evekhm/cms_iom_500 huggingface dataset:
2.11_Combined_A_121015.pdf
(light) (84311)Yes 347.29 347.29 347.29 0.00 GChemical analysis using spectrophotometry (light) (84311)Yes 347.29 347.29 347.29 0.00 GThyroxine (thyroid chemical) measurement (84439)Yes 151.04 151.04 151.04 0.00 GThyroid hormone, T3 measurement (84481)Yes 256.88 256.88 256.88 0.00 GClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveGThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 7 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Continued   Notes for Claims AboveHThis service is paid at 100% of the Medicare approved amount.Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowRed blood cell concentration measurement (85014)Yes 19.85 19.85 19.85 0.00 HRed blood cell concentration measurement (85014)Yes 59.55 59.55 59.55 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HRed blood cell concentration measurement (85014)Yes 59.55 59.55 59.55 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HRed blood cell concentration measurement (85014)Yes 39.70 39.70 39.70 0.00 HHemoglobin measurement (85018) Yes 12.78 12.78 12.78 0.00 HHemoglobin measurement (85018) Yes 38.34 38.34 38.34
2.11_Combined_A_121015.pdf
39.70 0.00 HHemoglobin measurement (85018) Yes 12.78 12.78 12.78 0.00 HHemoglobin measurement (85018) Yes 38.34 38.34 38.34 0.00 HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 HHemoglobin measurement (85018) Yes 38.34 38.34 38.34 0.00 HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 HHemoglobin measurement (85018) Yes 25.56 25.56 25.56 0.00 HHeparin assay (85520) Yes 1,188.50 1,188.50 1,188.50 0.00 HCoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 HCoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 HCoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 HClaim #21035000422104NYA (continued)Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer WashingtonOcboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Continued   Notes for Claims AboveIThis service is paid at 100% of the Medicare approved amount.Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowCoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02
2.11_Combined_A_121015.pdf
0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 54.02 54.02 54.02 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 ICoagulation assessment blood test (85730)Yes 108.04 108.04 108.04 0.00 IBlood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60Blood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60Blood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60Claim #21035000422104NYA (continued)Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 9 of
2.11_Combined_A_121015.pdf
2.60Claim #21035000422104NYA (continued)Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 9 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBlood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60Blood group typing (ABO) (86900) Yes 24.00 24.00 24.00 2.60Stool culture (87046) Yes 50.72 50.72 50.72 0.00 JBacterial culture (87070) Yes 108.05 108.05 108.05 0.00 JScreening test for pathogenic organisms (87081)Yes 72.77 72.77 72.77 0.00 JScreening test for pathogenic organisms (87081)Yes 72.77 72.77 72.77 0.00 KScreening test for pathogenic organisms (87081)Yes 72.77 72.77 72.77 0.00 JScreening test for pathogenic organisms (87081)Yes 72.77 72.77 72.77 0.00 JEvaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081)Yes 62.84 62.84 62.84 0.00 JEvaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081)Yes 62.84 62.84 62.84 0.00 JEvaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081)Yes 62.84 62.84 62.84 0.00 JEvaluation of antimicrobial drug (antibiotic, antifungal, antiviral) (87081)Yes 125.68 125.68 125.68 0.00 JSpecial stain for microorganism (87205)Yes 88.20 88.20 88.20 0.00 JSpecial stain for microorganism (87205)Yes 264.60 264.60 264.60 0.00
2.11_Combined_A_121015.pdf
stain for microorganism (87205)Yes 88.20 88.20 88.20 0.00 JSpecial stain for microorganism (87205)Yes 264.60 264.60 264.60 0.00 JSpecial stain for microorganism (87205)Yes 176.40 176.40 176.40 0.00 JSpecial stain for microorganism (87205)Yes 176.40 176.40 176.40 0.00 JClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveJThis service is paid at 100% of the Medicare approved amount.KThis item or service cannot be paid as billed.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 10 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeItem Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowSpecial stain for microorganism (87205)Yes 352.80 352.80 352.80 0.00 LTissue culture innoculation for virus isolation (87252)Yes 243.65 243.65 243.65 0.00 LDetection test for Adenovirus (virus) (87260)Yes 39.69 39.69 39.69 0.00 LDetection test for Parainfluenza virus (87279)Yes 119.07 119.07 119.07 0.00 LDetection test for Varicella (chicken pox) zoster virus (87290)Yes 70.38 70.38 70.38 0.00 LImmunologic analysis for detection of organism (87449)Yes 156.56 156.56 156.56 0.00 LImmunologic analysis for detection of organism (87449)Yes 156.56 156.56 156.56 0.00 LDetection test for; cytomegalovirus, quantification (87497)Yes 574.40 574.40 574.40 0.00 LDetection test for; cytomegalovirus, quantification (87497)Yes 574.40 574.40 574.40
