7/19/02 11:36:13 Page 1
Payments By Service Code Report
All Providers Combined Transactions 50319 to 51476
All Patients
Code Description # Amount Average
---------------------------------------------------------------
Type of Service Undefined 270 $6820.54
99232 HOSP VISIT/MODERATE 5 $206.04 $41.21
99238 HOSPITAL DISCHARGE 6 $277.56 $46.26
99239 HOSP DC OVER 30 MIN 1 $69.70 $69.70
99291 CRITICAL CARE 30-74 6 $891.77 $148.63
99292 CRITICAL CARE EACH 3 3 $215.50 $71.83
99356 EXTENDED CARE 30-60 1 $65.96 $65.96
99431 NEWBORN HOSP H & P 4 $241.76 $60.44
99433 SUBSEQUENT HOSP NB 3 $86.86 $28.95
99436 ATTENDANCE AT DELIVE 1 $64.70 $64.70
Type of Service H 30 $2119.85
90471 ADMIN 0NE IMMUNIZATI 6 $60.09 $10.02
90472 ADMIN IMMUNIZATIONS 3 $21.49 $7.16
90645 HIB 2 $54.63 $27.32
90669 PREVNAR (PNEUMOCOCCA 2 $132.92 $66.46
90702 DT (PEDIATRIC) 2 $13.90 $6.95
90707 MMR 2 $74.16 $37.08
90713 POLIO VACCINE INJ 5 $132.64 $26.53
90744 HEP B JUVENILE/ADOL 2 $39.79 $19.90
90746 HEP B VACCINE, ADULT 1 $50.00 $50.00
90782 ADMINISTRATION DRUG 2 $29.57 $14.79
95117 ADMIN ALLERGY INJ MU 1 $15.86 $15.86
J0704 CELESTONE (6MG X ) 2 $9.96 $4.98
J2000 LIDOCAINE 1 $3.08 $3.08
J3302 MARCAINE 1 $.66 $.66
Type of Service I 32 $638.75
81002 URINALYSIS DIP 15 $50.30 $3.35
82270 GUIAC (STOOL) 2 $8.98 $4.49
82962 BLOOD SUGAR 14 $51.43 $3.67
82985 GLYCOPROTEIN 9 $196.41 $21.82
87081 STREP SCREEN (QUICK 2 $20.15 $10.08
99000 HANDLING FEE 9 $48.66 $5.41
Type of Service L 51 $375.93
99311 NURSING HOME VISIT 4 $58.02 $14.51
99312 NURSING HOME VISIT 14 $521.57 $37.25
99313 NURSING HOME CARE EX 4 $217.52 $54.38
Type of Service N 22 $797.11
99202 LIMITED NEW PT O.V. 4 $135.88 $33.97
99203 INTERM NEW PT O.V. 7 $446.40 $63.77
99211 MINIMAL O.V. EST PT 1 $15.73 $15.73
99212 BRIEF O.V. EST PT 4 $107.82 $26.96
(Continued on next page)
7/19/02 11:36:14 Page 2
Payments By Service Code Report
All Providers Combined Transactions 50319 to 51476
All Patients
Code Description # Amount Average
---------------------------------------------------------------
99213 LIMITED O.V. - ESTPT 83 $3080.26 $37.11
99214 INTERMED O.V. EST PT 31 $1914.71 $61.76
99215 COMP O.V. EST PT 2 $159.11 $79.56
99381 PREVENT CARE NEW PT 1 $66.93 $66.93
99382 PREVENT CARE NEW PT 1 $52.56 $52.56
99383 PREVENT CARE NEW PT 2 $136.62 $68.31
99391 PREVENT CARE EST PT 3 $195.08 $65.03
99396 ESTAB PT PHYSICAL 40 1 $72.67 $72.67
Type of Service O 140 $6383.77
10140 DRAINAGE OF HEMATOMA 1 $74.95 $74.95
11040 DEBRIDEMENT SKIN 1 $30.53 $30.53
11622 EXC MALIG LESION 1.1 1 $74.78 $74.78
13131 COMPLEX REPAIR 1.1 T 1 $216.82 $216.82
17000 DESTRUCTION 1" BENIG 3 $170.08 $56.69
17003 DESTRUC 2ND-14TH LES 4 $197.94 $49.49
17261 DESTRUCT MALIG 0.6-1 1 $141.00 $141.00
20600 ASP/INJ SM JOINT/BUR 1 $46.17 $46.17
20610 ASP/INJ LARGEJOINT/B 2 $98.03 $49.02
53675 INSERT URINARY CATHE 1 $103.35 $103.35
59400 TOTAL OB CARE 1 $1088.56 $1088.56
59510 C-SECTION 1 $186.50 $186.50
69210 EAR WASH ONE OR BOTH 1 $36.32 $36.32
94640 INHALATION THERAPY 2 $42.92 $21.46
94760 OXIMETRY SINGLE 5 $40.60 $8.12
Type of Service P 26 $2548.55
A4550 SURGICAL TRAY 1 $21.00 $21.00
Type of Service S 1 $21.00
Total Payments 572 $19705.50
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