2.6_Multipledates_120511.pdf

Service Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowNovember 18, 2011Physical therapy evaluation  (97001-GP)Yes $100.00 $78.83 $63.06 $15.77 AApplication of hot or cold packs to 1 or more areas (97010-GP)Yes 10.00 10.00 8.00 2.00 ATherapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes  (97112-GP)Yes 60.00 33.31 26.65 6.66 ATherapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes (97110-GP)Yes 50.00 32.00 25.60 6.40 ANovember 20, 2011Therapeutic procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes  (97112-GP)Yes 60.00 33.31 26.65 6.66 ATherapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes (97110-GP)Yes 50.00 32.00 25.60 6.40 ATotal for Claim #83-11011-003-050 $50.00 $219.45 $175.56 $43.89November 18  November 20, 2011Dr. Jaagosild, Priit M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001  Referredy by Dupre, Gary WExhibit 2.6a  Part B multiple datesService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmountMedicare  PaidMaximum  You May  Be BilledSee  Notes  BelowDecember 9, 2010Hospital inpatient care (99233) Yes $116.00 $106.18 $84.94 $21.24 ADecember 10, 2010Hospital inpatient care (99232) Yes 81.00 73.85 59.08 14.77 ADecember 10  December 12, 2010Hospital inpatient care (99232) Yes 81.00 73.85 59.08 14.77 ADecember 12, 2010Hospital inpatient care (99232) Yes 81.00 73.85 59.08 14.77 ADecember 13, 2010Hospital discharge (99239) Yes 140.00 106.69 85.35 21.34 ATotal for Claim #02-10204-674-840 $499.00 $434.42 $347.53 $86.89December 9  December 13, 2011Bruce A. Lief, M.D., (555) 555-1234  2701 Holme Ave, Philadelphia, PA 19152-0000  Referred by Roy K AugusthyExhibit 2.6b  Part B multiple datesService Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmountMedicare  PaidMaximum  You May  Be BilledSee  Notes  BelowDr. Kevin W. BrownXray of chest, 2 views, front and side professional charge (71020-26)Yes $50.00 $12.07 $9.66 $2.41 AApplication of hot or cold packs to 1 or more areas (97010-GP)Yes 10.00 10.00 8.00 2.00 ADr. Jeffrey C. Pan, M.D.Ultrasound scan of veins of both arms or legs including assessment of compression and functional man (93970-26)Yes 174.00 37.76 30.21 7.55 ATotal for Claim #18-10209-086-660 $234.00 $59.83 $47.87 $11.96Service Provided & Billing CodeService  Approved?Amount  Provider  ChargedMedicare-  Approved  AmountAmountMedicare  PaidMaximum  You May  Be BilledSee  Notes  BelowJuly 14, 2011/Dr. Kevin W. BrownXray of chest, 2 views, front and side professional charge (71020-26)Yes $50.00 $12.07 $9.66 $2.41 AJuly 15, 2011/Dr. Jeffrey C. Pan, M.D.Ultrasound scan of veins of both arms or legs including assessment of compression and functional man (93970-26)Yes 174.00 37.76 30.21 7.55 AJuly 16, 2011/Dr. Kevin W. BrownXray of chest, 2 views, front and side professional charge (71020-26)Yes 50.00 12.07 9.66 2.41 AApplication of hot or cold packs to 1 or more areas (97010-GP)Yes 10.00 10.00 8.00 2.00 ATotal for Claim #18-10209-086-663 $284.00 $71.90 $57.53 $14.37July 13, 2011Rad Group of Abington, (555) 555-1234  PO Box 10668, Lancaster, PA 17605-0668  Referred by Dr. Christoph K. Blazes, M.D.July 14  July 16, 2011Rad Group of Abington, (555) 555-1234  PO Box 10668, Lancaster, PA 17605-0668  Referred by Dr. Christoph K. Blazes, M.D.Exhibit 2.6c  Part B multiple providers/datesQuantity, Item/Service Provided  & Billing CodeItem/  Service  Approved?Amount  Supplier  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowJune 9, 20102 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) RentalYes $459.68 $173.17 $138.54 $34.63 A2 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) RentalYes 122.31 28.77 23.02 5.75 AJuly 9, 20102 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) RentalYes 459.68 173.17 138.54 34.63 A2 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) RentalYes 122.31 28.77 23.02 5.75 AAugust 9, 20102 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) RentalYes 459.68 173.17 138.54 34.63 A2 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) RentalYes 122.31 28.77 23.02 5.75 ATotal for Claim #02-10204-674-860 $1,745.97 $605.82 $484.68 $121.14June 9  August 9, 2011Lincare Inc., (555) 555-1234  PO BOX 996, Blue Springs, MO 64013-0996  Referred by John K WhalenExhibit 2.6d  DME Multiple Dates