2.11_Combined_A_121015.pdf
574.40 574.40 574.40 0.00 LDetection test for; cytomegalovirus, quantification (87497)Yes 574.40 574.40 574.40 0.00 LDetection test for; cytomegalovirus, quantification (87497)Yes 574.40 574.40 574.40 0.00 LDetection test for; cytomegalovirus, quantification (87497)Yes 574.40 574.40 574.40 0.00 LDetection test for; cytomegalovirus, quantification (87497)Yes 574.40 574.40 574.40 0.00 LDetection test for; cytomegalovirus, quantification (87497)Yes 574.40 574.40 574.40 0.00 LBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 LBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 LBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 LBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 LClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveLThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 11 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals
2.11_Combined_A_121015.pdf
60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 60.64 60.64 60.64 0.00 MBlood test, basic group of blood chemicals (80048)Yes 181.92 181.92 181.92 0.00 MBlood test, basic group of blood chemicals (80048)Yes 181.92 181.92 181.92 0.00 MBlood test, basic group of blood chemicals (80048)Yes 181.92 181.92 181.92 0.00 MBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 MBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 MBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 MClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveMThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 12 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService
2.11_Combined_A_121015.pdf
B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 12 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 181.92 181.92 181.92 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NBlood test, basic group of blood chemicals (80048)Yes 121.28 121.28 121.28 0.00 NAlcohol (ethanol) level (82055) Yes 116.87 116.87 116.87 0.00 NAmmonia level (82140) Yes 72.77 72.77 72.77 0.00 NAmmonia level (82140) Yes 72.77 72.77 72.77 0.00 NAmylase (enzyme) level (82150) Yes 51.82 51.82 51.82 0.00 NCalcium level (82330) Yes 193.05 193.05 193.05 0.00 N,OCalcium level
2.11_Combined_A_121015.pdf
(enzyme) level (82150) Yes 51.82 51.82 51.82 0.00 NCalcium level (82330) Yes 193.05 193.05 193.05 0.00 N,OCalcium level (82330) Yes 579.15 579.15 579.15 0.00 N,OCalcium level (82330) Yes 386.10 386.10 386.10 0.00 N,OClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveNThis service is paid at 100% of the Medicare approved amount.OLocal Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of LCD # L28209. Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 13 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowCalcium level (82330) Yes 386.10 386.10 386.10 0.00 P,QCalcium level (82330) Yes 386.10 386.10 386.10 0.00 P,QCalcium level (82330) Yes 386.10 386.10 386.10 0.00 P,QCalcium level (82330) Yes 579.15 579.15 579.15 0.00 P,QCalcium level (82330) Yes 386.10 386.10 386.10 0.00 P,QCalcium level (82330) Yes 386.10 386.10 386.10 0.00 P,QCreatinine level to test for kidney function or muscle injury (82570)Yes 123.48 123.48 123.48 0.00 PCreatinine level to test for kidney function or muscle injury
2.11_Combined_A_121015.pdf
P,QCreatinine level to test for kidney function or muscle injury (82570)Yes 123.48 123.48 123.48 0.00 PCreatinine level to test for kidney function or muscle injury (82570)Yes 123.48 123.48 123.48 0.00 PCreatinine level to test for kidney function or muscle injury (82570)Yes 123.48 123.48 123.48 0.00 PCyanocobalamin (vitamin B-12) level (82607)Yes 108.05 108.05 108.05 0.00 PCyanocobalamin (vitamin B-12) level (82607)Yes 108.05 108.05 108.05 0.00 PFolic acid level (82746) Yes 144.43 144.43 144.43 0.00 PFolic acid level (82746) Yes 144.43 144.43 144.43 0.00 PBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 28.00 28.00 28.00 0.00 PBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 28.00 28.00 28.00 0.00 PBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 196.00 196.00 196.00 0.00 PBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 252.00 252.00 252.00 0.00 PClaim #21035000422104NYA (continued)Continued   Notes for Claims AbovePThis service is paid at 100% of the Medicare approved amount.PQLocal Coverage Determinations (LCDs) help Medicare decide what is covered. An LCD was used for your claim. You can compare your case to the LCD, and send information from your doctor if you think it could change our decision. Call 1-800-MEDICARE (1-800-633-4227) for a copy of LCD # L28209. Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer WashingtonOcboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService
2.11_Combined_A_121015.pdf
 Combined Claims, Part A Inpatient, B of A and Home HealthJennifer WashingtonOcboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 252.00 252.00 252.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 252.00 252.00 252.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 364.00 364.00 364.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 84.00 84.00 84.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 84.00 84.00 84.00 0.00 RBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 140.00 140.00 140.00 0.00 RClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveRThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 15 of 26Ocboter 20  November
2.11_Combined_A_121015.pdf
paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 15 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 112.00 112.00 112.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 84.00 84.00 84.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 112.00 112.00 112.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 56.00 56.00 56.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 112.00 112.00 112.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 112.00 112.00 112.00 0.00SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 112.00 112.00 112.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 336.00 336.00 336.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 336.00 336.00 336.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 SBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 196.00 196.00 196.00 0.00 SClaim #21035000422104NYA (continued)Continued   Notes for Claims AboveSThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home
2.11_Combined_A_121015.pdf
#21035000422104NYA (continued)Continued   Notes for Claims AboveSThis service is paid at 100% of the Medicare approved amount.Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 16 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Continued   Notes for Claims AboveTThis service is paid at 100% of the Medicare approved amount.Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 280.00 280.00 280.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 280.00 280.00 280.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 336.00 336.00 336.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 364.00 364.00 364.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 308.00 308.00 308.00 0.00 TBlood glucose (sugar) test performed by hand-held instrument (92962)Yes 140.00 140.00 140.00 0.00 TGlutamyltransferase (liver enzyme) level (82977)Yes 88.20 88.20 88.20 0.00 TGlutamyltransferase (liver enzyme) level (82977)Yes 88.20 88.20 88.20 0.00 TGlutamyltransferase (liver enzyme) level (82977)Yes 88.20 88.20 88.20 0.00 TGlutamyltransferase (liver enzyme) level (82977)Yes 88.20 88.20 88.20 0.00
2.11_Combined_A_121015.pdf
88.20 88.20 88.20 0.00 TGlutamyltransferase (liver enzyme) level (82977)Yes 88.20 88.20 88.20 0.00 TGlutamyltransferase (liver enzyme) level (82977)Yes 88.20 88.20 88.20 0.00 THaptoglobin (serum protein) level (83010)Yes 76.07 76.07 76.07 0.00 TLactic acid level (83605) Yes 184.12 184.12 184.12 0.00 TLactic acid level (83605) Yes 184.12 184.12 184.12 0.00 TClaim #21035000422104NYA (continued)Exhibit 2.11  Combined Claims, Part A Inpatient, B of A and Home HealthJennifer Washington THIS IS NOT A BILL | Page 17 of 26Ocboter 20  November 23, 2011/The New York and Presbyterian Hospital continued...Service Provided & Billing CodeService  Approved?Amount  Facility  ChargedMedicare-  Approved  AmountAmount  Medicare  PaidMaximum  You May  Be BilledSee  Notes  BelowLactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactate dehydrogenase (enzyme) level (83615)Yes
2.11_Combined_A_121015.pdf
184.12 184.12 0.00 ULactic acid level (83605) Yes 184.12 184.12 184.12 0.00 ULactate dehydrogenase (enzyme) level (83615)Yes 69.46 69.46 69.46 0.00 ULipase (fat enzyme) level (83690) Yes 38.59 38.59 38.59 0.00 UMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 97.02 97.02 97.02 0.00 U,WMagnesium level (83735) Yes 291.06 291.06 291.06 0.00