 41.76 16.76 DR 18-DEC-12 2165 BENIGN NEO SKIN TRUNK 99213 OFFICE VIS/EST PT-LIMITED 11 1 130.00 70.30 45.30 DR 18-DEC-12 2165 BENIGN NEO SKIN TRUNK 11100 BIOPSY OF SKIN 11 1 255.00 101.27 101.27 DR 18-DEC-12 2165 BENIGN NEO SKIN TRUNK 11200 REMOVAL OF SKIN TAGS, MULTIPLE 11 1 220.00 43.15 43.15 DR 18-DEC-12 7019 SKIN HYPERTRO/ATROPH NOS 88304 LEVEL III - SURGICAL PATHOLOGY 11 1 140.00 55.33 55.33 DR 18-DEC-12 37484 CYSTS OF EYELIDS 88304 LEVEL III - SURGICAL PATHOLOGY 11 1 140.00 55.33 55.33 FP 19-SEP-12 30000 ANXIETY STATE NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 84.36 69.36 FP 23-JUL-12 30000 ANXIETY STATE NOS 99213 OFFICE VIS/EST PT-LIMITED 72 1 87.00 84.36 69.36 PED 14-DEC-12 V0481 VACC/INOC AGAINST INFLUENZA 90657 INFLUENZA VIRUS VACCINE,SPLIT 11 1 18.23 6.65 6.65 PED 14-DEC-12 V0481 VACC/INOC AGAINST INFLUENZA 90471 IMMUNIZATION ADMINISTRATION 11 1 12.00 12.00 12.00 PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 88.00 88.00 88.00 PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 85018 BLOOD COUNT; HEMOGLOBIN 11 1 19.25 3.35 - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90716 IMMUNIZATION;VARICELLA(CHICKEN 11 1 100.00 81.75 81.75 PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90471 IMMUNIZATION ADMINISTRATION 11 1 12.00 12.00 12.00 PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90633 HEPATITIS A VACCINE,PEDIATRIC 11 1 38.00 23.94 23.94 PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90472 EACH ADD'L VACCINE, SINGLE OR 11 1 12.00 12.00 12.00 PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 99392 PREVENTIVE;EST PT;1-4 YRS 11 1 88.00 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 85018 BLOOD COUNT; HEMOGLOBIN 11 1 11.25 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 85018 BLOOD COUNT; HEMOGLOBIN 11 1 8.00 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90716 IMMUNIZATION;VARICELLA(CHICKEN 11 1 100.00 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90472 EACH ADD'L VACCINE, SINGLE OR 11 1 12.00 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90633 HEPATITIS A VACCINE,PEDIATRIC 11 1 38.00 - - PED 20-JUL-12 V202 ROUTINE CHILD HEALTH EXAM 90472 EACH ADD'L VACCINE, SINGLE OR 11 1 12.00 - - PED 21-SEP-12 52100 DENTAL CARIES, UNSPECIFIED 99213 OFFICE VIS/EST PT-LIMITED 11 1 84.00 - - AN 28-SEP-12 52100 DENTAL CARIES, UNSPECIFIED 00170 INTRAORAL PROCEDURES 22 16 528.96 224.96 - PED 05-DEC-12 V714 OBSERV-ACCIDENT NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 88.00 70.30 55.30 PED 05-DEC-12 V0481 VACC/INOC AGAINST INFLUENZA 90658 INFLUENZA VIRUS VACCINE,SPLIT 11 1 25.00 11.37 11.37 PED 05-DEC-12 V0481 VACC/INOC AGAINST INFLUENZA 90460 IMM ADMIN THRU 18 VIA ANY RTE 11 1 31.00 12.00 12.00 FNSP 01-NOV-12 78904 ABDOMINAL PAIN - LEFT LOWER QU 99284 ER EXAM;NEW PT;EXTENDED 23 1 200.00 128.06 102.45 DR 19-DEC-12 7061 ACNE NEC 99213 OFFICE VIS/EST PT-LIMITED 11 1 120.00 70.30 45.30 PSY 14-DEC-12 29632 RECURR DEPR PSYCHOS-MOD 90862 RX MANAGEMENT;INCLUDING PRESCR 53 1 47.00 45.24 20.24 GS 03-MAY-12 7062 SEBACEOUS CYST 11426 EXCISION, BENIGN LESION, EXCEP 22 1 615.00 311.11 233.74 GS 03-MAY-12 7062 SEBACEOUS CYST 12042 REP INTERMED NECK ETC 2.5-7.5C 22 1 550.00 109.27 87.42 FP 10-APR-12 4611 AC FRONTAL SINUSITIS J1885 INJECTION, KETOROLAC TROMETHAM 11 2 39.05 0.52 0.42 FP 10-APR-12 4611 AC FRONTAL SINUSITIS 96372 THER/PROPH/DIAG INJ SC/IM 11 1 16.00 16.00 12.80 