TIN 85-3448933,NPI  1376115279,Effective 1.1.2022
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ASC Payment Terms,1st Procedure  100%,
Revenue Code 490,2nd Procedure 50%,
,3rd Procedufe 25%,
,All Others 25%,
Implants - Revenue Code 278,Cost + 10%,
Implant Threshold,$500.00 Total Billed Charges,
High Cost Drugs - Revenue Code 636,Cost + 10%,
High Cost Drugs Threshold,$500.00 Total Billed Charges,
"Supplies - Revenue Codes 274,275,276",Included in ASC Payment,
All Other ASC Services Percent of Charge,50% of Billed Charges (50% Discount),
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ASC Category Grouper Structure,,
ASC GROUPER,RATE,
1,"$2,164.00 ",
2,"$2,814.00 ",
3,"$3,463.00 ",
4,"$4,111.00 ",
5,"$4,761.00 ",
6,"$5,411.00 ",
7,"$6,059.00 ",
8,"$6,710.00 ",
9,"$7,359.00 ",
10,"$8,466.00 ",
Ungrouped,"$4,244.00 ",