TIN|853448933||
NPI|1376115279||
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NOTE|ASC| LLC Services will be reimbursed as outlined below.||
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SERVICE|REV CODE|RATE|PAYMENT TERMS
ASC|490||1st Procedure 100%| 2nd Procedure 50%| 3rd Procedure 25%| All Others 25%
Implants|278|Cost + 10%|
Implant Threshold|278|$500.00 Total Billed Charges|
High cost Drugs|636|Cost + 10%|
High cost Drugs Threshold|636|$500.00 Total Billed Charges|
Supplies|274|278|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|$2164.00 ||
2|$2814.00 ||
3|$3463.00 ||
4|$4111.00 ||
5|$4761.00 ||
6|$5411.00 ||
7|$6059.00 ||
8|$6710.00 ||
9|$7359.00 ||
10|$8466.00 ||
Ungrouped|$4244.00 ||