GS 08-MAR-12 57511 CHRONIC CHOLECYSTITIS 47562 LAPAROSCOPY; CHOLECYSTECTOMY 22 1 2,575.00 899.93 719.94 FP 04-APR-12 3829 OTITIS MEDIA NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 85.00 70.30 55.30 FP 18-MAY-12 486 PNEUMONIA, ORGANISM NOS 99219 INIT OBSERV;PER DAY;MOD SEVERI 22 1 130.00 130.00 130.00 FP 24-MAY-12 486 PNEUMONIA, ORGANISM NOS 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 50.11 35.11 IM 15-MAY-12 7850 TACHYCARDIA NOS 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 25.00 8.70 8.70 IM 18-MAY-12 78605 SHORTNESS OF BREATH 93010 ELECTROCARDIOGRAM,INTERP & REP 22 1 25.00 8.70 8.70 PSY 02-MAY-12 29662 BIPOLAR AFFEC, MIXED-MOD 90806 IND PSYCHOTHERAPY INSIGHT 11 1 160.00 - - PSY 16-MAY-12 29662 BIPOLAR AFFEC, MIXED-MOD 90805 IND PSYCHOTHERAPY W/MED EVALU 13 1 150.00 - - FP 04-JUN-12 6089 MALE GENITAL DIS NOS 99212 OFFICE VIS/EST PT-BRIEF 72 1 60.00 41.76 26.76 FP 15-JUN-12 4619 ACUTE SINUSITIS NOS 70220 RADIOLOGIC EXAMINATION, SINUSE 11 1 48.00 24.36 24.36 FP 21-JUN-12 4011 BENIGN HYPERTENSION 99213 OFFICE VIS/EST PT-LIMITED 11 1 114.00 70.30 55.30 FP 05-JAN-12 5990 URIN TRACT INFECTION NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 80.00 70.49 55.49 FP 05-JAN-12 5990 URIN TRACT INFECTION NOS 81015 URINALYSIS; MICROSCOPIC ONLY 11 1 6.00 4.28 3.42 FP 06-JAN-12 7241 PAIN IN THORACIC SPINE 99213 OFFICE VIS/EST PT-LIMITED 11 1 80.00 70.49 55.49 FP 13-JAN-12 2724 HYPERLIPIDEMIA NEC/NOS 80061 LIPID PANEL 11 1 10.00 10.00 - FP 13-JAN-12 2724 HYPERLIPIDEMIA NEC/NOS 84436 THYROXINE; 11 1 10.00 9.73 - FP 13-JAN-12 2724 HYPERLIPIDEMIA NEC/NOS 84479 TRIDOTHYRONINE (T-3) 11 1 15.00 9.17 - FP 13-JAN-12 2724 HYPERLIPIDEMIA NEC/NOS 80050 GENERAL HEALTH PANEL 11 1 38.00 38.00 - FP 22-MAR-12 2749 GOUT NOS 99214 OFFICE VIS/EST PT-INTERMEDIATE 11 1 137.00 104.05 89.05 FP 22-MAR-12 2749 GOUT NOS 36415 ROUTINE VENIPUNCTURE 11 1 10.00 3.00 2.40 FP 22-MAR-12 2749 GOUT NOS 73660 RAD EXAM TOES- 2 VIEWS 11 1 40.00 21.23 16.98 FP 09-APR-12 2749 GOUT NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 91.00 70.30 55.30 PSY 29-FEB-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PSY 15-FEB-12 3099 ADJUSTMENT REACTION NOS 90808 IND PSYCHOTHERAPY 75-80 MINUTE 11 1 300.00 - - PSY 21-MAR-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 - - PED 19-APR-12 4659 ACUTE URI NOS 99213 OFFICE VIS/EST PT-LIMITED 11 1 65.00 65.00 50.00 PSY 16-FEB-12 3099 ADJUSTMENT REACTION NOS 90847 FAMILY PSYCHOTHERAPY 11 1 430.00 106.75 85.40 PSY 29-FEB-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 87.10 69.68 PSY 21-MAR-12 3099 ADJUSTMENT REACTION NOS 90806 IND PSYCHOTHERAPY INSIGHT 11 1 200.00 84.22 67.38 FP 05-JUN-12 7242 LUMBAGO 99212 OFFICE VIS/EST PT-BRIEF 72 1 52.00 50.11 35.11 Measure PEIA PPB Practice Patients % Diabetics with A1c 98.3500 100.0000 % Diabetics with Eye Exam 48.2400 59.4900 % Influenza Vaccine 42.5600 55.9700 % Pneumocccal Vacinne 5.0700 7.8200 % Breast Cancer Screening 67.2500 72.2500 % Cervical Cancer Screening 60.7500 62.6300 % Colorectal Cancer Screening 65.5200 63.7900 % Asthma Patients on Preferred Medications 84.4200 90.2700 ER Visits Per 1,000 286.5800 320.9300 % of diabetics with ER Visits for diabetes 3.8200 17.3300 % of asthmatics with ER Visits for asthma 6.7300 13.5100 Inpatient days PMPM 0.0065 0.0034 Average length of stay 3.9800 2.3200

Total Measures 13 Measures with Positive Outcomes 9

% Results 69.23%