Medicare Summary Notices - English Exhibits - 2.6_Multipledates_120511.pdf

Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below November 18, 2011 Physical therapy evaluation (97001-GP) Yes $100.00 $78.83 $63.06 $15.77 A Application of hot or cold packs to 1 or more areas (97010-GP) Yes 10.00 10.00 8.00 2.00 A Therapeutic procedure to re- educate brain-to-nerve-to-muscle function, each 15 minutes (97112-GP) Yes 60.00 33.31 26.65 6.66 A Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes (97110-GP) Yes 50.00 32.00 25.60 6.40 A November 20, 2011 Therapeutic procedure to re- educate brain-to-nerve-to-muscle function, each 15 minutes (97112-GP) Yes 60.00 33.31 26.65 6.66 A Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes (97110-GP) Yes 50.00 32.00 25.60 6.40 A Total for Claim #83-11011-003-050 $50.00 $219.45 $175.56 $43.89 November 18 – November 20, 2011 Dr. Jaagosild, Priit M.D., (555) 555-1234 Arnette Clinic, LLC, 8016 Reliable Pkwy, Chicago, IL 60686-0001 Referredy by Dupre, Gary W Exhibit 2.6a – Part B multiple dates Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below December 9, 2010 Hospital inpatient care (99233) Yes $116.00 $106.18 $84.94 $21.24 A December 10, 2010 Hospital inpatient care (99232) Yes 81.00 73.85 59.08 14.77 A December 10 – December 12, 2010 Hospital inpatient care (99232) Yes 81.00 73.85 59.08 14.77 A December 12, 2010 Hospital inpatient care (99232) Yes 81.00 73.85 59.08 14.77 A December 13, 2010 Hospital discharge (99239) Yes 140.00 106.69 85.35 21.34 A Total for Claim #02-10204-674-840 $499.00 $434.42 $347.53 $86.89 December 9 – December 13, 2011 Bruce A. Lief, M.D., (555) 555-1234 2701 Holme Ave, Philadelphia, PA 19152-0000 Referred by Roy K Augusthy Exhibit 2.6b – Part B multiple dates Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below Dr. Kevin W. Brown Xray of chest, 2 views, front and side professional charge (71020-26) Yes $50.00 $12.07 $9.66 $2.41 A Application of hot or cold packs to 1 or more areas (97010-GP) Yes 10.00 10.00 8.00 2.00 A 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 A Total for Claim #18-10209-086-660 $234.00 $59.83 $47.87 $11.96 Service Provided & Billing Code Service Approved? Amount Provider Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below July 14, 2011/Dr. Kevin W. Brown Xray of chest, 2 views, front and side professional charge (71020-26) Yes $50.00 $12.07 $9.66 $2.41 A July 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 A July 16, 2011/Dr. Kevin W. Brown Xray of chest, 2 views, front and side professional charge (71020-26) Yes 50.00 12.07 9.66 2.41 A Application of hot or cold packs to 1 or more areas (97010-GP) Yes 10.00 10.00 8.00 2.00 A Total for Claim #18-10209-086-663 $284.00 $71.90 $57.53 $14.37 July 13, 2011 Rad 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, 2011 Rad 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/dates Quantity, Item/Service Provided & Billing Code Item/ Service Approved? Amount Supplier Charged Medicare- Approved Amount Amount Medicare Paid Maximum You May Be Billed See Notes Below June 9, 2010 2 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) Rental Yes $459.68 $173.17 $138.54 $34.63 A 2 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) Rental Yes 122.31 28.77 23.02 5.75 A July 9, 2010 2 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) Rental Yes 459.68 173.17 138.54 34.63 A 2 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) Rental Yes 122.31 28.77 23.02 5.75 A August 9, 2010 2 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) Rental Yes 459.68 173.17 138.54 34.63 A 2 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concen (E1390-RR) Rental Yes 122.31 28.77 23.02 5.75 A Total for Claim #02-10204-674-860 $1,745.97 $605.82 $484.68 $121.14 June 9 – August 9, 2011 Lincare Inc., (555) 555-1234 PO BOX 996, Blue Springs, MO 64013-0996 Referred by John K Whalen Exhibit 2.6d – DME Multiple Dates